Every finding on record at Mid Valley Nursing & Rehabilitation

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 3 residents reviewed for care plans, in that: The facility failed to ensure Resident #1's care plan dated 11/20/17 reflected her Enhanced Barrier precautions due to pressure injury to left gluteus. This failure could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: Record review of Resident #1's electronic face sheet, dated 07/29/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included Cerebral infarction (a type of ischemic stroke that occurs when a blocked or narrowed blood vessel cuts off blood flow to a region of the brain), muscle wasting and atrophy (the shrinking and loss of muscle tissue), Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly). Record review of Resident #1's comprehensive person-centered care plan, dated 11/20/2017, did not reflect the Enhanced Barrier Precautions. Record review of Resident #1's 07/29/2026 Physician order sheet report reflected, Treatment Orders: Santyl External Ointment 250 UNIT/GM Apply to Pressure injury Left Glut topically one time a day for Pressure injury Left Gluteus stage 2 Cleanse Pressure injury Left Gluteus stage 2 with dakins solution, pat dry with gauze, apply Santyl and gentamicin ointment, cover with bordered foam dressing, every shift until resolved with a start date 06/11/2026. Record review of Resident #1's quarterly MDS dated [DATE] revealed:Section M- Skin ConditionsUnhealed Pressure Ulcers/Injuries YES During an interview on 07/29/26 at 4:46 p.m., MDS C nurse stated the care plan should have been updated when and by whomever received the order for the Enhanced Barrier Precautions. MDS nurse stated if the care plan was not updated it could affect the nurses by not being able to give the care that Resident #1 needed. MDS nurse stated that he was responsible to update the care plan and did not know that Enhanced Barrier Precautions were needed for wounds. During an interview on 07/29/26 at 4:27 p.m. the DON stated the care plan had to be updated to give Resident #1 the best care and to verify if the interventions were effective. The DON stated that EBP should have been on the care plan. The DON stated the care plan had to be updated as soon as possible to give the best care to Resident #1. The DON stated Resident #1 was at risk of not receiving the proper care that he required. The DON stated that the care plan was a way of communication between staff. Record review of facility's policy titled Care Plan Development, Review, and Update policy with a revised date January, 2026 reflected:Policy:The community will develop and maintain a comprehensive, interdisciplinary, person-centered care plan for each resident. the care plan will include measurable objectives, appropriate interventions, and resident-directed goals designed to support the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (wound care cart) of 7 medication carts. The facility failed to ensure that the wound care cart was secured and locked when it was left unattended by LVN B. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed. Findings included: During an observation on 07/29/2026 from 04:36 PM revealed the wound care medication cart was left unlocked on 200 hallway. During the observation LVN B came out of the room and surveyor informed her wound care medication cart was unlocked and the LVN B secured the cart by locking it. During an interview on 07/29/2026 at 04:36 PM with LVN B revealed she was responsible for the wound care medication cart that was left unlocked. She stated he was expected to lock the wound care medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. She stated he had left the cart unlocked because she just forgot. During an interview on 07/29/2026 at 07:18 PM with the DON stated her expectation of staff when they walk away from the medication cart was to lock it. DON stated that all staff were responsible for locking and monitoring the medication carts. DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. Record review of facility policy Medication Cart Use & Storage with a revised date January,2023 revealed Security: The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on interviews and record reviews, the facility failed to maintain clinical records that were complete and accurate in accordance with accepted professional standards and practices for 2 of 3 residents (Resident #1 and Resident #2) whose clinical records were reviewed for accuracy, in that: 1. The facility failed to have a physician order for the Enhanced Barrier Precautions for Resident #1.2. The facility failed to document in Resident #2's medical record when Resident #2 got orders for Moisture-Associated Skin Damage. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. Findings include: 1. Record review of Resident #1's electronic face sheet, dated 07/29/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included Cerebral infarction (a type of ischemic stroke that occurs when a blocked or narrowed blood vessel cuts off blood flow to a region of the brain), muscle wasting and atrophy (the shrinking and loss of muscle tissue), Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly). Record review of Resident #1's comprehensive person-centered care plan, dated 11/20/2017, did not reflected the Enhanced Barrier Precautions. Record review of Resident #1's 07/29/2026 Physician order sheet report reflected, Treatment Orders: Santyl External Ointment 250 UNIT/GM Apply to Pressure injury Left Glut topically one time a day for Pressure injury Left Gluteus stage 2 Cleanse Pressure injury Left Gluteus stage 2 with dakins solution, pat dry with gauze, apply Santyl and gentamicin ointment, cover with bordered foam dressing, every shift until resolved with a start date 06/29/2026. Record review of Resident #1's Order summary dated 7/29/26 did not reflect any EBP orders on 07/28/26 order was put in the electronic chart on 07/29/26. Record review of Resident #1's quarterly MDS dated [DATE] revealed:Section M- Skin ConditionsUnhealed Pressure Ulcers/Injuries YES 2. Record review Resident #2's face sheet dated 07/29/26 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), Muscle wasting and atrophy (the shrinking and loss of muscle tissue). Record review of Resident #2's care plan dated 04/21/2021 reflected a focus area that Resident #2 had had fragile skin and she was at risk for skin injury. Goal: will have intact skin, free of redness, blisters or discoloration by/through review date. Record review of Resident #2's quarterly MDS assessment, dated 07/10/26 reflected Section M- Skin ConditionsRisk for developing Pressure Ulcers/Injuries YES. During an interview on 7/29/26 at 09:00 a.m., the WCN stated that she called the wound care doctor and notified him that Resident #2 had a rash to her groin area and to her buttocks. The WCN stated that the wound care doctor ordered two creams to be administered to Resident #2. The WCN stated that the order was Calmoseptine External Ointment 0.44-20.6 % Apply to MASD buttock topically every shift for MASD buttock both Cleanse MASD buttock both with dakins solution, pat dry with gauze, apply Calmoseptine with Lotrisone leave open to air every shift, until resolved. The WCN stated that she forgot to document the new orders that she got from the wound care doctor in Resident #2 electronic chart. The WCN stated that if she did not document it meant it never happened. The WCN stated that she forgot to document. The WCN stated that she called the wound care doctor on 06/29/2026. During an interview on 07/29/26 at 4:46 p.m., MDS C nurse stated the care plan should have been updated when and by whomever received the order for the Enhanced Barrier Precautions. The MDS nurse stated if the care plan was not updated because the order was not put in Resident #1's electronic chart. MDS C nurse stated that it could affect the nurses by not being able to give the care that Resident #1 needed. During a phone interview on 7/29/26 at 5:20pm the Wound care Doctor stated that he gave the order to the WCN on 6/29/26 for Resident #2. The Wound care Doctor stated that he had constant communication with nurses and DON. The Wound care Doctor stated that he did not see a negative outcome for not documenting. During an interview on 07/29/2026 at 05:27 p.m., the DON stated that the nurse that got the order was in charge of documenting in Resident #2's electronic chart. The DON stated that she did not think there was a negative outcome. Record review of the facility's policy titled Professional Standard of Care with revised date January,2024 reflected .e. nurses should conduct assessments or evaluations and document within the medical record in the following instances

Based on observation, interviews, and record review, the facility failed to establish and 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 of 3 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN A performed proper hand hygiene for at least 20 seconds during wound care for Resident #1 on 07/28/26. This failure could place residents at risk of infections, healthcare associated with cross contamination, and the spread of infection. Findings include: Record review of Resident #1's electronic face sheet, dated 07/29/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included Cerebral infarction (a type of ischemic stroke that occurs when a blocked or narrowed blood vessel cuts off blood flow to a region of the brain), muscle wasting and atrophy (the shrinking and loss of muscle tissue), Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly). Record review of Resident #1's comprehensive person-centered care plan, dated 11/20/2017, reflected Focus [Resident #1] has a an ADL self-care performance deficit r/t Limit Mobility, Impaired balance. Interventions: The resident requires assistance by 1 staff to turn and reposition in bed as necessary. Record review of Resident #1's 07/29/2026 Physician order sheet report reflected, Treatment Orders: Santyl External Ointment 250 UNIT/GM Apply to Pressure injury Left Glut topically one time a day for Pressure injury Left Gluteus stage 2 Cleanse Pressure injury Left Gluteus stage 2 with dakins solution, pat dry with gauze, apply Santyl and gentamicin ointment, cover with bordered foam dressing, every shift until resolved. During an observation on 07/28/26 at 02:10 p.mBoth nurse and cna washed hands before treatment and after treatment was completed. They both donned PPE properly. They both sanitized hands in between glove changes. Old dressing was labeled and did not have drainage. No odor or drainage noted coming from wound. LVN A performed wound care following doctors order correctly. Dressing applied was dated and initialed. LVN A lathered her hands for 9 sec. During an interview on 07/28/2026 at 02:05 p.m., LVN A stated she should have lathered her hands for at least 20 seconds. LVN A stated that she sang the happy birthday song once. LVN A stated that she thought she lathered her hands for at least 20 seconds. LVN A stated the potential negative outcome was infection. During an interview on 07/29/2026 at 4:00 p.m., the DON stated the proper handwashing was to lather hands for at least 20 seconds. The DON stated if LVN A did not lather her hands for at least 20 seconds this would put Resident #1 at risk for infections. Record review of the facility's policy titled Hand Hygiene with an implemented date January 2023 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. Review of the Center for Disease Control and Prevention website, (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html), Know when to clean your hands:1. Wet hands with water.2. Apply the manufacturer recommended amount of product to your hands.3. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.4. Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet.5. Avoid using hot water to prevent drying of the skin.Note: Other entities recommend cleaning hands with soap and water for at least 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times and scrubbing hands and fingers with soap.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #1), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1's physician was notified when his blood sugar levels were over 300, per physician's orders. This failure could place residents at risk delayed medication adjustments. Findings included: Record review of Resident #1's admission record, dated 06/10/26, reflected an [AGE] year-old male with a re-admission date of 09/17/25 and an original admission date of 07/25/24. His relevant diagnoses included abnormal glucose (blood sugar level falls outside the healthy range), nontraumatic intracranial hemorrhage (when a blood vessel ruptures inside the skill without a preceding injury), malignant neoplasm of bladder (bladder cancer), and dysphagia (difficulty or discomfort when swallowing). Record review of Resident #1's quarterly MDS assessment, dated 04/01/26, reflected a BIMS score of 13, which indicated his cognition was intact.Record review of Resident #1's quarterly care plan, dated 03/30/26, reflected a Focus: [Resident #1] have diabetes and I am at risk for complications associated with diabetes.Interventions included administer my medications as recommended by my doctor, monitor labs as indicated. Promptly report abnormal labs results and significant clinical findings to my doctor as indicated. Date initiated/created 07/26/24.Record review of Resident #1's physician summary order, dated 06/10/26, reflected an order for Insulin Aspart subcutaneous solution Pen-Injector 100 unit/ML (Insulin Aspart). Inject as per sliding scale: if150-200= 1 unit201-250= 2 units251-300= 3 units301-350= 4 units351-400= 6 unitsNotify MD if less than 60 or greater than 300, subcutaneously before meals. Start date 03/11/2026. Record review of Resident #1's physician summary order, dated 06/10/26, reflected an order for Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ML (insulin Glargine) inject 5 units subcutaneously one time a day for hyperglycemia (high blood sugar levels), hold if less than 120 mg/ml, effective 03/23/26.Record review of Resident #1's June 2026 medication administration record reflected Lantus had been administered from 06/01/26 to 06/09/26 at 5:00 p.m.Record review of Resident #1's June 2026 medication administration record reflected his blood sugar was checked and insulin administered from 06/01/26 to 06/10/26 at 7:00 a.m., 11:00 a.m., 4:00 p.m. Resident #1's readings over 300 were as followed:06/04/26-305-4 units administered by LVN A at 7:00 a.m.06/05/26-400-6 units administered by LVN A at 11:00 a.m.06/08/26-386-6 units administered by LVN A at 7:00 a.m.06/09/26-389-6 units administered by LVN A at 7:00 a.m. During an observation and interview on 06/10/26 at 11:30 a.m., Resident #1 was observed lying in bed awake. He was observed having a continuous glucose monitoring device on his left upper arm. Resident #1 said he was feeling well and was not in pain. He said nursing staff administered his medications several times a day.During an interview and observation on 06/10/26 at 11:49 a.m., LVN A said she was Resident #1's charge nurse. She said Resident #1 had a continuous glucose monitoring device on his left arm, which was used to check his blood sugar levels. She said Resident #1's blood sugar readings were continuously high throughout the day. She said even though his readings were high, he remained asymptomatic. She said Resident #1's blood sugar levels were checked 5 times a day, before meals, before his scheduled blood sugar medication, and 1 time overnight. She said Resident #1 was administered insulin 4 times a day. LVN A said Resident #1's sliding scale insulin had parameters that required his NP to be notified. LVN A said of the top of her head she recalled one of those parameters was if Resident #1's blood sugar reading was over 400 to notify his NP. LVN A was observed as she reviewed Resident #1's electronic medical record and said Resident #1 had an order for Lantus which was a scheduled blood sugar medication and a sliding scale insulin order. LVN A said after reading his order for insulin sliding scale she realized his NP needed to be notified if his blood sugar readings were over 300 and not 400 like she thought. She said at one point his sliding scale insulin had parameters of notifying NP if his blood sugar levels were over 400. LVN A said Resident #1's blood sugar readings were continuously over 300 throughout the day. She said Resident #1's NP would round 2 to 3 times a week and was closely monitoring his blood sugar levels. LVN A said Resident #1 was administered insulin 4 times a day, 3 of which depended on his blood sugar readings and had not had a change of condition due to his high blood sugar readings. LVN A said there were no negative outcomes to Resident #1 not having his NP notified when his blood sugar levels were over 300 because Resident #1 was being administered his blood sugar medication several times a day, had not had a change of condition due to his blood sugar readings, and his NP was closely monitoring his blood sugar levels.During an interview and observation on 06/10/6 at 12:11 p.m., the DON said Resident #1 had a continuous glucose monitoring device on his left arm. She said Resident #1 had a history of elevated glucose levels. The DON was observed as she reviewed Resident #1's electronic medical record and said he had a scheduled order of Lantus one time a day and Insulin sliding scale 3 times a day. The DON said Resident #1 had his blood sugar levels checked 5 times a day and insulin administered 4 times a day. She said Resident #1's NP would visit him at least 2 times a week and was well aware of his high blood sugar readings. The DON said, ever since he was discharged from the hospital in March, his blood sugar levels have run high. She said Resident #1's NP was still titrating his blood sugar medication, which she said meant his dose was being adjusted gradually to find the correct level. The DON said Resident #1's was being administered a low dose of the sliding scale insulin. The DON said it was the responsibility of the nursing staff and medication aides to follow a resident's order. She said LVN A should have followed Resident #1's Insulin Aspart order and should have contacted his NP when his blood sugar readings were over 300 as his order indicated. The DON said Resident #1 had not shown signs of distress when his blood sugar readings were over 300, was administered insulin 4 times a day, and his NP would review his blood sugar reading when he rounded. The DON said it was her responsibility to ensure nursing staff and medication aides followed a resident's medication order(s). She said every morning, she would review resident's orders and compare them to their medication admistration record to ensure accuracy. The DON said she had failed to recognize that, LVN A had not notified Resident #1's NP when his blood sugar readings were over 300. The DON said a possible negative outcome for Resident #1 would be his NP would not know if his insulin sliding scale needed to be increased but said that was not the case because Resident #1's NP was closely monitoring his blood sugar readings, had not had a change of condition due to his high blood sugar readings, nursing staff checked his blood sugar levels 5 times a day and was administered insulin 4 times a day. During an interview on 06.10.26 at 2:00 p.m., the NP said he had cared for Resident #1 for 2 years. He said he had prescribed Resident #1 a scheduled blood sugar medication and a sliding scale insulin medication. The NP said Resident #1 had his blood sugar levels checked 5 times a day and blood sugar medication administered 4 times a day. The NP said Resident #1 was on a low dose insulin medication. He referred to Resident #1 as a special kind of resident because his blood sugar readings would run high on a daily basis. He said his readings could run from 250 to over 300. The NP said Resident #1 was on a low dose regimen, and he was still undergoing titration to determine the dose that would be most appropriate and effective for him. The NP said Resident #1 was being closely monitored, and he would visit him at least 2 times a week. He said Resident #1 was doing fine. The NP said the facility's nursing staff would notify him if his blood sugar readings were over 400. The NP said at some point Resident #1's insulin sliding scale had a parameter if his blood sugar was below 60 or above 400 to notify him. The NP said in his medical opinion, there were no negative outcomes to Resident #1 not having his blood sugar readings reported to him when they were over 300. He said Resident #1 was being administered his blood sugar medications 4 times a day and had not had a change of condition related to his blood sugar readings and was being closely monitored by nursing staff and himself. Record review of the facility's Medication Administration policy, dated March 2019 and revised on January 2024 reflected: Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner. Responsible Disciplines:Licensed Nurses, C.M.A.s 2. Verify the medication label against sheet for accuracy of drug frequency, duration, strength, and route.a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels.

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 2 (Resident #1 and Resident #7) of 5 residents reviewed for medication errors. 1. The facility failed to ensure LVN A did not administer Resident #1's morning dose of IV Vancomycin (an antibiotic) before obtaining a Vancomycin trough (blood is collected and sent to the laboratory to determine if the Resident's Vancomycin level is therapeutic, too high, or too low) level on 04/08/26. 2. The facility failed to ensure MA D administered Resident #7's morning (8:00 am) dose of Amlodipine (blood pressure lowering medication) on 9 (03/03/26, 03/05/26, 03/13/26, 03/17/26, 03/18/26, 03/29/26, 03/30/26, 04/01/26 and 04/05/26) of 25 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.3. The facility failed to ensure MA D administered Resident #7's morning (8:00 am) dose of Carvedilol (blood pressure and pulse lowering medication) on 9 (03/03/26, 03/05/26, 03/13/26, 03/17/26, 03/18/26, 03/29/26, 03/30/26, 04/01/26 and 04/05/26) of 25 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.4. The facility failed to ensure MA D administered Resident #7's morning (8:00 am) dose of Losartan Potassium (blood pressure lowering medication) on 9 (03/03/26, 03/05/26, 03/13/26, 03/17/26, 03/18/26, 03/29/26, 03/30/26, 04/01/26 and 04/05/26) of 25 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.5. The facility failed to ensure MA J administered Resident #7's morning (8:00 am) dose of Amlodipine on 3 (03/10/26, 03/21/26 and 03/22/26) of 12 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.6. The facility failed to ensure MA J administered Resident #7's morning (8:00 am) dose of Carvedilol (blood pressure and pulse lowering medication) on 3 (03/10/26, 03/21/26 and 03/22/26) of 12 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.7. The facility failed to ensure MA J administered Resident #7's early evening (5:00 pm) dose of Carvedilol (blood pressure and pulse lowering medication) on 5 (03/04/26, 03/10/26, 03/11/26, 03/27/26 and 03/30/26) of 18 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.8. The facility failed to ensure MA J administered Resident #7's morning (8:00 am) dose of Losartan Potassium (blood pressure lowering medication) on 3 (03/10/26, 03/21/26 and 03/22/26) of 12 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.9. The facility failed to ensure MA J administered Resident #7's bedtime (9:00 pm) dose of Losartan Potassium (blood pressure lowering medication) on 5 (03/04/26, 03/10/26, 03/11/26, 03/24/26 and 03/30/26) of 15 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.10. The facility failed to ensure LVN K administered Resident #7's early evening (5:00 pm) dose of Carvedilol (blood pressure and pulse lowering medication) on 2 (03/01/26 and 03/14/26) of 4 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.11. The facility failed to ensure LVN K administered Resident #7's bedtime (9:00 pm) dose of Losartan Potassium (blood pressure lowering medication) on 2 (03/01/26 and 03/14/26) of 7 opportunities between 03/01/26 and 04/09/26 when her blood pressure was within the required parameters for administration per the physician's orders.12. The facility failed to ensure LVN L administered Resident #7's early evening (5:00 pm) dose of Carvedilol (blood pressure and pulse lowering medication) on 1 (03/16/26) of 4 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.13. The facility failed to ensure LVN L administered Resident #7's bedtime (9:00 pm) dose of Losartan Potassium (blood pressure lowering medication) on 1 (03/16/26) of 4 opportunities between 03/01/26 and 04/09/26 when her blood pressure and pulse were within the required parameters for administration per the physician's orders.These failures could place residents at an increased risk for complications, exacerbation of symptoms and disease process, and potential hospitalization.The findings included:Record review of Resident #1's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] with most recent admission [DATE]. Her relevant diagnoses included acute respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), tracheostomy (a hole made through the front of the neck into the windpipe when medical conditions make the use of a breathing machine, also known as a ventilator, necessary for an extended period of time), and ventilator associated pneumonia (a lung infection that develops in a person who is on a ventilator when bacteria gets into the lungs and causes an infection).Record review of Resident #1's quarterly MDS dated [DATE] reflected no BIMS score, as she was unable to speak. Her Cognitive Skills for Daily Decision Making score was 3 which indicated severe impairment and she never or rarely made decisions.Record review of Resident #1's care plan dated 04/16/25 reflected the focus: At risk for infection or recurrent/chronic infection related to compromised medical condition: respiratory failure. Chronic infection noted: ESBL (Extended-Spectrum Beta Lactamase- multidrug resistant germs that produce enzymes that break down many common antibiotics) site: Sputum. 4/8/26- Droplet isolation due to Acinetobacter Baumannii (bacteria that can cause infections in the blood, urinary tract, lungs (pneumonia) or wound which typically occur in healthcare settings) initiated 04/16/25 and revised on 04/08/26. Interventions included: enhanced barrier precautions as clinically indicated and administer medication and/or antibiotic as per MD orders, initiated 04/16/25. The care plan also reflected the focuses: tracheostomy related to dysphagia (difficulty swallowing) and ventilator dependent related to respiratory failure initiated 04/16/25. Interventions included: Administer medications and treatments as ordered/indicated, obtain labs and diagnostic studies as indicated and report abnormal findings to physician initiated on 04/17/25. Record review of Resident #1's order summary report reflected the following orders: VANCOMYCIN, TROUGH ** SCHEDULED 4/8/2026; Auto-Send 4/7/2026 8:00 PM** one time only related to Ventilator Associated Pneumonia ordered on 04/07/26 to start on 04/08/26. Vancomycin HCl Intravenous Solution Reconstituted 1 GM. Use 1 gram intravenously every 12 hours for Ventilator Associated Pneumonia for 14 Days ordered on 04/04/26 to start on 04/05/26.Record review of Resident #1's MAR (Medication Administration Record) on 04/08/26 at 4:05 pm reflected LVN A administered Resident #1's 8:00 am Vancomycin dose on 04/08/26.Record review of Resident #1's Results tab in her EMR (Electronic Medical Record) on 04/08/26 at 4:14 pm reflected she did not have a Vancomycin trough level pending or resulted. Record review of the facility's laboratory logbook on 04/08/26 at 4:40 pm reflected Resident #1's blood draw order for her Vancomycin trough level was not done by the laboratory technician on 04/08/26.In an interview on 04/08/26 at 4:32 pm, the ADON stated she was not sure exactly how long before the next dose a Vancomycin trough was to be drawn. She stated Resident #1 started receiving the Vancomycin on 04/05/26 at 8:00 am. The ADON stated the order for the Vancomycin trough was for 04/08/26 but she did not know the time. She stated the lab tech usually went to the facility to draw labs around 7:00 am and they knew to do labs because the EMR order was linked to the laboratory. She stated she did not know if the Vancomycin trough was drawn, she would have to go check the logbook. The ADON stated Vancomycin troughs were drawn to ensure the Vancomycin level was within the therapeutic range. If it was not within the range, the nurse would contact the provider to either hold or possibly adjust the dosage. She stated if the Vancomycin level was too high and the Vancomycin was given it could damage the kidneys and if it was too low, the resident was not getting the proper dose to treat the infection. The ADON checked the lab logbook, and it appeared the Vancomycin trough level was not collected. She called the lab and was told they were short on lab technicians, so they did not send anyone to the facility that morning (04/08/26). The ADON contacted the provider and ordered a STAT Vancomycin level to be drawn at 7:00 pm on 04/08/26. The ADON stated if the nurse noticed the lab was not drawn, they called the lab to find out what happened, then contacted the provider for orders or changes. She stated the nurses could not draw their own labs because they did not have the supplies to draw labs or the equipment to result them. She stated one of the night shift nurses printed out the pending labs and put them in the logbook. The ADON stated she was responsible for making sure the labs were done. She stated she was busy on 04/08/26 and simply forgot. She stated the lab did not automatically call the facility if they were not able to send a tech out to draw labs. The ADON stated the lab technician told her it would take about an hour to result a Vancomycin trough level. In an interview on 04/09/26 at 10:23 am the ADON stated Resident #1's Vancomycin trough got drawn around 7:00 pm on 04/08/26, but the provider cancelled the Vancomycin order before the lab had resulted, so the test was cancelled. She stated the Vancomycin was cancelled because the provider got the sputum culture results and changed the antibiotics. She stated Resident #1 received her 8:00 am Vancomycin dose on 04/08/26 even though the trough was not drawn. The ADON stated the nurse should not have administered the Vancomycin on 04/08/26 because the trough had not been drawn.In an interview on 04/09/26 at 3:10 pm, LVN A stated she knew if blood was supposed to be collected on a resident through pass down report and it showed up on the orders tab in the EMR. She stated if the lab work was drawn, it showed up under results. She stated she did not recall if Resident #1 had any labs pending on 04/08/26. She stated Resident #1 had labs drawn weekly and probably needed a Vancomycin trough drawn. She stated she spoke to NP I who told her the troughs were done after every 4th dose for Resident #1. LVN A stated Vancomycin troughs were done to see if the level was too high or too low. It was important to know if it was too high or too low for dosage adjustments. LVN A stated if the Vancomycin trough level was too high it could cause kidney damage. She stated the Vancomycin trough lab did not show up in the orders tab that she recalled on the morning of 04/08/26. She stated she did not remember when the last in-service was over following up on lab results. LVN A stated night shift printed out the lab manifest and put it in the logbook, then when the lab technician came in, they got the lab orders from the book and that was how they knew what labs to draw on what resident. LVN A stated she did not usually mess with that book unless she ordered a STAT lab, then she printed it out and put it in the book. In an interview on 04/09/26 at 4:04 pm, NP I stated she cancelled Resident #1's Vancomycin administration because it was not effective against her [NAME] (Ventilator Associated Pneumonia). She stated she normally checked vancomycin trough levels before the 4th dose of Vancomycin. She stated it was important to check Vancomycin levels to ensure the kidneys were not damaged and if the Vancomycin level was too high, the dose or timing were adjusted. NP I stated if the Vancomycin trough was not checked, it could lead to altered mental status and kidney damage if it was too high and if it was too low, it would not be effective and could lead to antibiotic resistance. She stated when she had a resident on any antibiotics or medications that required monitoring, she checked the resident's medical records to see the laboratory results. NP I stated the facility was supposed to contact her to let her know if the blood was not drawn for some reason. She stated she and the primary NP for Resident #1 were working together in another facility on 04/08/26 so she knew he was not notified the Vancomycin trough level was not drawn on 04/08/26.In an interview on 04/09/26 at 12:00 pm, the DON stated Vancomycin level blood work was important to track the Vancomycin levels that were in the resident's system. She stated the levels were needed to see if the medication needed to be titrated or discontinued. The DON stated, If the medication levels were not being tested, we would have no way to know what the level was. The DON stated the physician was notified to see what he wanted to do if the Vancomycin level was too low or too high. She stated if the Vancomycin level was too high, it could cause toxicity, but she did not know what could happen if it was too low. Record review of Resident #7's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her relevant diagnoses included hypertension (high blood pressure), cerebral infarction (stroke), aphasia following cerebral infarction (an impairment in the ability to read, write, and speak), dysphagia following cerebral infarction (difficulty swallowing), and other sequelae of cerebral infarction (a variety of medical, musculoskeletal, and psychosocial complications following a stroke).Record review of Resident #7's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #7's care plan dated 04/05/24 reflected a focus of heart disease with a risk for complications such as chest pain, shortness of breath, edema, and high blood pressure. The interventions included administer medications as ordered by the physician and monitor vital signs as indicated and report abnormal findings to physician as indicated, initiated on 05/16/25.Record review of Resident #7's order summary report on 04/09/26 reflected the following orders for anti-hypertensive (blood pressure lowering) and pulse lowering medications:Amlodipine Besylate Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for HTN (High Blood Pressure). Hold if SBP (systolic blood pressure- the top number in blood pressure) is less than 100 and notify Nurse/MD (Medical Doctor). Ordered on 12/31/25.Carvedilol Oral Tablet 12.5 MG. Give 1 tablet by mouth two times a day (8:00 am and 5:00 pm) for HTN. Hold if SBP less than 100, pulse less than 60 and notify Nurse/MD. Ordered on 12/31/25.Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day (8:00 am and 9:00 pm) for hypertension. Hold if SBP less than 100 Notify Nurse/MD. Ordered on 06/11/24.Record review of Resident #7's March 2026 and April 2026 MARs reflected the following:03/01/26, Morning, MA D documented BP 107/56, Pulse 64 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan.03/01/26, Evening and Bedtime, LVN K documented BP 126/56, Pulse 63 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/04/26, Evening and Bedtime, MA J documented BP 120/54, Pulse 60 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/05/26, Morning, MA D documented BP 107/56, Pulse 65and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/10/26, Morning, MA J documented BP 104/56, Pulse 70 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/10/26, Evening and Bedtime, MA J documented BP 126/56, Pulse 64 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/11/26, Evening and Bedtime, MA J documented BP 124/54, Pulse 66 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/13/26, Morning, MA D documented BP 103/50, Pulse 68 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan.03/14/26, Evening and Bedtime, LVN K documented BP 103/55, Pulse 65 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/16/26, Evening and Bedtime, LVN L documented BP 115/53, Pulse 60 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.03/17/26, Morning, MA D documented BP 123/50, Pulse 64 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/18/26, Morning, MA D documented BP 104/54, Pulse 60 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/21/26, Morning, MA J documented BP 108/56, Pulse 66 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/22/26, Morning, MA J documented BP 106/50, Pulse 64 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/24/26, Bedtime, MA J documented BP 124/54, Pulse 58 and 3= Held: BP outside parameters for Losartan Potassium.03/27/26, Evening, MA J documented BP 114/50, Pulse 68 and 3= Held: BP outside parameters for Carvedilol.03/29/26, Morning, MA D documented BP 120/56, Pulse 60 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/30/36, Morning, MA D documented BP 112/53, Pulse 60 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.03/30/26, Evening and Bedtime, MA J documented BP 130/54, Pulse 62 and 3= Held: BP outside parameters for Carvedilol and Losartan Potassium.04/01/26, Morning, MA D documented BP 107/50, Pulse 61 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.04/05/26, Morning, MA D documented BP 116/54, Pulse 61 and 3= Held: BP outside parameters for Amlodipine, Carvedilol and Losartan Potassium.In an interview on 04/09/26 at 8:25 am, MA D stated she did not administer the medications because Resident #7's blood pressure was outside of the parameters for administration. MA D stated Resident #7's diastolic blood pressure (the bottom number) was below 60, so she held the medication. When MA D checked Resident #7's orders and blister packs for the medication orders, she stated the hold parameters only included the systolic blood pressure (the top number) and the pulse. MA D stated on her computer, further down in the order, it sated to hold if systolic blood pressure was below 110 and diastolic blood pressure was below 60. MA D stated she told the nurse she held the medication and about the conflicting hold parameters. MA D stated if a blood pressure medication was not administered according to the physician's orders, it could cause the resident's blood pressure to go up which could cause a stroke. She stated in-services on medication administration were usually once a month and the last one was approximately 2 1/2 weeks ago and covered notification to the nurse for non-administration for refusal or vital signs outside of parameters as well as other medication administration topics. In an interview on 04/09/26 at 9:38 am, LVN E stated when MA D notified her that Resident #7's blood pressure medications were held, she checked the Losartan, Amlodipine, and Carvedilol orders and they all only said hold if systolic blood pressure was below 100. She added that Carvedilol also had a hold parameter of pulse below 60. She stated the MA notified her and she contacted the doctor to clarify the hold parameters. LVN E stated MA D should not have held the blood pressure medications, as the order stated to hold if systolic blood pressure was below 100 and did not have a hold parameter for the diastolic number. She stated if anti-hypertensive medications were held when they should have been given, it could cause the resident's blood pressure to go high and cause the resident to get a headache or a stroke. LVN E stated in-services on medication administration were every 1-3 months and she did not recall when the last one was.In an interview on 04/09/26 at 10:15 am, Resident #7 stated she did recall a few times in the past month when the nurse told her that her blood pressure was a little bit low and did not administer her blood pressure medications but did not recall having any symptoms of high blood pressure on those days. In an interview on 04/09/26 at 10:23 am, the ADON stated the old hold parameters were in the pharmacy comments area of the chart and were not part of the administration order. The ADON stated the pharmacy did not completely remove the previous hold parameters on Resident #7's anti-hypertensive medications when the physician updated the orders with new parameters, so it could appear there were 2 sets of hold parameters if the order screen was expanded to show the pharmacy information. She stated the pharmacy information shown was part of the original provider's order and should have been removed when the provider updated the order. She stated she did not know how long that information had been there. She stated MA D should not have held Resident #7's blood pressure medications because her vital signs were not outside of parameters to give them, per the physician's order. She stated LVN E called the doctor and administered the medications after she got clarification on the orders. The ADON stated if there were conflicting or confusing hold parameters for a medication, the nurse notified the pharmacy to remove the old parameters and updated the orders. The ADON stated if a blood pressure medication was held when it should have given, it could cause the blood pressure to go up which could lead to high blood pressure, hypertensive crisis, stroke, hospitalization, or even death. She stated in-services on medication administration were quarterly and as needed and the last one was within the last 2-3 weeks. She stated the DON did annual check offs with the nurses and MAs for medication administration.In an interview on 04/09/26 at 12:00 pm, the DON stated Resident #7's blood pressure medications were given after LVN E contacted the nurse practitioner. She stated if there were conflicting orders, the nurse should contact the provider to clarify the order. The DON stated if a blood pressure medication was held when it should have been given, it could cause the resident's blood pressure to be too high which could lead to stroke. The DON stated medication administration was observed by the pharmacist monthly and as needed and medication aides had medication administration check-offs done every year. The DON stated medication administration in-services were done every 3 months and as needed and the last in-service was last month. Record review of the facility's Medication Administration Policy dated March 2019 and revised January 2024 reflected in part: Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner.RESPONSIBLE DISCIPLINES:Licensed Nurses, C.M.A.s 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration,strength, and route.a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule.5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose.6. Administer medications as ordered by the physician.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #6), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #6's physician's ordered Midodrine was correct. This failure could place residents at risk for not receiving medication as ordered.The findings included:Record review of Resident #6's admission record, dated 04/09/26, a [AGE] year-old male with an admit date of 04/06/26 and an initial admission date of 01/27/26. His relevant diagnoses included end stage renal disease (permanent, irreversible kidney failure where kidneys can no longer function on their own), dependence on renal dialysis (a life sustaining chronic need for hemodialysis or peritoneal dialysis due to end-stage renal disease), and hypotension (low blood pressure).Record review of Resident #6's Medicare-5 day MDS assessment, dated 03/14/26, reflected he had a BIMS score of 15, which indicated his cognition was intact.Record review of Resident #6's dated 03/10/26, reflected a:Focus: [Resident #6] have ESRD (end stage renal disease) and require dialysis treatments. I am at risk for increase, SOB, chest pain, increased or decreased blood pressure, itchy skin, nausea/vomiting, loose stools, dehydration, and infected/malfunctioning access site. Dialysis on MWF 7:30 am, date initiated/revised 03/10/26. Interventions: in part included give medications as ordered by my physician, date initiated 03/10/26.Record review of Resident #6's physician's order summary dated 04/09/26, reflected: Midodrine HCI Oral tablet 5 MG (Midodrine HCI), give 1 tablet by mouth one time a day every Mon, Wed, Fri for hypotension on dialysis days-send to dialysis. Hold if SBP is less than 140 notify nurse/MD. Start date: 04/08/2026.Record review of Resident #6's April 2026 Medication Administration Record reflected, Midodrine HSCI Oral Tablet 5 MG was not administered on 04/08/26 and a code 3 was entered. Code 3 indicated medication was held: BP outside parameters.In a telephone interview on 04/09/26 at 11:18 a.m. NP G said Resident #6 was one of his residents. He said he had ordered Midodrine HCI oral tablet 5 mg to Resident #6 to help increase his blood pressure while in dialysis. He said the nursing facility was to send the medication to the dialysis center in case Resident #6's blood pressure dropped. This surveyor read Resident #6's active order for Midodrine HCI oral tablet 5 mg to NP G and he said the parameter to hold if systolic blood pressure less than 140 was not correct. NP G said the order should not have any parameters and regardless of his blood pressure the medication should have been sent with him to the dialysis clinic. NP G said a negative outcome to Resident #6 would be if the nursing facility followed the parameters on his Midodrine order, they would not send the medication with him to the dialysis clinic if his systolic blood pressure was outside the prescribed parameters, which could result if a further drop while being dialyzed.In an interview on 04/08/26 at 11:31 a.m., the DON said Resident #6 had been readmitted on [DATE] after being in the hospital. She said Resident #6 was a dialysis patient and his dialysis days were Mondays, Wednesdays, and Fridays. She said Resident #6 had an order of Midodrine and it was to be sent with the him to the dialysis clinic in case his blood pressure dropped. The DON said the dialysis clinic where Resident #6 went to did not have medications on hand to administer. She said per the dialysis clinic request and per Resident #6's order a Midodrine pill should be sent to the clinic in case Resident #6's blood pressure dropped. She said the facility maintained an ongoing communication with the dialysis clinic regarding Resident #6. She said before Resident #6 left the faciity on his scheduled dialysis days, a Midodrine pill would be placed in a plastic bag, labeled with his name, route, indication, and dose and attached to the dialysis communication sheet. The DON said the communication sheet was to be given to the EMS personnel and they in turn would hand deliver it the facility. She said at no time did Resident #6 handle the medication. She said if Resident #6 did not require his Midodrine medication, the dialysis clinic would discard it. The DON said the dialysis clinic would indicate on the dialysis communication sheet whether or not Resident #6 required his Midodrine medication on that day. The DON said Resident #6's Midodrine order with a start date of 04/08/26 was not correct, she said it should not have had any parameters. The DON said LVN F followed the order as it read of being held if Resident #6's SBP was below 140. She said the facility had not sent a Midodrine pill with Resident #6 when he went to dialysis today (04/08/26). The DON said there were no negative outcomes to Resident #6 having an incorrect Midodrine order.In a telephone interview on 04/08/26 at 3:25 p.m., Dialysis RN H said Resident #6 was one of their patients. He said Resident #6 would receive dialysis on Mondays, Wednesdays, and Fridays. He said the nursing facility would send a Midodrine pill labeled with Resident #6's name, dose, indication, route, and frequency in a plastic bag stapled to his dialysis communication sheet. He said if Resident #6's blood pressure dropped; he would be administered Midodrine. Dialysis RN H said at no time would Resident #6 handle the Midodrine pill. He said EMS personnel would hand deliver the medication to a facility's nurse and they would keep it in case Resident #6 required it. In an interview on 04/08/26 at 3:45 p.m., Resident #6 said he had just returned from dialysis and did not want to be interviewed. He said he was tired and just wanted to go back to sleep.Record review of Resident #6's Dialysis Communication form post treatment dated 04/08/26 reflected: Patient with asymptomatic hypotension during treatment, please send Midodrine with pt.In a telephone interview on 04/08/26 at 5:20 p.m., LVN F said she had worked the overnight shift (10:00 p.m. to 6:00 a.m.) on 04/07/26. She said she had been assigned to Resident #6's hall and she had cared for him during her shift. She said Resident #6 was a dialysis patient and was scheduled dialysis on Mondays, Wednesdays, and Fridays. She said she had checked his blood pressure on 04/08/26 at 4:00 a.m. and it was outside the ordered parameter. She said she had not administered Resident #6 Midodrine and had not prepared it to be sent to the dialysis clinic. She said she used code 3 which indicated it was held due to blood pressure outside parameter. This surveyor read Resident #6's Midodrine order to LVN and she said the parameters were not correct. She said the parameter should have read if SBP was greater not less than 140. She said she had not notified her DON nor had called Resident #6's NP to get clarification. She said the negative outcome for Resident #6 would be that his blood pressure could drop while in dialysis and without the Midodrine medication, dialysis would need to stop. In an interview on 04/09/26 at 3:00 p.m., Resident #6 said he was scheduled to go to dialysis on Mondays, Wednesdays, and Fridays in the morning. He said while in dialysis there had been times his blood pressure dropped. Resident #6 said the nursing facility would send a blood pressure medication in an envelope to the dialysis clinic in case his blood pressure would drop. He said the envelope was given to the EMS personnel and they would hand it over to a nurse at the dialysis clinic. Resident #6 said he had never handled the medication himself. He said if his blood pressure would drop, a dialysis clinic nurse would ask him if he wanted to take the pill. Resident #6 said if he did not require the pill the dialysis clinic stayed with it. Resident #6 said he had not had any complication while being dialyzed on 04/08/26 and was able to complete his treatment. Record review of the facility's Medication Administration policy revised on January 2024 reflected:Compliance guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner.2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels.If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule.Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 (Resident #43) of 3 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure Resident #43's personal refrigerator was maintained. Resident #43's personal refrigerator had 3 small individual cups of pudding that were expired as well as a half-eaten carrot cupcake that did not have an open or expiration date.This failure could place residents who store food items in resident refrigerators, at risk of cross-contamination and food-borne illnesses if consumed.Findings were:Record review of Resident #43's admission Record dated 04/09/26 revealed a [AGE] year-old male with diagnoses of Alzheimer's Disease Unspecified (brain disorder causing decline in memory, thinking, and daily functioning) , Essential (Primary) Hypertension (high blood pressure), Gastro-Esophageal Reflux Disease without Esophagitis (heartburn), Hyperlipidemia (high levels of fats such as cholesterol), and Cognitive communication deficit (difficulty communicating, such as listening, speaking).Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS of 5 which indicated severe cognitive impairment. In an observation on 04/07/26 at 9:01 am of Resident #43's personal refrigerator revealed 3 small sealed individual cups of pudding with an expired date of 12/10/25 as well as a half-eaten carrot cupcake that did not have an open or expiration date.In an observation on 04/07/26 at 9:02 am the Resident Refrigerator and Freezer Temperature Log that had been pinned on the wall next Resident #43's refrigerator revealed the refrigerator had last been checked on 04/07/26 in the AM. In an interview on 04/07/26 at 9:02 am Resident #43 stated he did not know when the food items were brought.In an interview on 04/07/26 at 11:52 am Housekeeper A stated she had been in charge of checking resident's personal refrigerators when she cleaned their rooms. She said she had checked Resident #43's refrigerator earlier in the morning and had made sure the temperature was correct. She said she had not checked the dates on the food that had been stored in there. Housekeeper A said she had not been told to check for expirations dates on the food items. She said a resident could get sick if they ate food that was expired.In an interview on 04/07/26 at 2:46 pm the Housekeeping Supervisor said housekeeping staff was responsible for checking residents personal refrigerators. She said they were told to check the temperatures, expiration dates and also to label the open date. The Housekeeping Supervisor said a resident could get ill, not feel well if they ate food that was expired.In an interview on 04/10/26 at 4:00 pm the ADM said housekeeping checked the residents' personal refrigerators. He said they were checked every day. He said expiration dates should be checked. The ADM said depending on the date of expiration of the food, it may cause stomach discomfort.Record review of the facility's policy Outside Foods revised date September 2025 revealed; Compliance Guidelines:2.The outside food should be labeled with the Resident's name and date.3. Proper food handling should be used once outside food is brought into the facility.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for two (Resident #14 and Resident #82) of 6 residents reviewed for infection control practices. 1. The facility failed to ensure MA D performed hand hygiene for at least 20 seconds before she administered Resident #14's medication.2. The facility failed to ensure MA D performed hand hygiene for at least 20 seconds before and after she administered Resident #82's medication.This failure could place residents at risk for healthcare associated cross-contamination and infections.Findings included:Record review of Resident #14's admission record reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included unspecified dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), paroxysmal atrial fibrillation (irregular, often fast heartbeat that comes and goes on its own), type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), hyperlipidemia (high cholesterol), essential (primary) hypertension (high blood pressure), and cognitive communication deficit (difficulty with communication).Record review of Resident #14's quarterly MDS dated [DATE] reflected a BIMS score of 3 which indicated he had severe cognitive impairment.Record review of Resident #82's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of right patella (broken kneecap), 03/30/26. Her diagnoses included fracture of right patella (broken kneecap), type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), hyperlipidemia (high cholesterol), essential (primary) hypertension (high blood pressure), and long term (current) use of anticoagulants (blood thinning medication).Record review of Resident #82's admission MDS dated [DATE] reflected a BIMS score of 15 which indicated she was cognitively intact. Observation on 04/09/26 at 8:41 am reflected MA D scrubbed her hands for 8 seconds before she administered medication to Resident #14. Observation on 04/09/26 at 9:14 am reflected MA D scrubbed her hands for 8 seconds before she administered medication to Resident #82.Observation on 04/09/26 at 9:19 am reflected MA D scrubbed her hands for 11 seconds after she administered medication to Resident #82.In an interview on 04/09/26 at 9:30 am MA D stated hands were washed for 30-35 seconds and it was for the scrub time, not the total time. She stated she usually sang the happy birthday song to herself, but she was not counting just scrub time when she was being timed, she was counting total time. MA D stated if hands were not washed properly, it could lead to spread of infection to other residents. She stated they were in-serviced on hand washing everyday. She stated in-services on infection control were once a month, and the last one was within the last 2 weeks. In an interview on 04/09/26 at 10:23 am the ADON stated in-services on infection control were done quarterly and as needed. She stated hand washing scrub time was supposed to be at least 20 seconds and if hand washing was not done properly it could lead to spread of germs and cause other residents to get sick. In an interview on 04/09/26 at 12:00 pm, the DON stated infection control was in-serviced all the time. She stated hand washing was observed on random staff every month. The DON stated if hands were not washed correctly, it could cause the spread of germs which could lead to illness for other residents. Record review of the facility's Infection Prevention and Control Policy dated 03/13/19 and revised April 2024 reflected in part:Compliance Guidelines:The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance program.Staff Responsibilities:Includes all staff to include direct and indirect care functions, contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the community, and students in the community's nurse aid training programs or from an affiliated academic institution.1. Coordination/ Oversite/ Educatione. Staff will receive training on the community's infection prevention and control program to include but not limited to preventative measures. 2. Policies and Proceduresa. Policies and procedures are utilized as the standards of the infection prevention and control program.9. Prevention of Infection3. Educating staff and ensuring that they adhere to proper techniques and procedures.6. Educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/ her role responsibilities and situation.14. DefinitionsHand washing refers to washing hands with soap and water.Record review of the facility's Infection Prevention and Control Policy did not reflect specific hand washing procedures.www. cdc.gov guidelines reflected: The CDC provides a clear, five-step process for effective handwashing with soap and water. Here are the steps to follow:1. Wet your hands with clean, running water (warm or cold).2. Apply soap and lather your hands by rubbing them together.3. Scrub your hands for at least 20 seconds, ensuring all areas are covered.4. Rinse your hands well under clean, running water.5. Dry your hands using a clean towel or an air dryer.

Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not five percent or greater. The medication error rate was 8.11% based on 3 errors out of 37 opportunities for 1 (Resident #7) of 5 residents observed for medication administration.The facility failed to ensure MA D administered Resident #7's 3 anti-hypertensive medications (Amlodipine Besylate, Carvedilol, and Losartan Potassium) when her blood pressure was within parameters for administration per the physician's orders.This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.The findings included:Record review of Resident #7's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her relevant diagnoses included hypertension (high blood pressure), cerebral infarction (stroke), aphasia following cerebral infarction (an impairment in the ability to read, write, and speak), dysphagia following cerebral infarction (difficulty swallowing), and other sequelae of cerebral infarction (a variety of medical, musculoskeletal, and psychosocial complications following a stroke).Record review of Resident #7's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #7's care plan dated 04/05/24 reflected a focus of heart disease with a risk for complications such as chest pain, shortness of breath, edema (fluid retention causing swelling), and high blood pressure. The interventions included to administer medications as ordered by the physician and monitor vital signs as indicated and report abnormal findings to physician as indicated, initiated on 05/16/25.Record review of Resident #7's order summary report on 04/09/26 reflected the following orders for anti-hypertensive (lowering blood pressure) medications:Amlodipine Besylate Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for HTN (high blood pressure). Hold if SBP (systolic blood pressure- the top number in blood pressure) is less than 100 and notify Nurse/MD (Medical doctor). Ordered on 12/31/25.Carvedilol Oral Tablet 12.5 MG. Give 1 tablet by mouth two times a day for HTN. Hold if SBP less than 100, pulse less than 60 and notify Nurse/MD. Ordered on 12/31/25.Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day for hypertension Hold if SBP less than 100 and Notify Nurse/MD. Ordered on 06/11/24.During an observation on 04/09/26 at 8:11 am, Resident #7's blood pressure was 122/53 and her pulse was 64. MA D did not administer Resident #7's Amlodipine Besylate, Carvedilol, or Losartan Potassium as ordered by the physician.In an interview on 04/09/26 at 8:25 am, MA D stated she did not administer the medications because Resident #7's blood pressure was outside of the parameters for administration. MA D stated Resident #7's diastolic blood pressure (the bottom number) was below 60, so she held the medication. When MA D checked Resident #7's orders and blister packs for the medication orders, she stated the hold parameters only included the systolic blood pressure (the top number) and the pulse. MA D stated on her computer, further down in the order, it sated to hold if the systolic blood pressure was below 110 and diastolic blood pressure was below 60. MA D stated she told the nurse she held the medication and about the conflicting hold parameters. MA D stated if a blood pressure medication was not administered according to the physician's orders, it could cause the resident's blood pressure to go up which could cause a stroke. She stated in-services on medication administration were usually once a month and the last one was approximately 2 1/2 weeks ago and covered notification to the nurse for non-administration for refusal or vital signs outside of parameters as well as other medication administration topics. In an interview on 04/09/26 at 9:38 am, LVN E stated when MA D notified her that Resident #7's blood pressure medications were held, she checked the Losartan, Amlodipine, and Carvedilol orders and they all only said hold if systolic blood pressure was below 100. She added that Carvedilol also had a hold parameter of pulse below 60. She stated the MA notified her and she contacted the doctor to clarify the hold parameters. LVN E stated MA D should not have held the blood pressure medications, as the order stated to hold if systolic blood pressure was below 100 and did not have a hold parameter for the diastolic number. She stated if anti-hypertensive medications were held when they should have been given, it could cause the resident's blood pressure to go high and cause the resident to get a headache or a stroke. LVN E stated in-services on medication administration were every 1-3 months and she did not recall when the last one was. In an interview on 04/09/26 at 10:15 am, Resident #7 stated she did recall a few times in the past month when the nurse told her that her blood pressure was a little bit low and did not administer her blood pressure medications but did not recall having any symptoms of high blood pressure on those days.In an interview on 04/09/26 at 10:23 am, the ADON stated the old hold parameters were in the pharmacy comments area and were not part of the administration order. The ADON stated the pharmacy did not completely remove the previous hold parameters on Resident #7's anti-hypertensive medications when the physician updated the orders with new parameters, so it could appear there were 2 sets of hold parameters if the order screen was expanded to show the pharmacy information. She stated MA D should not have held Resident #7's blood pressure medications because her vital signs were not outside of parameters to give them, per the physician's order. She stated LVN E called the doctor and administered the medications after she got clarification on the orders. The ADON stated if there were conflicting or confusing hold parameters for a medication, the nurse notified the pharmacy to remove the old parameters and updated the orders. The ADON stated if a blood pressure medication was held when it should have given, it could cause the blood pressure to go up which could lead to high blood pressure, hypertensive crisis, stroke, hospitalization, or even death. She stated in-services on medication administration were quarterly and as needed and the last one was within the last 2-3 weeks. She stated the DON did annual check offs with the nurses and MAs for medication administration.In an interview on 04/09/26 at 12:00 pm, the DON stated Resident #7's blood pressure medications were given after LVN E contacted the nurse practitioner. She stated if there were conflicting orders, the nurse should contact the provider to clarify the order. The DON stated if a blood pressure medication was held when it should have been given, it could cause the resident's blood pressure to be too high which could lead to stroke. The DON stated medication administration was observed by the pharmacist monthly and as needed and medication aides had medication administration check-offs done every year. The DON stated medication administration in-services were done every 3 months and as needed and the last in-service was last month. Record review of the facility's Medication Administration Policy dated March 2019 and revised January 2024 reflected in part: Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner.RESPONSIBLE DISCIPLINES:Licensed Nurses, C.M.A.s 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration,strength, and route.a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels.b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule.5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose.6. Administer medications as ordered by the physician.

Based on interviews and record reviews, the facility failed to ensure each resident had the right to access personal and medical records pertaining to himself or herself within 24 hours and allow the resident to obtain a copy of the records or any portions thereof upon request for 1of 4 residents (Resident #1) reviewed for resident rights. The facility failed to provide a copy of Resident #1's medical records to Resident #1's RP after requesting the records on 10/15/25. This failure could place residents at risk of not having access to records when requested. The findings included: Record review of Resident #1's face sheet, dated 01/13/26, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 08/29/25 with diagnoses that included: unspecified dementia (decline in thinking skills and causing issues with memory, planning, focus and mood ), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus (high blood sugar) without complications and acute pain due to trauma. Record review of Resident #1's discharge MDS assessment, dated 08/29/25, revealed Resident #1 had a BIMS score of 09, indicating moderate cognitive impairment. Record review of Resident #1's care plan with an initiation date of 08/11/25 reflected a focus of I have impaired cognitive function/dementia or impaired thought process r/t (Dementia). Record review of authorization to disclose protected health information form completed and signed by Resident #1's RP reflected it was signed on 10/15/25. During an interview with Medical Records LVN on 01/08/26 at 2:51 pm, she stated the RP for Resident #1 requested records on 10/15/25. The Medical Records LVN stated she sent the request to her supervisor, the Health Information Management Director on 10/15/25. The Medical Records LVN stated the Health Information Management Director let her know that she would communicate with the family of Resident #1 because it takes long to get those documents since they were requesting all of the records. During a telephone interview with the Health Information Management Director on 01/08/26 at 3:20 pm, she stated on 11/06/25 she sent the Medical Records LVN an email that she had finished getting the records requested by Resident #1's family and was going to be sending them out. The Health Information Management Director stated she would send records via secure email and stated usually the person receiving them would have to confirm when they were received and she would get a confirmation receipt via email. The Health Information Management Director reviewed her email and did not have any records of her sending any email with Resident #1's requested records and stated she did not have any confirmation receipts received. The Health Information Management Director stated she thought she had sent out the records that were requested for Resident #1 but stated she had a number of record requests coming in and that time and was unable to find any records of the requested records for Resident #1 being sent in her email. During an interview with the Medical Records LVN on 01/13/26 at 2:24 pm, stated the Health Information Management Director was responsible for sending out the requested records to Resident#1's RP and stated when records such as a medication list or profile were requested she would get it cleared from the Health Information Management Director and then she would provide the medical records to the resident or RP. The Medical Records LVN stated but due to Resident #1's family requesting the entire chart the Health Information Management Director had spoken to her when they were almost ready and they had agreed that the Health Information Management Director would email the requested records to Resident #1's RP. The Medical Record LVN was not sure how long she had to send out requested records and stated she would need to review the facility policy but stated they usually sent them timely. The Medical Records LVN stated she felt she followed the facility policy in this situation and stated she received an email from the Health Information Management Director on 01/11/26 that the requested records had been sent to the family for Resident #1. The Medical Records LVN stated she did not know why the records were not sent out on time. The Medical Records LVN stated she received informal training when she started her position as medical records but stated it was something that was verbal. The Medical Records LVN stated not sending out records in the allotted time frame could have negative out come because information was requested and they did not get it on time. On 01/13/26 at 3:25 pm, the Health Information Management Director was attempted to be reached via phone for follow up questions however the call was unsuccessful and a voicemail was left with no response. Record review of signed position agreement for Medical Records Manager by the Medical Records LVN on 08/16/24 stated, 3. Retrieve/Request medical records promptly upon request by authorized individuals Record review of facility policy titled, Medical Records with a revised date of January 2023 stated, 2. The resident has the right to access all records pertaining to his or her care and stay in the nursing home, including current medical records. The community allows access to all of the residents records upon receipt of an oral request followed with a signed, written request by an authorized representative within 24 hours (excluding weekends and holidays). An oral request is sufficient to produce the current record for review only. Under the section titled, Purchase of medical record it contained verbiage stating, After receipt of records for inspection, the resident may purchase copies at a cost not to exceed the state copying fees for photocopies. Requests will be granted in two working days.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's behavior of removal of nasal cannula and non-compliance with oxygen was care planned. This deficient practice could place residents at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #2's face sheet, dated 01/10/26, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and discharged on 01/07/26 with diagnoses that included: unspecified dementia (decline in thinking skills and causing issues with memory, planning, focus and mood ), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus (high blood sugar) without complications and unspecified combined systolic (congestive) and diastolic (congestive) heart failure (the heart has difficulty with both emptying and filling properly), chronic pulmonary edema (build up of fluid in the lungs) and paroxysmal atrial fibrillation (fast, irregular heartbeat that last a few hours or days) Record review of the 5 day MDS assessment, dated 12/14/25, revealed Resident #2 had a BIMS score of 14, indicating she was cognitively intact. Record review of physician orders reflected Resident #2 had an order for continuous oxygen 2 liters per nasal cannula with an order date of 12/09/25. Record review of Resident #2's care plan with an initiation date of 12/10/25 reflected a focus of Oxygen Therapy r/t CHF with intervention to Administer oxygen per MD orders with an initiation date of 12/30/25. There was no verbiage related to Resident #2 removing her oxygen, or non-compliance with oxygen therapy. During an interview with LVN A on 01/13/26 at 1:55 pm, she stated Resident #2 would occasionally remove her oxygen and stated the nurses and respiratory therapist would have to place the oxygen back on Resident #2 when they would be notified by the aides during their rounds or when they would round on Resident #2. During an interview with CNA B on 01/12/26 at 5:41 pm, she stated Resident #2 would remove her oxygen and stated staff would put it back on her all the time and Resident #2 would remove it. During an interview with LVN C on 01/12/26 at 4:50 pm, she stated Resident #2 would remove her oxygen constantly and she would always have to fix it for her. During an interview with RT D on 01/13/26 at 1:48 pm, she stated Resident #2 was always taking off her oxygen and stated they were constantly checking on her to make sure she had it on. RT D stated staff was aware of her removing her oxygen because she would get report to make sure to check Resident #2 because she had a tendency to remove the cannula. During an interview and record review with MDS nurse E on 01/13/26 at 3:45 pm, he stated Resident #2 had orders in place for continuous oxygen and stated staff said Resident #2 would remove her oxygen sometimes but not all the time and they would have to remind her that she needed it. MDS nurse E stated staff was aware of this behavior because they were the ones who reported it. MDS nurse E stated Resident #2 had no negative impact due to removing her oxygen. MDS nurse E stated Resident #2's behavior of removing her oxygen should have been on her care plan. MDS nurse E reviewed Resident #2's care plan and stated her behavior of removing it was not on her care plan. MDS nurse E stated it was not on there because the behavior was not reported since her readmission from the hospital and stated he was responsible for putting behaviors on the care plan and for reviewing the care plans to ensure behaviors were included and stated he updated the care plan based on any reports of behaviors or on review dates and stated he was still reviewing the care plan. MDS nurse E stated it was important to have behaviors such as removing oxygen on the care plan because if the patient had an order for oxygen its like a medication and they need to be complaint because for Resident #2 she had a diagnoses of congestive heart failure and needed the oxygen because if she was non complaint and her oxygen saturation dropped it could cause hypoxia or respiratory failure. MDS nurse E stated the facility policy stated behaviors should be documented on the care plan and stated he followed the facility policy in this situation. During an interview with the DON on 01/13/26 at 4:38 p.m., she stated Resident #2 had continuous orders for oxygen. The DON stated when Resident #2 was first admitted to the facility she would constantly remove her oxygen and stated since her most recent readmission in December 2025 she was not aware if she was still removing it and stated there was no recent documentation of her removing it either and clarified if Resident #2 was still non complaint with her oxygen then she was not aware. The DON stated staff was aware that Resident #2 would remove her oxygen because staff had to monitor her. The DON stated Resident #2 had no negative impact due to removing her oxygen and stated her oxygen saturation was always good. The DON stated Resident #2's behavior of removing her oxygen should have been on her care plan. The DON stated it was not on her most recent care plan because they had no reports of her being non complaint after her last hospital visit in December of 2025. The DON stated anyone could update the care plan but stated for the most part it was MDS nurse E. The DON stated it was important to have those behaviors on the care plan so that staff are aware and because it was a part of their plan of care to see what behaviors the residents had. The DON stated MDS nurse E reviewed the care plan to ensure behaviors were included and stated he did them quarterly and if there were any changes then he could input things at any time. The DON stated she did not think the facility policy stated anything regarding behaviors. The DON stated MDS nurse E had been trained by his consultants over the care plan and what to put on the care plan. The DON stated there was no negative impact to resident due to not including her behavior on the care plan because she was complaint with her oxygen. Record review of facility training dated 07/18/24 included topics of comprehensive care plans and acute care plans and reflected MDS nurse E had received the training. Record review of facility policy titled, Oxygen Administration with a revised date of January 2023 and implementation date of 03/14/19 and policy titled, Care Plans did not have any verbiage related to documentation of behaviors on residents care plan.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 residents (Resident #1) reviewed for medication storage. The facility did not ensure a medication named Normal Saline flush was not stored at the bedside for Resident #1 on 12/29/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of Resident #1 face sheet dated 12/31/2025 revealed an [AGE] year-old female admitted to facility on 12/11/2025 with diagnosis of Diabetes Mellitus type 1 (a chronic autoimmune disease where the immune system mistakenly destroys the insulin-producing beta cells in the pancreas, leading to little or no insulin production, causing high blood sugar), Muscle wasting and atrophy, dehydration (your body doesn't have enough water and fluids to function properly). Record review of Resident #1's MDS assessment dated [DATE] reflected he scored a 5 on his BIMS which reflected severely cognitively impaired. Record Review of Resident #1 comprehensive care plan dated 12/26/2025 revealed Resident #1 is at risk for complications associated with intravenous therapy related to peripheral line, with interventions frequently monitor/check IV access site upon each care encounter, careful when providing care & look for s/s of infection or infiltration (abnormalities) such as redness, swelling, puffiness, pain, discomfort, tenderness, drainage, warm to touch at or near the site. If any abnormalities are noted, then promptly notify Nurse /MD/NP.During an observation and interview on 12/29/2025 at 9:30 am Resident # 1 was observed with a normal saline flush on his television stand. She stated the nurse left the normal saline flush on top of the television stand. During an interview on 12/29/2025 at 9:35am with LVN A said no resident should have medications or the normal saline flush at their bedside. She said a resident could take the normal saline, other residents or visitors. She said residents could have an allergic reaction or the normal saline flush could get contaminated. During an interview 12/31/2025 at 2:00 pm with DON said no resident should have medication of any kind at their bedside. She said another resident could go in the room and take the medication. She said Resident #1 could get an adverse reaction. Record Review of facility policy titled Medication Cart Use and Storage revealed: Security: the medication cart and its storage should be kept closed, secured and/or in the line of sight when not in use.

Based on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 1 of 3 residents reviewed for intravenous fluids. (Resident #1) The facility failed on 12/29/2025 to ensure the dressing on Resident #1's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed. This failure could place residents at risk of not receiving the appropriate IV care and services. Findings included: Record review of Resident #1 face sheet dated 12/31/2025 revealed an [AGE] year-old female admitted to facility on 12/11/2025 with diagnosis of Diabetes Mellitus type 1 (a chronic autoimmune disease where the immune system mistakenly destroys the insulin-producing beta cells in the pancreas, leading to little or no insulin production, causing high blood sugar), Muscle wasting and atrophy, dehydration (your body doesn't have enough water and fluids to function properly). Record Review of Resident #1 comprehensive care plan dated 12/26/2025 revealed Resident #1 is at risk for complications associated with intravenous therapy related to peripheral line, with interventions frequently monitor/check IV access site upon each care encounter, careful when providing care & look for s/s of infection or infiltration (abnormalities) such as redness, swelling, puffiness, pain, discomfort, tenderness, drainage, warm to touch at or near the site. If any abnormalities are noted, then promptly notify Nurse /MD/NP. Record review of Resident #1's MDS assessment dated [DATE] reflected he scored a 5 on his BIMS which reflected severely cognitively impaired. During an observation on 12/29/2025 at 9:30 am Resident # 1 had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on her right hand. There were no signs or symptoms of infection or infiltration noted at the IV site. During an interview on 12/29/25 at 9:25 a.m. LVN A stated she was the nurse for Resident #1. She stated that the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN A stated that it was important to label the IV site to know when the IV was placed or the last time it was changed. She stated that if the IV was changed within the ordered time, then it could cause an infection. She stated that the last time he had checked the resident's IV site was this morning, at the beginning of his shift. LVN A stated that the IV site should be checked at every shift. The site was to be checked for any signs of infection, the date and signature on the dressing, and check that the saline lock cap was in place. She stated he could not recall when the last training was he had received on IV administration. LVN A stated the resident had a peripheral IV lock on her right hand covered with a transparent dressing that was not labeled or dated. In an interview on 12/31/25 at 2:00 p.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated that the nurse that had inserted the IV should have dated and initialed the dressing that was over the IV site. The DON searched through orders on their computer system to verify who had placed the IV, however, she was able to find the progress note indicating placement. The DON stated that labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated that the negative outcome of not labeling the dressing was that it could go over the recommended standard time of every 72 hours and could cause infection. She stated that IV administration class was done annually and as needed. Record review of facility policy named IV Policies and Procedures Manual revealed: Procedure: 12. With sterile tape, secure the catheter and apply dressings. Label appropriately.

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #1) of 3 residents reviewed for Advance Directives. The facility failed to ensure Resident #1's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #1 face sheet dated [DATE] revealed an [AGE] year-old female admitted to facility on [DATE] with diagnosis of Diabetes Mellitus type 1 (a chronic autoimmune disease where the immune system mistakenly destroys the insulin-producing beta cells in the pancreas, leading to little or no insulin production, causing high blood sugar), Muscle wasting and atrophy, dehydration (your body doesn't have enough water and fluids to function properly). Resident #1's electronic face sheet reflected Code Status: DNR. Record Review of Resident #1 comprehensive care plan dated [DATE] revealed Resident #1 advanced directives/care choices/ code status with interventions: code status: DNR. Record review of Resident #1's MDS assessment dated [DATE] reflected he scored a 5 on his BIMS which reflected severely cognitively impaired. Record review of Resident #1's physician order dated [DATE] reflected ***Code Status: ***DNR*** Record review of Resident #1's OOH-DNR form undated reflected the form was not signed by the attending physician below section E, Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician did not sign section F, All persons who have signed above must sign below, acknowledging that this document has been properly completed. During an interview on [DATE] at 9:43am ADON stated that the DNR form was discussed upon admission. She stated residents who were DNR should have a completed and signed by all parties, the OOH DNR. She stated all parties were residents or family, witnesses, and the doctor. ADON stated DNR form was signed by the family and the order was placed in the Resident #1's electronic record. She stated that the DNR status of a resident was located on the electronic system for resident's records. ADON stated if it showed DNR on the electronic system for resident's records that meant the OOH DNR form had been verified and completed. During an interview on [DATE] at 11:50 a.m., Social Services stated that he was the one responsible for completing the OOH DNR form. He stated that upon admission, he informed the resident and/or family of their rights regarding the DNR status. If it was confirmed for the resident to be DNR, he provided them with the form, and obtained their signatures, and the doctor ' s signature. He stated that the OOH DNR form should be signed by the doctor as soon as possible. He stated that it was important for the OOH DNR form to be signed by the doctor because it makes the document official, a legal document that all parties signs. The Social Services stated the DNR was not complete until the doctor signed it. During an interview [DATE] at 2:00 pm with DON stated that the social worker was responsible for completing the OOH DNR form. She stated the facility explains the document and if they say yes that they want to be DNR, the facility would obtain the resident/RP and witnesses signatures. DON said that she got a verbal order from the MD and that was why the code status was changed to DNR. DON said that there was not a negative outcome because she had the verbal order. Record review of the facility's Advanced Directives policy date reviewed/revised [DATE], revealed the Advance directive implementation: the IDT should honor the care decision expressed and initiate the advance directive by initiating the out of hospital Do Not Resuscitate (OOH DNR) form and should obtain the medical provider/physician's signature as per the OOH DNR form instructions.

Based on observation, record review, and interview, the facility failed to ensure a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections for one of two (Resident#2) residents reviewed for catheter care. The facility failed to ensure CNA A used the proper wiping technique when providing perineal/in continent care to Resident #2. CNA A reused wipes when cleaning the urethral opening of Resident #2's penis and provided incontinence care with Resident #2 standing. This deficient practice could place residents with catheters at risk of infection and decline in health. The findings included: Record review of Resident #2's face sheet, dated 04/11/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: hematuria (blood in the urine), benign prostatic hyperplasia (nonmalignant enlargement of prostate gland) without lower urinary tract symptoms, retention of urine ( inability to empty all the urine from the bladder), and urinary tract infection (infection that affects part of the urinary tract). Record review of Resident #2's quarterly MDS assessment, dated 01/26/25, revealed Resident #2 had a BIMS score of 00, indicating his cognition was severely impaired. Resident #2's section H - bladder and bowel reflected Resident #2 had an indwelling catheter. Record review of Resident #2's care plan with an initiated date of 08/14/23 reflected a focus of, I require a foley catheter (F20 [French tubing size] 30cc [inflation amount] balloon) DX [diagnosis] obstructive uropathy (blockage that prevents urine from flowing normally through the urinary system). Interventions included, Catheter Care every shift and as indicated. Record review of Resident #2's active physician's orders on 04/11/25 revealed an order for Foley catheter care with perineal wipes and/or soap and water Q SHIFT and PRN with a frequency of every shift and scheduled every day with a start date of 12/21/24 and end date of indefinite. During an interview and observation RN Surveyor completed an observation of perineal care/incontinent care completed by CNA A and CNA B on Resident #2 on 04/11/25 at 10:05am. CNA A was observed placing Resident #2's wheelchair near a grab bar in the restroom. Resident #2 grabbed the bar with both hands and was assisted to standing by CNAs A and B. During observation of care RN surveyor observed CNA A wipe the top of Resident #2's penis 3 times reusing the same wipe each time. RN Surveyor noted Resident #2 was tired of standing, holding on to the grab bar and was asked if he was okay and if anything was bothering or hurting him. Resident #2 stated in Spanish, Si me molesta [NAME] lo aguanto, which when translated to English means, yes, it bothers me but I put up with it. During this time RN Surveyor observed Resident #2's catheter tubing appeared to hang due to gravity. CNA A stated she had always provided incontinence care with Resident #2 standing. CNA A was observed returning to Resident #2's head of penis and wiped 2 more times reusing the same wipe each time. During an interview with CNA A on 04/11/25 at 12:15pm she stated she had last been trained or in-serviced over incontinent care for a male resident with a Foley catheter in November or December of 2024. CNA A stated CNA C provided the training for catheter care. CNA A stated she had been trained to wipe once and throw the wipe away after. CNA A stated she did not recall reusing any wipes when providing incontinent care to Resident #2 and stated she should not have done that. CNA A stated reusing a wipe could contaminate the area she was providing care to and could cause the resident to get an infection. CNA A stated it was important to provide the correct care because it could cause infection. CNA A stated they normally stood Resident #2 when providing perineal care. CNA A was not sure why it was done in standing but stated it has always been done that way. During an interview with the DON on 04/11/25 at 3:15pm she stated staff were trained over perineal care annually and during random check offs. The DON stated when staff completed check offs it included residents with foley catheters. The DON stated CNA C was in charge of the trainings and she would observe. The DON stated if staff used wipes, it was usually the same steps as when using a wash cloth which was to fold and use another side. The DON stated staff could use the same wipe as long as they folded it and used a clean side. The DON stated she thought this was the process. The DON stated she was not the one who did the training, and she would just observe the training and was not sure if that was how CNA A was trained. The DON stated if the proper technique was not used residents could develop a buildup of bacteria or a bacterial infection. During an interview on 04/11/25 at 3:57pm with CNA C she stated she provided the aides monthly training over catheter care with males. CNA C stated aides were trained to use a new wipe for every swipe. CNA C stated when using a washcloth, you are able to fold it but not when using a wipe. CNA C stated she had trained CNA A over this exact procedure and had previously observed her and had not seen her use an incorrect wipe technique. CNA C stated you wanted to use one wipe per swipe because it was infection control. CNA C stated you wouldn't want the resident to be standing during catheter care and stated the best thing to do was to do it in bed because you're able to see from that angle. CNA C stated having Resident #2 stand and using the same wipe was not the correct procedure. CNA C stated it was important to use the correct technique because it could impact residents by causing rashes, fungus or urinary tract infections. CNA C stated she kept herself up to date on techniques by looking and learning techniques online and trained herself that way. During a follow up interview with the DON on 04/11/25 at 4:18pm she stated when she looked up CNA A's technique used during perineal care it stated her technique was okay, but stated CNA C stated it was not. The DON stated that CNA A should have provided the care to Resident #2 while he was laying down as it would have made the procedure easier. Record review of CNA A's trainings revealed she had completed a training titled, performing perineal care for a male patient on 12/27/24. Record review of CNA A's trainings revealed she had completed a training titled, CNA - Urinary catheter care on 10/16/24. During a follow up interview with the DON on 04/11/25 at 6:13pm the DON stated they didn't use the [NAME] for their catheter care and stated they used the Texas curriculum for nurse aides in long term care facilities that was provided by health and human services. Record review of CNA A's competency checklist dated 04/30/24, reflected under section titled, PERSONAL CARE, CNA A was checked off as met for Pericare [perineal]/incontinent male and Foley cath [catheter] care male. Record review of undated facility document titled Indwelling catheter care (daily cleansing) stated While the CDC (Centers of Disease Control) does not endorse routine meatal cleansing (urethral opening), this community does conduct daily and as needed (PRN) indwelling catheter cleansing. There was also verbiage that stated, This standard servers to override the [NAME] textbook requirement for sterile technique. Clean technique will be used for cleansing care. The policy did not include a reference or definition of the clean technique and did not include verbiage related to reusing wipes or only using each wipe once per swipe. Record review of the Texas curriculum for nurse aides in long term care facilities dated March 2024 included a section titled 2.7.5 Procedural Guideline #22 - Catheter Care which included steps to Lower head of bed and position the resident on his or her back but did not include verbiage regarding the use of wipes and only mentioned the use of a wash cloth.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to document Resident #1's physician ordered weekly total body skin assessment. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #1's face sheet, dated 03/07/25, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (high blood sugar) without complications, malignant neoplasm of bladder (bladder cancer or cancerous tumor that develops in bladder), unspecified, acute respiratory failure with hypoxia, dysphagia, oral pharyngeal phase (swallowing disorder that affects the muscles and nerves in the mouth, throat and upper esophagus), and nontraumatic intracranial hemorrhage (bleeding within the brain that occurs without head injury), unspecified. Record review of Resident #1's quarterly MDS assessment, dated 01/31/25, revealed Resident #1 had a BIMS score of 15, indicating he was cognitively intact. Record review of Resident #1's care plan with an initiation date of 07/26/24included a focus of Admission/Readmission Care Plan; I may be at risk for: self-care, deficits, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress with an initiation date of 07/26/24 and interventions of, 1. Administer medication, care & treatments as per MD recommendation . 4. Monitor vital signs and health conditions as indicated,. Record review of Resident #1's active physician's orders revealed orders to Complete the [electronic documentation software] skin & wound - Total Body Skin Assessment, with a frequency of every day shift every Mon (Monday) for Skin Integrity with a start date of 08/12/24 and end date of indefinite. Record review of Resident #1's total body assessment revealed Resident #1's last total body skin assessment was completed on 02/19/25. Record review of Resident #1's February 2025 TAR reflected his order for total body skin assessment on 02/24/25 had been signed off by the ADON. During an interview and observation with the Treatment Nurse on 03/07/25 at 3:38pm she stated she was responsible for completing skin assessments and completed them every Monday and Tuesday. The Treatment Nurse reviewed Resident #1's physician orders and stated he had orders for weekly body audits on Mondays. The Treatment Nurse stated after 02/19/25 Resident #1's next skin assessment would have been due on 02/26/25. The Treatment Nurse stated she was not working from 02/13/25-03/03/25 and stated during that time the DON would have had to delegate somebody to complete the skin assessments or she would have made herself responsible for completing the skin assessments. The Treatment Nurse stated she did not know who completed the skin assessment on 02/26/25 for Resident #1 but she stated she was able to see it on her end. Treatment Nurse reviewed the copy of Resident #1's assessments retrieved on 03/05/25 by Surveyor A and stated the last skin assessment she saw was on 02/19/25 and did not know why there was not one documented on 02/26/25. The Treatment Nurse stated during the time of Resident #1's missed skin assessment he did not have any skin break down and was just monitored for any itchiness. The Treatment Nurse stated it was important to follow physician orders and complete and document residents skin assessments weekly to make sure there was no skin breakdown and stated her goal was to keep residents free of wounds. The Treatment Nurse did not know what the facility policy stated in regard to following physician orders and documenting skin assessments, she stated she had not been trained over completing and documenting skin assessments. The Treatment Nurse stated the DON would monitor her skin assessments to ensure completion and documented had been completed. The Treatment Nurse stated not completing and documenting skin assessment could negatively impact residents because it was not done. During an interview and observation on 03/07/25 at 5:37 p.m., with the DON she stated the Treatment Nurse was responsible for completing the skin assessment but stated she was responsible for the previous 2 weeks because the Treatment Nurse was out, the DON did not recall the exact dates the Treatment Nurse was out. The DON reviewed Resident #1's physician orders and stated he had orders for weekly skin assessments. The DON reviewed Resident #1's list of assessments from 03/05/25 and confirmed the last skin assessment completed was on 02/19/25 and stated the following date for a skin assessment for Resident #1 was on 02/26/25. The DON stated she was responsible for completing the skin assessment for Resident #1 on 02/19/25 and 02/26/25. The DON stated she did complete the skin assessment on 02/26/25 and her ADON signed the MAR but did not complete the skin assessment form, the DON stated the forms do not tell you much. The DON stated she did not complete the skin assessment form because it just got passed her and she must have forgot. The DON stated Resident #1 did not have any skin issues during the time his skin assessment was not documented. The DON stated it was important to follow physician orders and complete and document skin assessments because they have to make sure they are checking residents and to prevent anything or catch something the was not being done. The DON stated the facility policy regarding following physician orders and documenting skin assessments stated if they found a wound, they had to complete a different assessment with the measurements of the wound and the notifications made. The DON stated the facility did follow this policy. The DON stated she had been trained over completing and documenting skin assessments but did not know by who and stated she was trained during in services via [video conferencing platforms]. The DON Stated she monitored and oversaw the skin assessment to ensure completion and documentation had been completed during their daily meetings. The DON stated if they don't do their weekly audits there was no negative impact on the residents and stated they sign off on the MAR and if there's anything new, they will document and call the MD so there's no negative impact. Record review of licensed nurse competencies checklist dated 04/10/24 revealed the DON was checked off as met under the general assessment section of skin, hair, nails, and under the evaluation/notification/documentation section on admission orders and physician orders. Record review of licensed nurse competencies checklist dated 05/06/24 revealed the Treatment Nurse was checked off as met under the general assessment section of skin, hair, nails, and under the evaluation/notification/documentation section on admission orders and physician orders. Record review of facility policy titled, Skin and Wound Prevention and Management with am implemented date of 03/14/29 and revised date of January 2023 included verbiage under the section titled Guideline: that reflected, 1 A licensed nurse should at least weekly conduct a routine skin assessment/evaluation in order to identify new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks in the resident's medical record.

Based on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for comprehensive care plans. The facility did not include Resident #1's pruritis (itchy skin) and behavior of itching and scratching on care plan. This failure could place residents at risk for not receiving appropriate treatment and services. The findings included: Record review of Resident #1's face sheet, dated 03/07/25, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (high blood sugar) without complications, malignant neoplasm of bladder (bladder cancer or cancerous tumor that develops in bladder), unspecified, acute respiratory failure with hypoxia, dysphagia, oral pharyngeal phase (swallowing disorder that affects the muscles and nerves in the mouth, throat and upper esophagus), and nontraumatic intracranial hemorrhage (bleeding within the brain that occurs without head injury), unspecified. Record review of Resident #1's quarterly MDS assessment, dated 01/31/25, revealed Resident #1 had a BIMS score of 15, indicating he was cognitively intact. Record review of Resident #1's nursing notes from 01/23/25 revealed, CARE PLAN MEETING: IDT met with patient in his room .expressed concerns regarding itching to his skin, Nursing informed, MD aware. Record review of Resident #1's notes from 01/31/25 documented by PA stated, Dermatology referral to [MD] Record review of Resident #1's order summary report reflected an active order to refer to dermatology for DX: Pruritus with an order date of 01/31/25. Record review of Resident #1's care plan with an initiation date of 07/26/24 included a focus of Admission/Readmission Care Plan; I may be at risk for: self-care, deficits, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress with an initiation date of 07/26/24 and interventions of, 1. Administer medication, care & treatments as per MD recommendation . 4. Monitor vital signs and health conditions as indicated,. Further review of care plan did not include any verbiage related to pruritus or Resident #1's behavior of itching. During an interview with Resident #1 on 03/06/25 at 1:12pm he stated he previously use to be itchy all over his body and was scratching his whole body before. Resident #1 stated they were using creams and it helped fix his issue and stated it had gotten better and he did not itch anymore. During an interview and observation with the Treatment Nurse on 03/07/25 at 3:38pm she stated the DON or MDS nurse was responsible for completing and updating resident care plans, she was unaware of how often resident care plans were updated or completed. The Treatment Nurse stated Resident #1 had dry, itchy skin, pruritus, and behaviors such as itching and scratching, and stated he had this on and off since he had been at the facility. The Treatment Nurse stated residents skin conditions such as dry, itchy skin, pruritus, and behaviors such as itching and scratching should be on the care plan. The Treatment Nurse stated she did not personally attend any meetings and did not know how the MDS nurse was notified of any skin conditions or behaviors identified on residents. The Treatment Nurse reviewed Resident #1's care plan and stated there was nothing on there related to Resident #1 having pruritus, dry, itchy skin, having behaviors of itching or scratching. The Treatment Nurse stated the care plan she reviewed only included a general focus on skin assessment and that Resident #1 was at high risk for skin break down. The Treatment Nurse was unable to answer why Resident #1's care plan did not reflect his related skin conditions/behaviors. The Treatment Nurse stated it was important that the care plan reflected any skin changes or related behaviors so that everyone would know and because it was the process of caring for the resident, and stated they had to know what was being done and resolved at all times. The Treatment Nurse stated not accurately reflecting residents skin changes, condition and behaviors on the care plans could negatively impact them because they would not be providing the care, they needed for the resident's quality of care. During an interview and observation with the MDS nurse on 03/07/25 at 4:59p.m., he stated he was responsible for completing and updating the care plans and stated they should be updated upon admission and when a resident had a change in medication, treatment, orders or any assessments. The MDS nurse stated residents skin conditions such as dry, itchy skin, pruritus and behaviors such as itching and scratching should be on the resident's care plan. The MDS nurse stated he was notified of any skin conditions or behaviors identified on residents during morning meetings, by nurses reporting any treatment, reviewing new orders daily and stated he also shared an office with the Treatment Nurse. The MDS nurse stated Resident #1 had pruritus, itchy, dry skin and behaviors of itching and scratching and stated they had a care plan meeting with him and he referred it to nursing and had told them about getting a consult with a skin doctor so they could know what was going on. The MDS nurse stated Resident #1 would keep scratching with a back scratcher he had and stated he provided him health education on not scratching for prevention. MDS nurse stated he had noted Resident #1 with those skin conditions and behaviors since Resident #1 had been at the facility. The MDS nurse reviewed Resident #1's care plan and stated there was nothing on there related to Resident #1 having pruritus or having behaviors or itching or scratching. The MDS nurse could not recall and was not sure why Resident #1's care plan did not reflect his related skin conditions/behaviors. The MDS nurse stated it was important that the care plan reflected any skin changes or related behaviors so that treatment would be followed. The MDS nurse stated he had been trained over completing or updating resident care plan by his regional but did not remember when. The MDS nurse stated he had reviewed the facility policy related to accurate and updated care plans but could not recall the exact policy, the MDS nurse stated he had followed the facility related policy. The MDS nurse stated he monitored and oversaw care plans to ensure they accurately reflected residents skin changes, conditions, and behaviors. The MDS nurse stated not accurately reflecting residents skin changes, condition and behaviors on the care plans could negatively impact them because treatment would not be followed and there would be no continuity of care and you won't be able to evaluate the effective of treatment. During an interview and observation with the DON on 03/07/25 at 5:37p.m., she stated usually the MDS nurse was responsible for completing and updating the care plans and stated any of her nurse managers and herself could also do it. The DON stated care plans were completed and updated daily because the MDS nurse would print out any new orders and if something was coming up they would discuss it in their morning meetings. The DON stated the MDS was notified of any skin condition or behaviors during the morning meeting and should identify them himself when reviewing the orders and documentation. The DON stated residents skin conditions such as dry, itchy skin, pruritus and behaviors such as itching and scratching should be on the residents care plan if they are current and should be resolved when done. The DON stated Resident #1 did not currently have anything. The DON stated Resident #1 was scratching but did not know if he had a diagnosis of pruritus and stated he currently did not have anything active, The DON stated Resident #1 has had this on and off since admission. The DON reviewed Resident #1's care plan and stated there was nothing on there related to pruritus. The DON stated she was unable to say why Resident #1's care plan did not reflect his related skin conditions/behaviors and stated the only thing she could think of was because he did not currently have any treatment in place. The DON stated it was important that the care plan reflected any skin changes or related behaviors because it was part of their assessment and care plans had to be personalized to the residents and whatever they are going through. The DON stated her and the MDS nurse had trained over completing or updating resident care plans but did not know by who or when. The DON stated the facility policy related to accurate and updated care plans stated care plans had to be updated and personalized to the residents. The DON stated in this situation she thought they had followed the facility policy. The DON stated the MDS nurse, herself or any nurse mangers monitored and oversaw care plans to ensure they accurately reflected residents skin changes, conditions and behaviors. The DON stated she did not think not accurately reflecting residents skin changes, condition and behaviors on the care plans would have negatively impacted residents. The DON stated she thought they did everything they could for Resident #1 and stated he got treatment in house and will still be done as needed for Resident #1. Record review of licensed nurse competencies checklist dated 04/10/24 revealed the DON checked off as met under the general section for Kardex/Plan of Care. Record review of licensed nurse competencies checklist dated 05/06/24 revealed the Treatment Nurse checked off as met under the general section for Kardex/Plan of Care. Record review of licensed nurse competencies checklist dated 02/02/24 revealed the MDS nurse was checked off as met under the general section for Kardex/Plan of Care. Record review of facility policy titled Care Plans with an implemented date of February 2017 and a revised date of January 2023 included a section titled, Guidelines: .Care Plans that included the following verbiage: The Care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk outcome objective, and the resident's ability, needs, medical condition, preventive measure.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 2 residents by 4 of 4 nurses (LVN B, LVN D, LVN E, and LVN F) reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN B, LVN D, LVN E, and LVN F correctly completed Resident #1's nuero checks between 05/30/24 and 06/01/24. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health. Findings included: Record review of Resident #1's admission sheet, dated 02/03/25 , reflected a [AGE] year-old female admitted on [DATE], an original admitted [DATE] and a discharge date of [DATE]. Resident #1's relevant diagnoses included end stage renal failure ( the final stage of chronic kidney disease) , muscle weakness, history of falling, fracture of pelvis, and fracture of T-11-T-12 vertebra (a break in the vertebrae located at the T11 and T12 levels of the spine). Record review of Resident #1's MDS assessment dated [DATE], reflected BIMS score question not answered, which indicated resident was not able to answer questions. Record review of Resident #1's care plan dated 05/27/24, reflected had a history of falls related to pubic symphysis, non-displaced right sacral bone fracture, L-1 vertebral, compression fracture and T-12 vertebral (a pelvic injury where the joint connecting the pubic bones is not displaced, but there is a fracture in the right sacral bone that is also isn't shifted out of place). Record review of Resident #1's physician's orders indicated she was not on blood thinners. Record review of Resident #1's progress notes dated 05/29/24 at 5:00 a.m., authored by LVN G reflected, [Resident #1] noted laying supine on floor next to bed, bed noted on lowest position with call light within reach but not in use. [Resident #1] states she was reaching for snacks that were on bedside table and she slid off bed. Head to toe completed no visible injuries noted. [Resident #1] was assisted back to bed x2 assistance and was provided with bedside table near her. [Resident #1] is alert and oriented X3 no change in LOC [Doctor] was notified, no new orders were given. Neuro checks were initiated per facility protocol. RP aware. Record review of Resident #1's nuero checks on her electronic medical record dated 05/29/24 reflected only 4 checks ( from 5:00 a.m. to 5:45 a.m.) had been completed and signed on 05/29/24 by LVN G. Record review of Resident #1's, 2nd nuero checks on her electronic medical record initiated on 05/29/24 reflected a total of 24 neuro checks from 05/29/24 at 5:00 a.m. through 06/01/24 at 3:45 a.m. The intervals of the neuro checks were as followed: Number 1-4 were 15-minute checks Number 5-8 were 30-minute checks Number 9-12 were 60-minute checks Number 13-16 were 2-hour checks Number 17-18 were 4-hour checks Number 19-24 were 8-hour checks LVN D failed to enter new vital signs for neuro checks 5-14 and 19. LVN E failed to enter new vital signs for neuro checks 15 and 16. LVN B failed to enter new vital signs for neuro check 22. LVN F failed to enter new vital signs for neuro check 23. Neuro checks number 5, 6,7,8,9,10,11,12,13,14,15,16,19,22, and 23 had the same blood pressure readings of 108/50, temperature of 97.5, most recent pulse of 76, and more recent respiration of 17.0 and dated 05/30/24. An observation and interview on 02/05/25 at 11:00 a.m., LVN B said when a resident required neuro checks, their vital signs needed to be rechecked at each interval. She said when she conducted neuro checks, she would write the resident's vitals on my notepad and at a later time, she would transfer the information to the resident's medical electronic record. LVN B was observed as she checked Resident #1's electronic medical record and said recalled conducting a neuro check on Resident #1 on 05/31/24 at 11:45 a.m. She said answered all the questions and rechecked her vitals at that time, and all were within normal range. LVN B said she must have forgotten to enter Resident #1's vitals on her electronic medical record and that was the reason the vitals that showed were dated 05/30/24. She said the neuro checks were standard protocol for residents who fell . She said Resident #1's neuro check was normal. LVN B said a negative outcome for not documenting the correct vital signs could be her doctor would not be getting an accurate account of her vitals. An observation and interview on 02/05/25 at 11:17 a.m., LVN E was observed as she checked Resident #1's electronic medical record and said she had conducted a neuro check on her on 05/29/24 at 5:45 p.m. and 05/29/24 at 7:45 p.m., and both were normal. She said she had answered all questions and had rechecked Resident #1's vitals both times but had no explanation as to why the vitals showed a future date of 05/30/24. LVN E said the negative outcome for Resident #1 were that the correct vitals were not recorded. An observation and interview on 02/05/25 at 3:30 p.m., LVN F said when he conducted neuro checks, he would write the resident's vitals on paper and at a later time, she would transfer the information to the resident's medical electronic record. LVN F was observed as he checked Resident #1's electronic medical record and said he had conducted a neuro check on 05/31/24 at 11:45 a.m. He said he remembered he answered all the questions and had rechecked Resident #1's vitals but must have forgotten to enter her new vital readings that that was the reason the date on the vitals had 05/30/24. An observation and interview on 02/05/24 at 4:00 p.m., The DON was observed as she checked Resident #1's electronic medical record. The DON said Resident #1 had sustained a fall on 05/29/24 with no injuries. The DON said neuro checks had been initiated by LVN G. The [NAME] said the only explanation she could think of as to why there were two neuro check assessments done was because something went wrong on the first one and a new nuero check assessment had to be initiated. The DON said she was not sure why the vitals for neuro check number 5, 6,7,8,9,10,11,12,13,14,15,16,19,22, and 23 had the same blood pressure readings of 108/50, temperature of 97.5, most recent pulse of 76, and more recent respiration of 17.0 and dated 05/30/24. The DON said nursing staff conducted nuero checks, they were supposed to answer all questions and recheck all vitals. She said the date they are done and the date on the vitals should match. The DON said she did not know what had happened. The DON said there were no negative effects on Resident #1 as she had not sustained any injuries due to the fall. Record review of facility's policy on Professional Standard of Care, dated February 2017 and revised in January 2024 reflected: Compliance Guidelines: The community provides services tat meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified). Compliance with Professional Standards of Care Nursing: e) Nurses should conduct assessments or evaluations and document within the medical record in the following instances: 1. admission, re-admission and as clinically indicated 3. when exceptions are identified

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 the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #187) of 8 residents reviewed for care plans. The facility failed to include oxygen treatment in Resident #187's comprehensive care plan. This deficient practice could affect residents who received oxygen and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings Included: Record Review of Resident #187's face sheet, dated 02/05/2025, revealed a [AGE] year-old male admitted on [DATE], and original admitted on 10/25/2024 with pertinent diagnoses of Pneumonia, Encephalopathy (damage or disease that affects the brain), History of Transient Ischemic Attack (mini stroke) and Cerebral Infarction (stroke), Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and Major Depressive Disorder. Record review of Resident #187's MDS assessment, dated 01/12/2025, a BIMS score of 05 revealed the resident's cognition was severely impaired. Record Review of Resident #187's physician's order summary dated 02/02/2025 revealed no oxygen order. During an observation on 02/02/2025 at 11:55 a.m., Resident #187 was lying in his bed with head of the bed elevated and had on a nasal cannula with the oxygen concentrator set at 1.5 liters per minute. During an interview on 02/02/2025 at 11:57 a.m. with Resident #187 ' s was lying in his bed with head of the bed elevated. His family member was at bedside, stated that Resident #187 has being using oxygen via NC every day since before he was readmitted to the facility. During an interview with LVN B on 02/02/2025 at 12:02 p.m., stated that MDS was responsible for care planning. She stated the oxygen needed to be care planned because staff need to know Resident #187 was on oxygen and we do not want the resident to desaturate (blood oxygen levels drop below normal range). During an interview on 02/02/2025 at 05:07 p.m. the DON stated that the staff knew Resident #187 was on oxygen. She stated a possible negative outcome of the oxygen not being care planned was that the care plan tells you what the resident was supposed to be on. The DON stated the care plan of the resident revolves around the resident's needs. She stated if they have no physician order for oxygen then care planning will be overlooked. During an interview on 02/02/2025 at 05:25 p.m. MDS stated he was responsible for writing care plans for the whole facility. He stated that he did not get the physician order for the oxygen. MDS stated that what he care plans gets administered. He stated that once he gets the order, he checks that it had been followed through and formulate a care plan. The negative outcome of not having the oxygen care planned was that staff was not going to follow through with it and would not evaluate if effective. He stated that oxygen was considered a medication and if not following orders, the patient would desaturate for not having oxygen. Record review of facility policy titled Care Plans and date revised January 2023 revealed the following: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective, and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident ability, needs, medical condition, preventative measure.

Based on observation, interview, and record review the facility failed to ensure that a resident with a urinary catheter received appropriate treatment and services for 1 (Resident #2) of 8 Residents reviewed for catheter care, in that: The facility failed to ensure LVN D and LVN R did not stop and notify doctor when resistance was felt during Resident #2's Foley catheter change. An Immediate Jeopardy was identified on 12/20/2024. The Immediate Jeopardy template was provided to the facility on [DATE] at 08:43 PM. While the Immediate Jeopardy was removed on 12/21/2024 at 06:05 PM. Immediate Jeopardy was lowered to isolated with no actual harm with a potential for more than minimal harm, as once Immediate Jeopardy is lowered, harm cannot exist. This failure had the potential to affect residents receiving Foley catheter change could experience injury and pain. The findings included: Record review of Resident #2's Face Sheet, dated 12/20/2024, revealed a [AGE] year old male admitted initially on 08/14/2023, readmitted on [DATE] with the diagnoses including: Urinary Tract Infection (UTI), Hematuria (blood in the urine), benign prostatic hyperplasia without lower urinary tract symptoms (Age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning such as forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), and heart failure. Record review of Resident #2's Minimum Data Set assessment dated [DATE] revealed he: -Had a BIMS of 00 which indicated severely impaired cognition -Minimal difficulty hearing -Clear speech -Sometimes he was understood by others -Sometimes he understands others -Incontinence of bladder was not rated. Resident #2 had an indwelling catheter. -Always continent of bowel Record review of Resident #2's comprehensive care plan dated 11/26/2024 documented, FOCUS: o I require a foley catheter DX Obstructive Uropathy (a structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction) Date Initiated: 09/10/2024 Created on: 08/14/2023 Revision on:12/21/2024 GOALS: o I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Date Initiated: 08/15/2023 Created on: 08/15/2023 Target Date: 02/24/2025 INTERVENTIONS/TASKS: o Monitor for s/sx infection. Date Initiated: 08/14/2023 Created on: 08/14/2023 NSG o Monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Date Initiated: 10/02/2024 Created on: 10/02/2024 NSG Record review of Resident #2's physician's orders revealed, Start Date: 12/14/24 Order Summary: Foley Catheter 20Fr 30CC, change 3weeks and PRN, per (Dr.) (urologist), change foley bag with f/c change as needed related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS Record review of Resident #2's physician's orders revealed, Start Date: 12/16/24 Order Summary: REFER TO DR. DX: BLOOD LOSS ANEMIA REQUIRING IRON INFUSION. Record review of 12/14/24 Hospital's Final Report, revealed: HISTORY OF PRESENT ILLNESS: 84 -year-old male with . BPH with chronic urinary obstruction with chronic indwelling Foley catheter status, recurrent UTIs, nursing home resident, bedbound, Alzheimer's dementia, who has Foley catheter exchanged today and at 11 AM initiated with [NAME] hematuria, persistent, associated with suprapubic and penile pain. Sent to hospital for further evaluation, urology consulted and agreed to evaluate. ASSESSMENT/PLAN: 1. Hematuria R31.9 Most likely traumatic after Foley insertion, regardless the UA looks dirty. Record review of Resident #2's Treatment Administration Record revealed Resident #2 had a foley catheter change on 12/06/24. Record review of Resident #2's progress notes dated 12/06/2024 at 11:39 am written by LVN D revealed, Foley catheter changed due to leaking; resident tolerated well, yellow color urine flow noted. Resident tolerated procedure well, no acute distress at this time. In an interview on 12/20/24 at 04:05 pm LVN R stated she went in with LVN D for the foley change. LVN R stated when she went into the room, LVN D had started the change. LVN R stated resident asked what they were doing and LVN D told him they were going to change his foley. LVN R could not remember if resident said anything else during the change. LVN R does not recall resident saying anything or crying out. LVN R stated if the resident tells them to stop or cries out, they are supposed to stop because that is what the resident wants. LVN R stated she was not sure what the negative outcome would be if they did not stop when resident said to or cried out. LVN R stated CNAs notified her of blood in catheter bag when they did their 2 hour check. LVN R stated she notified LVN D and ADON/RN they needed to check the catheter bag and then they went to notify the doctor. In an interview on 12/20/24 at 04:46 pm LVN D stated she had done the foley change on Resident #2. LVN D stated LVN R filled the foley balloon. LVN D stated Resident #2 was not medicated prior to change and did not recall if LVN R gave him something after. LVN D stated Resident #2 did not cry out, say no, or anything. She said he was aware of what was going to happen. LVN D stated she also aided him in breathing to relax when changing the foley. LVN D stated it was not difficult to change the foley catheter. LVN D stated there was yellow urine return when foley catheter was placed. LVN D stated if a resident says stop or no, we stop. LVN D stated at the end of inflating the balloon, LVN D stated she noticed pink-tinged urine at the connection of the tube to the bag. LVN D stated she showed ADON / RN. LVN D stated ADON / RN said that sometimes happens when replacing or changing a foley, you get pink tinged urine. LVN D stated they never pulled the catheter out and in and out and in. LVN D did not say what negative outcome would be if they did not stop when resident said to. LVN D stated she went on break and when she came back, LVN R told her of blood in the catheter bag. LVN D stated when the doctor came in, ADON / RN did rounds with him. LVN D stated she was working when they asked the doctor to come in and checked Resident #2. LVN D stated the doctor ordered resident to be sent out to the hospital In an interview on 12/20/24 at 05:13 pm ADON/RN stated LVN R came to her and told her LVN D needed her. ADON / RN stated she went to Resident #2's room and LVN D told her when she tried to advance the catheter, she felt resistance and asked for assistance. ADON / RN stated she moved the catheter maybe an inch or two with no resistance and she inflated the balloon. ADON/RN stated the return was yellow with tinge of pink. ADON/RN stated she went back to her office. ADON/RN stated LVN R notified ADON/RN of the hematuria. ADON/RN stated she called the MD and had an order for flush. The ADON/RN stated she flushed the catheter and the resident was not in distress. In an interview on 12/20/24 at 05:28 pm telephone interview with CNA U stating LVN D and LVN R were in Resident #2's room CNA U stated at the end the ADON/RN came in. CNA U stated she was in the room the whole time when the foley catheter was changed (on Resident #2). CNA U stated LVN D was doing the Foley change and LVN R was preparing what LVN D needed. CNA U stated LVN R did not do anything. CNA U stated LVN D did everything. CNA U stated at the beginning the resident was asking what they were doing and why. CNA U stated when they were almost done, the resident started complaining. CNA U stated LVN R left the room to get ADON/RN and LVN D stopped what she was doing. CNA U stated ADON/RN came in and asked the resident if he were in pain and he said he was in a little pain. CNA U stated they started assessing the resident. CNU stated ADON/RN checked the foley catheter and said it was in right. CNA U stated ADON/RN asked the resident again if her were in pain and the resident stated no. CNA U stated by the time they left, there was no blood. CNA U stated thirty minutes later, she went to drain the bag and it had dark red blood in the bag missed with urine. CNA U stated the bag was 1/4 the way full. CNA U stated the Resident #2 was in his room. CNA U stated she went and told LVN R and they both went back to the room to check the foley bag. CNA U said that was at the end of her shift and when she came back to work, he was in the hospital. CNA U stated Resident #2 never cried out and resident would say he had no pain until the end when they went to get ADON/RN. CNA U stated she was unsure if resident received medication before or after for pain. CNA U stated she asked about resident and the nurses told her he had been sent to the hospital because of bleeding. In an interview on 12/20/24 at 05:45 pm the DON stated one of the LVNs told her the Resident #2's foley was bleeding and the doctor came in and gave orders to send Resident #2 out to the hospital. The DON stated RP told them it was possibly trauma that caused the bleeding. In an interview on 12/20/24 06:07 pm meeting with DON, LVN R, LVN D, and ADON/RN. Surveyor asked them if Resident #2 had cried out, showed discomfort or pain. LVN R and LVN D stated Resident #2 had not. Surveyor played video from 12/06/24 during Foley catheter change, where resident was heard yelling, saying no no no, just put a bullet in me, please, please, etc. LVNs said nothing. Both LVNs stated that when a resident was in pain or discomfort or calling out, they should stop what they were doing. LVNs would not say anything further. In an interview on 12/21/24 at 02:33 pm The DON stated she had watched/listened to the video FM sent to administrator. She said she was very upset. The DON stated she was not upset with surveyor, she was hurt, disappointed, and upset with her nurses for lying to her (Resident #2's pain and discomfort). In an interview on 12/20/24 at 06:35 pm FM stated she was sending the video to administrator's email. An Immediate Jeopardy was identified on 12/20/2024. The Immediate Jeopardy template was provided to the facility on [DATE] at 08:43 PM. While the Immediate Jeopardy was removed on 12/21/2024 at 06:05 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on residents receiving appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible . This was determined to be an IJ and the Administrator was provided the IJ template on 12/20/24 at 08:43 pm. The following Plan of Removal submitted by the facility was accepted on 12/21/24 at 09:05 am. Immediate Corrective Action Response: The resident identified as #2 was reassessed on 12/20/24. Resident #2's plan of care reviewed to validate that appropriate intervention is in place and noted on the care plan related to foley insertion and care. Regional Nurse / Director of Nursing provided in-service training LVN D (now LVN R), E (now LVN D), and RN ADON regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Identification Risk Response All residents who require and indwelling foley catheter may be at risk of the alleged deficient practice. Director of Nursing / Assistant Director of Nursing / Designee conducted an audit to identify all residents with indwelling foley catheters to identify any resident having s/s of pain associated with the catheter and/or s/ s of hematuria. Outcome: There were no negative outcomes identified. Date completed: 12/21/24 Director of Nursing / Assistant Director of Nursing / Designee interviewed residents who were identified as interviewable and who require and indwelling foley catheter in order to identify any concerns of pain during the procedure of changing of catheter. Outcome: no negative outcomes identified. Date completed: 12/21/24 Systemic Change Response The Regional Nurse / DNS educated the licensed nurses regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Director of Nursing / Assistant Director of Nursing and Clinical Leadership will conduct training for all newly hired nurses, PRN nurses and agency nurses prior to the nurses working. In-service training: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Date completed: 12/21/24 Director of Nursing / Assistant Director of Nursing will require nurses to perform return demonstration of the procedure for the insertion of the foley catheter in order to establish competency prior to the nurse performing this procedure on the actual resident / patient. Date completed: 12/21/24 The Administrator and Director of Nurses conducted and Ad Hoc QAPI review of this situation and this immediate corrective action plan with the facility's Medical Director. Date completed: 12/21/24 Monitoring response: Director of Nursing / Assistant Director of Nursing / Designee will conduct at least weekly audits / rounds to inspect resident / residents with indwelling foley catheters to identify s/s of hematuria and will observe nurse / nurses during the procedure of placing / changing an indwelling catheter in order to evaluate competency. Director of Nursing / Assistant Director of Nursing / Designee will review the nursing 24hr report, and progress notes to identify and issues placing / changing the indwelling foley catheter and ensure appropriate follow up interventions are in place. All findings will be reported to the QAPI committee for the next 2 months and the committee will then determine compliance or will determine additional training and oversight is required. Verification: Started on 12/21/2024 at 12:30 PM and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 12/20/2024 and 12/21/2024: Head to toe assessments completed on 11 / 11 residents with Foley catheters. 11 /11 resident's foley catheters draining yellow urine. 11/11 residents foley bag with no blood in the urine or bag. 7 verbal residents out of 7 verbal residents denied pain or discomfort. Interviews with 8 nurses verbalizing understanding regarding: - In-services on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, - Education (computer education), and - Return demonstrations of placing an indwelling foley catheter on dummies both male and female. - Documentation for education and return demonstrations for 97% of nursing staff. 3 PRN nurses will not be allowed on the floor until in-service, education, and return demonstration are completed. Documentation for assessment of 11 residents with indwelling foley catheters with no issues, concerns or change in condition. Record review of the licensed nurse's In-Service Program Attendance Record for the following topic Abuse Neglect and Exploitation Prevention, Reporting and Protecting conducted by DON / designee. 15 LVN's and 1 RN were in-serviced between 12/20/2024 and 12/21/2024. Record review of the licensed nurse's computer-based education on catheter insertion. 15 LVN's and 1 RN reviewed computer-based training between 12/20/2024 and 12/21/2024. Record review of the licensed nurse's return demonstration conducted by DON /designee 15 LVN's and 1 RN were in-serviced between 12/20/2024 and 12/21/2024. Interviews on 12/21/2024 between 12:30 PM and 5:00 PM, the survey team interviewed 8 licensed staff (7 LVN's and 1 RN), interviewed licensed staff verbalized understanding of what they learned during in-services they received between 12/20/2024 and 12/21/2024. Interview on 12/21/2024 at 02:35 PM, LVN T was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:13 PM, LVN X was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:26 PM, LVN Y was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:43 PM, LVN D was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 04:04 PM, ADON / RN was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 04:20 PM, LVN Z was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Observation of Timeline on 12/23/24 at 08:30 AM: 12/06/24 11:10 AM LVN D, LVN R, and CNA entered room to do a foley catheter change. LVN D explained to resident #2 what and why they were there. 12/06/24 11:13 AM Resident starts yelling out. LVN D tells him to breathe. 12/06/24 11:21 AM LVN D stopped due to resistance and LVN R went to get RN. 12/06/24 11:25 AM RN enters room and advances / completes F/C change. Resident does not cry out. 12/06/24 11:27 AM RN leaves room. 12/06/24 02:05 PM Doctor #1 first notified of blood in foley bag. 12/06/24 02:27 PM Doctor #2 (Urologist) notified. His MA said to monitor resident for discomfort or pain. MA stated it was normal for bleeding to occur when foley is changed. 12/06/24 02:38 PM Doctor #3 notified. He said to continue to monitor and new order for UA given. 12/06/24 04:09 PM Doctor #4 gave order for IV antibiotics for 1 time a day until 12/13/24. 12/06/24 04:49 PM Doctor #3 went in to see resident. Order for resident to be sent out to hospital. Diagnosis was microscopic Acute Hematuria. 12/06/24 05:08 PM EMS called to transport resident to hospital. 12/06/24 05:30 PM EMS arrives. 12/06/24 09:36 PM resident admitted to hospital diagnosis hematuria (blood in urine). 12/14/24 04:51 PM Resident readmitted to facility. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2024 at 06:05 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. In an interview and observation on 12/23/24 at 12:45 PM The DON stated check off list for POR had 97% of nursing staff signed off. The DON stated the only staff left to be in-serviced, educated, and trained were the PRN staff. The DON stated they would not be allowed on the floor until they completed all. Check off list was reviewed. Review of the facility's policy on Incontinence and Catheterization Assessment and Evaluation Date revised: January 2023 revealed, Indwelling Catheter For a resident who was admitted to the community with an indwelling urinary catheter or who had one placed after admission, the community will: -Recognize and assess factors affecting the resident's urinary function and identified the medical justification for the use of an indwelling urinary catheter. -Define and implement pertinent interventions consistent with resident conditions, goals, and recognized standards of practice to try to minimize complications from an indwelling urinary catheter and to remove it if clinically indicated. -Monitor and evaluate the resident's response to interventions. -Revise the approaches as appropriate. Review of the facility's policy on Pain Management Date Implemented: 03/14/2019, Date Revised: [DATE], revealed: Compliance Guidelines: To assess the resident pain control and management needs at admission/readmission, quarterly, annual and when a change of condition indicates a need for initiating or modifying a pain management program for the residents. The goal of the community Pain Management Program is that pain is identified and treated timely, effectively and consistently. OVERVIEW .Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by team members inquiring if they have pain and observation of the resident for nonverbal signs and symptoms of pain.

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 8 residents (Resident#2) reviewed for abuse and neglect, in that: The facility failed to implement their Abuse Neglect Exploitation (ANE) policy when LVN D and LVN R did not stop advancing the Foley catheter tubing when Resident #2 was experiencing pain, which resulted in hospitalization . Per region response, the facility's ANE policy was obtained. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy template was provided to the facility on [DATE] at 08:43 PM. While the Immediate Jeopardy was removed on [DATE] at 06:05 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm because LVN D and LVN R did not implement facility abuse policy related to reporting abuse to the Administrator when Resident #2 experienced pain and blood to his urine from advancement of a Foley when there was resistance. This failure could place residents at risk of abuse and neglect. The findings included: Record review of Resident #2's Face Sheet, dated [DATE], revealed a [AGE] year old male admitted on [DATE] with the diagnoses including: Urinary Tract Infection (UTI), Hematuria (blood in the urine), benign prostatic hyperplasia without lower urinary tract symptoms (Age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning such as forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), and heart failure. Record review of Resident #2's Minimum Data Set assessment dated [DATE] revealed he: -Had a BIMS of 00 which indicated severely impaired cognition -Minimal difficulty hearing -Clear speech -Sometimes he was understood by others -Sometimes he understands others -Incontinence of bladder was not rated. Resident #2 had a indwelling catheter -Always continent of bowel Record review of Resident #2's comprehensive care plan dated [DATE] documented, FOCUS: o I require a foley catheter DX Obstructive Uropathy Date Initiated: [DATE] Created on: [DATE] Revision on:[DATE] GOALS: o I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Date Initiated: [DATE] Created on: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o Catheter Care every shift and as indicated. Provide catheter secure band/tape as indicated. Offer/provide a privacy bag or cover drainage bag as indicated. Date Initiated: [DATE] NSG CNA Created on: [DATE] o Change catheter per my physician's orders. Date Initiated: [DATE] Created on: [DATE] Revision on: [DATE] NSG CNA o Check tubing for kinks each shift & during care encounters. Date Initiated: [DATE] Created on: [DATE] NSG o Monitor for s/sx infection. Date Initiated: [DATE] Created on: [DATE] NSG o Monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Date Initiated: [DATE] Created on: [DATE] NSG o Remind pt. not to move foley catheter to prevent leaking and injuries. Date Initiated: [DATE] Created on: [DATE] Record review of Resident #2's Progress Notes revealed Resident #2 was transferred to the hospital on [DATE] due to blood in the Foley catheter bag. Record review of Resident #2's Progress Notes revealed Resident #2 was Record review of Resident #2's physician's orders revealed, Start Date: [DATE] Order Summary: Foley Catheter 20Fr 30CC, change 3weeks and PRN, per (Dr.) (urologist), change foley bag with f/c change as needed related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS Record review of Resident #2's physician's orders revealed, Start Date: [DATE] Order Summary: REFER TO DR. (name) DX: BLOOD LOSS ANEMIA REQUIRING IRON INFUSION. Record review of Resident #2's Treatment Administration Record revealed Resident #2 had a foley catheter change on [DATE]. Record review of Resident #2's progress notes dated [DATE] at 11:39 am written by LVN D revealed, Foley catheter changed due to leaking; resident tolerated well, yellow color urine flow noted. Resident tolerated procedure well, no acute distress at this time. Record review of Resident #2's progress notes dated [DATE] at 02:05 pm written by LVN R revealed, placed call out to Dr. d/t foley catheter changed, resident noted with blood in foley leg bag after foley changed, pending call back. Record review of Resident #2's progress notes dated [DATE] at 5:10 pm written by ADON/RN revealed, May flush foley catheter with 60mls of NS as needed for leakage/blockage as needed for leakage/blockage PRN Administration was: Ineffective resident continues with hematuria, resident being sent to ER Record review of Resident #2's progress notes dated [DATE] at 09:36 pm written by LVN S revealed, Received call from RN stating that resident will be admitted to hospital DX: Hematuria. Record review of Resident #2's progress notes dated [DATE] at 10:13 PM written by LVN S revealed, admitted to Hospital. In a telephone interview on [DATE] at 02:24 pm Complainant, stated sent pictures of foley bag and video through Messenger of the foley change on Resident #2 on [DATE] to surveyor. Observation on [DATE] at 02:25 pm of videos of Resident #2's room with audio of foley catheter change with LVN D, LVN R, ADON/RN, and CNA U. In an interview on [DATE] at 04:05 pm LVN R stated resident asked what they were doing and LVN D told him they were going to change his foley. LVN R could not remember if resident said anything else during the change. LVN R does not recall resident saying anything or crying out. LVN R stated if the resident tells them to stop or cries out, they are supposed to stop because that is what the resident wants. LVN R stated she was not sure what the negative outcome would be if they did not stop when resident said to or cried out. LVN R stated CNAs notified her of blood in catheter bag when they did their 2 hour check. LVN R stated she notified LVN D and ADON/RN they needed to check the catheter bag and then they went to notify the doctor. LVN R stated the doctor stated to continue to monitor and flush. LVN R stated she heard when she returned from her days off that Resident #2 had been sent out to the hospital and she had not worked in that hall since then. LVN R stated the return at the time of the foley change was light red. LVN R stated resident was not medicated before or after the foley catheter change. LVN R stated catheter was changed every two weeks but since his return from the hospital it is every three weeks. LVN R stated she heard that RNs were the only ones to change Resident #2's foley from now on. In an interview on [DATE] T 04:46 pm LVN D stated the DON asked her to assist LVN R with a foley change because two always go in Resident #2's room because the family is particular. LVN D is Medical Records and works the floor and works on call. LVN D stated she had done the foley change on Resident #2. LVN D stated LVN R filled the foley balloon. LVN D stated Resident #2 was not medicated prior to change and did not recall if LVN R gave him something after. LVN D stated Resident #2 did not cry out, say no, or anything. She said he was aware of what was going to happen. LVN D stated she also aided him in breathing when changing the foley. LVN D stated it was not difficult to change the foley catheter. LVN D stated there was yellow urine return when foley catheter was placed. LVN D stated LVN R and a CNA were in the room for the foley change. LVN D stated if a resident says stop or no, we stop. Resident #2 cried out when LVN R inflated the balloon and LVN D told LVN R to stop, deflate the balloon, and get ADON/RN. ADON/RN came in the room and LVN D had pulled catheter out ,d+[DATE]cm and resident did not react. LVN D stated ADON/RN came in and pushed the catheter in and inflated the balloon. She said the resident did not react. LVN D stated at the end of inflating the balloon, LVN D stated she noticed pin-tinged urine at the connection of the tube to bag. LVN D stated she showed ADON / RN. LVN D stated ADON / RN said that sometimes happens when replacing or changing a foley, you get pink tinged urine. LVN D stated they never pulled the catheter out and in and out and in. LVN D did not say what negative outcome would be if they did not stop when resident said to. LVN D stated she was working when they asked the doctor to come in and check resident. LVN D stated the doctor ordered resident to be sent out to the hospital. LVN D stated they let the RP know the catheter needs changed and she decides who is going to change the catheter. LVN D stated she went on break and when she came back, LVN R told her of blood in the catheter bag. LVN D stated when the doctor came in, ADON / RN did rounds with him. In an interview on [DATE] at 05:13 pm ADON/RN stated LVN R came to her and told her LVN D needed her. ADON / RN stated she went to Resident #2's room and LVN D told her when she tried to advance the catheter, she felt resistance and asked for assistance. ADON / RN stated she moved the catheter maybe an inch or two with no resistance and she inflated the balloon. ADON/RN stated the return was yellow with tinge of pink. ADON/RN stated she went back to her office. ADON/RN stated LVN R notified ADON/RN of the hematuria. ADON/RN stated she called the MD and had an order for flush. The ADON/RN stated she flushed the catheter and the resident was not in distress. In an interview on [DATE] at 05:28 pm telephone interview with CNA U stating LVN D and LVN R were in Resident #2's room CNA U stated at the end the ADON/RN came in. CNA U stated she was in the room the whole time when the foley catheter was changed. CNA U stated LVN D was doing the Foley change and LVN R was preparing what LVN D needed. CNA U stated LVN R did not do anything. CNA U stated LVN D did everything. CNA U stated at the beginning the resident was asking what they were doing and why. CNA U stated when they were almost done, the resident started complaining. CNA U stated LVN R left the room to get ADON/RN and LVN D stopped what she was doing. CNA U stated ADON/RN came in and asked the resident if he were in pain and he said he was in a little pain. CNA U stated they started assessing the resident. CNU stated ADON/RN checked the foley catheter and said it was in right. CNA U stated ADON/RN asked the resident again if her were in pain and the resident stated no. CNA U stated LVN D and ADON/RN left and LVN R and her stayed to settle the resident. CNA U stated by the time they left, there was no blood. CNA U stated thirty minutes later, she went to drain the bag and it had dark red blood in the bag missed with urine. CNA U stated the bag was ,d+[DATE] the way full. CNA U stated the Resident #2 was in his room. CNA U stated she went and told LVN R and they both went back to the room to check the foley bag. CNA U said that was at the end of her shift and when she came back to work, he was in the hospital. CNA U stated Resident #2 never cried out and resident would say he had no pain until the end when they went to get ADON/RN. CNA U stated she was unsure if resident received medication before or after for pain. CNA U stated she asked about resident and the nurses told her he had been sent to the hospital because of bleeding. In an interview on [DATE] at 05:45 pm the DON stated she knew about the foley catheter change. DON stated she spoke with RP saying the catheter was leaking. The DON stated LVN R was busy so she asked LVN D to go check his foley catheter. The DON stated one of the LVNs told her the foley was bleeding and the doctor came in and gave orders to send Resident #2 out to the hospital. The DON said RP showed her other videos but she could not remember if she showed her the video of the foley change. The DON stated RP wanted only RNs to change the foley catheter on Resident #2 and the DON told her there were only 2 RNs and if either were at the facility, sure they would, but all the nurses knew how to change a foley catheter. DON stated RP told them it was possibly trauma that caused the bleeding. DON and the administrator were in the administrator's office talking to her and the DON stated if a resident said no or cried out, the nurses should stop because it was the resident's right to say no. In an interview on [DATE] at 06:00 pm the administrator stated he was notified of the resident being sent out to the hospital. The administrator said he did not think the Resident #2's RP showed or attempted to show video of foley catheter change. [DATE] 06:07 pm meeting with DON, LVN R, LVN D, and ADON / RN. Surveyor asked them all if resident cried out, showed discomfort or pain. LVN R and LVN D stated he did not. Surveyor played video where resident was heard yelling, saying no no no, just put a bullet in me, please, please, [NAME], etc. LVNs said nothing. Both LVNs stated that when a resident was in pain or discomfort or calling out, they should stop what they were doing. LVNs would not say anything further. In an interview on [DATE] at 02:33 pm The DON stated she had watched/listened to the video FM sent to administrator. She said she was very upset. The DON stated she was not upset with surveyor, she was hurt, disappointed, and upset with her nurses for lying to her (Resident #2's pain and discomfort). In an interview on [DATE] at 06:35 pm FM stated she was sending the video to administrator's email. [DATE] 08:43 pm IJ presented to facility. [DATE] 12:15 am Facility sent POR to surveyor, ARD, and PM. [DATE] 09:05 am POR accepted. Observation on [DATE] at 05:27 pm of incontinent care of Resident #2 by CNA V and CNA W with no deficiencies cited. In an interview on [DATE] at 02:33 pm The DON stated she had watched/listened to the video FM sent to administrator. She said she was very upset. The DON stated she was not upset with surveyor, she was hurt, disappointed, and upset with her nurses for lying to her. ,d+[DATE]:24 06:05 pm IJ lifted. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 06:05 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Immediate Corrective Action Response: The resident identified as #2 was reassessed on [DATE]. Resident #2's plan of care reviewed to validate that appropriate intervention is in place and noted on the care plan related to foley insertion and care. Regional Nurse / Director of Nursing provided in-service training LVN D (now LVN R), E (now LVN D), and RN ADON regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Identification Risk Response All residents who require and indwelling foley catheter may be at risk of the alleged deficient practice. Director of Nursing / Assistant Director of Nursing / Designee conducted an audit to identify all residents with indwelling foley catheters to identify any resident having s/s of pain associated with the catheter and/or s/ s of hematuria. Outcome: There were no negative outcomes identified. Date completed: [DATE] Director of Nursing / Assistant Director of Nursing / Designee interviewed residents who were identified as interviewable and who require and indwelling foley catheter in order to identify any concerns of pain during the procedure of changing of catheter. Outcome: no negative outcomes identified. Date completed: [DATE] Systemic Change Response The Regional Nurse / DNS educated the licensed nurses regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Director of Nursing / Assistant Director of Nursing and Clinical Leadership will conduct training for all newly hired nurses, PRN nurses and agency nurses prior to the nurses working. In-service training: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Date completed: [DATE] Director of Nursing / Assistant Director of Nursing will require nurses to perform return demonstration of the procedure for the insertion of the foley catheter in order to establish competency prior to the nurse performing this procedure on the actual resident / patient. Date completed: [DATE] The Administrator and Director of Nurses conducted and Ad Hoc QAPI review of this situation and this immediate corrective action plan with the facility's Medical Director. Date completed: [DATE] Monitoring response: Director of Nursing / Assistant Director of Nursing / Designee will conduct at least weekly audits / rounds to inspect resident / residents with indwelling foley catheters to identify s/s of hematuria and will observe nurse / nurses during the procedure of placing / changing an indwelling catheter in order to evaluate competency. Director of Nursing / Assistant Director of Nursing / Designee will review the nursing 24hr report, and progress notes to identify and issues placing / changing the indwelling foley catheter and ensure appropriate follow up interventions are in place. All findings will be reported to the QAPI committee for the next 2 months and the committee will then determine compliance or will determine additional training and oversight is required. Verification: Started on [DATE] at 12:30 PM and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between [DATE] and [DATE]: Head to toe assessments completed on 11 / 11 residents with Foley catheters. 11 /11 resident's foley catheters draining yellow urine. ,d+[DATE] residents foley bag with no blood in the urine or bag. 7 verbal residents out of 7 verbal residents denied pain or discomfort. Interviews with 8 nurses verbalizing understanding regarding: - In-services on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, - Education (computer education), and - Return demonstrations of placing an indwelling foley catheter on dummies both male and female. - Documentation for education and return demonstrations for 97% of nursing staff. 3 PRN nurses will not be allowed on the floor until in-service, education, and return demonstration are completed. Documentation for assessment of 11 residents with indwelling foley catheters with no issues, concerns or change in condition. Record review of the licensed nurse's In-Service Program Attendance Record for the following topic Abuse Neglect and Exploitation Prevention, Reporting and Protecting conducted by DON / designee. 15 LVN's and 1 RN were in-serviced between [DATE] and [DATE]. Record review of the licensed nurse's computer-based education on catheter insertion. 15 LVN's and 1 RN reviewed computer-based training between [DATE] and [DATE]. Record review of the licensed nurse's return demonstration conducted by DON /designee 15 LVN's and 1 RN were in-serviced between [DATE] and [DATE]. Interviews on [DATE] between 12:30 PM and 5:00 PM, the survey team interviewed 8 licensed staff (7 LVN's and 1 RN), interviewed licensed staff verbalized understanding of what they learned during in-services they received between [DATE] and [DATE]. Interview on [DATE] at 02:35 PM, LVN T was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on [DATE] at 03:13 PM, LVN X was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on [DATE] at 03:26 PM, LVN Y was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on [DATE] at 03:43 PM, LVN D was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on [DATE] at 04:04 PM, ADON / RN was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on [DATE] at 04:20 PM, LVN Z was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Observation of Timeline on [DATE] at 08:30 AM: [DATE] 11:10 AM LVN D, LVN R, and CNA entered room to do a foley catheter change. LVN D explained to resident #2 what and why they were there. [DATE] 11:13 AM Resident starts yelling out. LVN D tells him to breathe. [DATE] 11:21 AM LVN D stopped due to resistance and LVN R went to get RN. [DATE] 11:25 AM RN enters room and advances / completes F/C change. Resident does not cry out. [DATE] 11:27 AM RN leaves room. [DATE] 02:05 PM Doctor #1 first notified of blood in foley bag. [DATE] 02:27 PM Doctor #2 (Urologist) notified. His MA said to monitor resident for discomfort or pain. MA stated it was normal for bleeding to occur when foley is changed. [DATE] 02:38 PM Doctor #3 notified. He said to continue to monitor and new order for UA given. [DATE] 04:09 PM Doctor #4 gave order for IV antibiotics for 1 time a day until [DATE]. [DATE] 04:49 PM Doctor #3 went in to see resident. Order for resident to be sent out to hospital. Diagnosis was microscopic Acute Hematuria. [DATE] 05:08 PM EMS called to transport resident to hospital. [DATE] 05:30 PM EMS arrives. [DATE] 09:36 PM resident admitted to hospital diagnosis hematuria (blood in urine). [DATE] 04:51 PM Resident readmitted to facility. In an interview and observation on [DATE] at 12:45 PM The DON stated check off list for POR had 97% of nursing staff signed off. The DON stated the only staff left to be in-serviced, educated, and trained were the PRN staff. The DON stated they would not be allowed on the floor until they completed all. Check off list was reviewed. Review of the facility's policy on Abuse Guidance: Preventing, Identifying, and Reporting Date Implemented: February 2017 Date revised: [DATE] revealed, Types of Abuse -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. -Neglect occurs when the facility is aware of or should have been aware of, goods or services that are resident requires but the facility fails to revive them to the resident that has resulted in or may result in physical harm pain mental anguish or emotional distress. Neglect includes cases where the facilities indifference or disregard for resident care comfort or safety resulted in or could have resulted in physical harm pain mental anguish or emotional distress.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure R#1 received adequate supervision to prevent her from exiting the facility undetected on 03/21/2024. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/21/2024 and ended on 03/21/2024. The facility corrected the non-compliance before the investigation began. Past Non-Compliance form sent to Administrator on 12/20/2024 at 9:59 a.m. This failure could place the residents with exit seeking behaviors at risk for injury or death. The findings included: Record review of R#1's admission record dated 12/18/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and an original admitted [DATE]. Her diagnoses including dementia, muscle weakness, and malnutrition. Record review of R#1's quarterly MDS dated [DATE] reflected a BIMS score of 03, indicating R#1 was severely cognitive impaired and had a wandering behavior that occurred 4-6 days, but less than daily. Record review of R#1's quarterly care plan dated 12/18/2024 reflected a focus of [R#1] she was exit seeking and a risk for elopement and/or wandering with unsafe boundaries r/t cognitive impairment, date initiated 03/27/2024. The following Interventions/tasks created on 03/27/2024 included 1:1 until further notice, and to be distracted from exit seeking by being offered pleasant diversions, structured activities, food, conversation, television, and books. Record review of R#1's admission assessment dated [DATE] completed by LVN S reflected R#1 was not physically able to leave the building on her own and no behaviors were identified. Record review of R#1' progress note dated 01/04/2024 at 11:48 a.m., authored by SW reflected contacted RP to discuss a care plan meeting regarding her [R#1's] care. She was informed that due to her [R1's] decline in memory and wandering, it would be best that we discuss with family options that may include a memory care unit. Record review of R#1's progress note dated 02/19/2024 at 11:40 a.m., authored by the DON reflected Resident noted in front lobby. Re-directed back to dining area for lunch. Record review of R#1's progress note dated 02/20/2024 at 3:57 p.m. authored by LVN L, resident brought back to nurses station from secretary desk and redirected to hall 400. Record review of R#1's progress note dated 02/20/2024 at 4:22 p.m., authored by the SW reflected contacted RP along with DON. We discussed R#1's walking and wanting to go home. RP acknowledged understanding that his mother is at risk for exit seeking. He related that he would be talking with family about sending more support to be with her during the day. He also agreed for care plan meeting on Friday February 23, 2024, at 1pm. Record review of R#1's Exit Seeking Risk Tool dated 02/20/2024 and signed on 03/22/2024 reflected the following behaviors were checked off for R#1 wandering (exhibited wandering and/or confused behavior), confusion (although there is no medical diagnosis with symptoms of confusion, resident sometimes exhibits behavior associated with confusion, possibly leading to wandering in the future), and mobility (resident is physically able to exit on foot or by wheelchair.) Record review of R#1's progress note on 03/22/2024 at 7:27 a.m., authored by LVN L reflected late entry for 03/21/24 during noon time SN was called that resident was outside in the parking lot .resident continues to ask (I want to go home). Record review of R#1's progress note (late entry) on 03/21/2024, authored by LVN L reflected .RP requested to take [R#1] home for a couple of days with all medications to see how resident does at home. Record review of R#1's progress notes reflected she was out on pass from 03/21/2024. Record review of R#1's progress note reflected she was out on pass on 03/22/2024. Record review of R#1's progress note reflected she was out on pass on 03/23/2024. Record review of R#1's progress note reflected she was out on pass on 03/24/2024. Record review of R#1's progress note on 03/25/2024 to 03/28/2024 she had been one a 1:1 monitoring due to her exiting the facility on 03/21/2024. Record review of R#1's progress note on 03/28/2024 at 4:02 authored by LVN O reflected R#1 was discharged . An interview on 12/18/2024 at 12:30 p.m., CNA A said she remembered of at least 2 or 3 times the front receptionist had called the cna's to inform them R#1 was in the front lobby wanting to exit the facility. She said whoever was available would go to the front lobby to re-direct R#1 back to her room. She said she reported R#1's behavior to her charge nurse on several occasions. An interview on 12/18/24 at 12:37 p.m., LVN L, said R#1 would ambulate on her own or on a wheelchair depending on how she would wake up. LVN L said R#1 would sometimes wander into other resident's rooms when not sleeping at night. She said she notified the DON of R#1's behaviors. LVN L said had made a late entry progress note on 03/22/2024 for the 03/21/2024 incident where R#1 exited the facility. She said all she remembered was that the staff was notified R#1 was outside in the front parking lot and had been re-directed back to the facility. She said she R#1 had not sustained any injuries. She said after 03/21/2024, R#1 was on a 1:1 supervision until she was discharged . An interview on 12/18/2024 at 1:06 p.m., the SW said he had contacted R#1's RP regarding her wandering and exit seeking behavior on at least 2 occasions. The SW said staff had notified him of R#1's wandering and exit seeking behaviors and he had also personally observed R#1 in the front lobby trying to exit the facility. He said R#1's wandering and exit seeking behaviors had been discussed with RP and had been informed R#1 would benefit from being in a memory care unit at another facility. He said on 2/20/24, he and the DON called the RP to notify him that R#1 wandering and exit seeking behaviors continued and that she required constant re-direction and at times 1:1 supervision. The SW said RP expressed understanding and had agreed to send family members to assist the facility in caring for R#1. An interview and observation on 12/18/24 at 1:15 pm, the ADON/RN said R#1 was admitted to the facility for rehabilitation services and required a wheelchair to ambulate. She said R#1's mobility started to improve with therapy, and she started walking on her own soon after. ADON/RN said that's when R#1's behavior of wandering and exit seeking began. She said had been advised by the nursing staff that R#1 would try to push to emergency exits doors to exit the facility and would also try to exit the facility through the front doors. She said R#1's behaviors had been discussed in their morning meetings but was not sure if they had been care planned. She said MDS was responsible for care plans. The ADON/RN said the facility did not have wander guards, but the emergency exits do have an alarm. ADON/RN was observed checking R#1's electronic medical record (care plan) to verify if her wandering and exit seeking behavior had been care planned prior to 03/21/24, and she said, I don't see one not for before 3/21/24. ADON/RN was not able to say if there was a negative outcome to R#1 not having her wandering and exit seeking behavior care planned. An interview on 12/18/2024 at 2:18 p.m., the Administrator said on 03/21/2024, R#1 had exited the facility though the front doors and had been found in the middle of the parking lot in front of the facility but did not leave the premises. He said the facility does have surveillance camera's outside the building, but he no longer had the footage of the incident since it had been over 60 days and it had not been saved. The Administrator said certainly [R#1] was wandering but didn't mean that was going to lead to exit. The Administrator said he recalled two previous care plan meetings in which R#1's behavior of wandering and the need for her to be on a 1:1 supervision had been discussed with the IDT and with her RP. The Administrator said he had not reported the incident to state because based on the guidelines he didn't have to. He also said R#1 had been found pretty quickly and didn't seem like they needed to report it. The Administrator said he was not sure if the facility's code yellow was activated. A phone interview on 12/19/2024 at 8:40 a.m., CNA B said that on 03/21/2024 she remembered working the 6a-2p shift. She said sometime in the morning she remembered CNA C and CNA J were taking their break in the dining room located at the end of hall 100 when all of a sudden one of them ran down the hall shouting that R#1 was in the parking lot in the front of the facility. CNA B said both CNA C and CNA J had seen R#1 through the windows while taking their break in the dining room. CNA B said she remembered staff immediately going outside including herself to re-direct R#1. She said by the time she made it outside; R#1 was already being escorted back into the facility by another staff member but got to see R#1 was at the far end of the parking lot which was close to the 2-way street in front of the facility. CNA B said R#1 was dressed in her own personal clothing and was wearing shoes. CNA B said staff had not noticed R#1 missing until CNA C and CNA J saw her through the window. CNA B said she had been in-serviced that same day on exit seeking. An interview on 12/19/2024 at 10:36 a.m., CNA J said that on 03/21/2024 she worked the 6a-2p shift. She said while she and CNA C were taking their break in the dining room located at the end of hall 100, CNA C asked her to look out the window and check if the person walking through the middle of the parking lot was R#1. CNA J said took a quick look and immediately recognized R#1. CNA J said R#1 had already reached the far end of the parking lot, close to the busy two-way street that ran directly in front of the facility. CNA J said that's when CNA C ran down the hall shouting R#1 was in the parking lot in front of the facility. CNA J said she did not see any staff members following R#1 at the time she saw her through the window. She said staff were in-serviced that day on exit seeking behaviors. An interview on 12/19/2024 at 9:55 a.m., CNA C said that on 03/21/2024 she worked the 6a-2p shift. She said while she and CNA J were taking their break in the dining room located at the end of hall 100, she saw a person outside the facility walking through the middle of the parking lot that resembled R#1. She said she immediately asked CNA J to look out the window to confirm if that person was R#1. She said CNA J confirmed that it was R#1 and that's when she ran down the hall shouting R#1 was in the front parking lot in front of the facility. CNA C said by the time R#1 was first noticed outside she had made her way to the far end of the parking lot which was close to the 2-way street in the front of the facility. she did not see any staff member following R#1 when she saw her through the window. CNA C said R#1 was dressed in her own clothing and was wearing shoes. She said staff were in-serviced that day on exit seeking behaviors. An interview on 12/19/2024 at 1:48 p.m., the DON said that on 03/21/2024, R#1 made her way to the front lobby and exited the facility. The DON said the front receptionist was on the phone and when she saw R#1 exit the facility, she quickly hung up the phone and ran after her. She said the receptionist always had eyes on R#1. The DON said despite R#1 being [AGE] years old, she was able to walk fast and was able to make her way to the parking lot before the receptionist caught up to her. The DON said R#1 was redirected back to the facility and had not sustained any injuries. The DON said because R#1 had a low BIMS score, she was not able to say if she lacked safety awareness and/or had a sense of direction. The DON said the incident was not reported to state because R#1 was still in the parking lot. The DON said the reason R#1's exit seeking risk tool dated 02/20/2024 and signed on 03/22/2024 was because she probably forgot to sign it until 03/22/2024. She said even though, she signed it on 03/22/2024 staff had access to see the form on PCC. The DON said code yellow was not activated because R#1 was not missing. She said staff were in-serviced on 03/21/2024 on exit seeking behaviors and code used to alert of a missing resident. Record review of the facility's Elopement and Exit Seeking Management policy dated 2019 and revised in January 2023 reflected: E. Risk response: Identifying those at risk for exit seeking or elopement: 1. IDT will review and/or complete the elopement/exit seeking risk assessment in PCC to determine we have identified those at risk. 3. Update the care plan accordingly. Record review of facility's in-services revealed the following in-services were conducted with staff after the incident: Record review of the facility's in-service reflected the following in-services were conducted with staff after the incident on 03/21/2024: Topic: falls (anticipate resident needs, do not leave resident unattended in room, frequent rounds, exit seeking, and code yellow which was to announce a missing resident) Topic: customer service ( exit seeking, code yellow which was to announce a missing resident, and R#1 requiring 1:1 supervision). An interview on 12/18/2024 CNA's A, B, C, E, F, G, H, I, J, and K said they had been in-serviced on the topics of definitions of exit seeking and wandering, and code yellow. An interview on 12/18/2024 LVN's D, E, L, M, N, O, P, Q and R said they had been in-serviced on the topics of definitions of exit seeking and wandering, and code yellow.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse or neglect, for one of four residents (Resident #2) reviewed for neglect: LVN D and LVN R did not stop advancing the Foley catheter tubing when Resident #2 was experiencing discomfort or pain and crying /groaning out. An Immediate Jeopardy was identified on 12/20/2024. The Immediate Jeopardy template was provided to the facility on [DATE] at 08:43 PM. While the Immediate Jeopardy was removed on 12/21/2024 at 06:05 PM. The IJ was lowered to isolated with no actual harm with a potential for more than minimal harm. This failure could place residents at risk of abuse / neglect resulting in serious injury, harm, impairment or death. Findings include: Record review of Resident #2's Face Sheet, dated 12/20/2024, revealed a [AGE] year old male admitted on [DATE] with the diagnoses including: Urinary Tract Infection (UTI), Hematuria (blood in the urine), benign prostatic hyperplasia without lower urinary tract symptoms (Age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning such as forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), and heart failure. Record review of Resident #2's Minimum Data Set assessment dated [DATE] revealed he: -Had a BIMS of 00 which indicated severely impaired cognition -Minimal difficulty hearing -Clear speech -Sometimes he was understood by others -Sometimes he understands others -Incontinence of bladder was not rated. Resident #2 had a indwelling catheter -Always continent of bowel Record review of Resident #2's comprehensive care plan dated 11/26/2024 documented, FOCUS: o I require a foley catheter DX Obstructive Uropathy Date Initiated: 09/10/2024 Created on: 08/14/2023 Revision on:12/21/2024 GOALS: o I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Date Initiated: 08/15/2023 Created on: 08/15/2023 Target Date: 02/24/2025 INTERVENTIONS/TASKS: o Catheter Care every shift and as indicated. Provide catheter secure band/tape as indicated. Offer/provide a privacy bag or cover drainage bag as indicated. Date Initiated: 08/14/2023 NSG CNA Created on: 08/14/2023 o Change catheter per my physician's orders. Date Initiated: 09/10/2024 Created on: 08/14/2023 Revision on: 09/10/2024 NSG CNA o Check tubing for kinks each shift & during care encounters. Date Initiated: 08/14/2023 Created on: 08/14/2023 NSG o Monitor for s/sx infection. Date Initiated: 08/14/2023 Created on: 08/14/2023 NSG o Monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Date Initiated: 10/02/2024 Created on: 10/02/2024 NSG o Remind pt. not to move foley catheter to prevent leaking and injuries. Date Initiated: 10/02/2024 Created on: 10/02/2024 Record review of Resident #2's Progress Notes revealed Resident #2 was transferred to the hospital on 12/06/24 due to blood in the Foley catheter bag. Record review of Resident #2's Progress Notes revealed Resident #2 was Record review of Resident #2's physician's orders revealed, Start Date: 12/14/24 Order Summary: Foley Catheter 20Fr 30CC, change 3weeks and PRN, per (Dr.) (urologist), change foley bag with f/c change as needed related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS Record review of Resident #2's physician's orders revealed, Start Date: 12/16/24 Order Summary: REFER TO DR. (name) DX: BLOOD LOSS ANEMIA REQUIRING IRON INFUSION. Record review of Resident #2's Treatment Administration Record revealed Resident #2 had a foley catheter change on 12/06/24. Record review of Resident #2's progress notes dated 12/06/2024 at 11:39 am written by LVN D revealed, Foley catheter changed due to leaking; resident tolerated well, yellow color urine flow noted. Resident tolerated procedure well, no acute distress at this time. Record review of Resident #2's progress notes dated 12/06/2024 at 02:05 pm written by LVN R revealed, placed call out to Dr. d/t foley catheter changed, resident noted with blood in foley leg bag after foley changed, pending call back. Record review of Resident #2's progress notes dated 12/06/2024 at 5:10 pm written by ADON/RN revealed, May flush foley catheter with 60mls of NS as needed for leakage/blockage as needed for leakage/blockage PRN Administration was: Ineffective resident continues with hematuria, resident being sent to ER Record review of Resident #2's progress notes dated 12/06/2024 at 09:36 pm written by LVN S revealed, Received call from RN stating that resident will be admitted to hospital DX: Hematuria. Record review of Resident #2's progress notes dated 12/06/2024 at 10:13 PM written by LVN S revealed, admitted to Hospital. In a telephone interview on 12/20/24 at 02:24 pm Complainant, stated sent pictures of foley bag and video through Messenger of the foley change on Resident #2 on 12/06/24 to surveyor. Observation on 12/20/24 at 02:25 pm of videos of Resident #2's room with audio of foley catheter change with LVN D, LVN R, ADON/RN, and CNA U. In an interview on 12/20/24 at 04:05 pm LVN R stated resident asked what they were doing and LVN D told him they were going to change his foley. LVN R could not remember if resident said anything else during the change. LVN R does not recall resident saying anything or crying out. LVN R stated if the resident tells them to stop or cries out, they are supposed to stop because that is what the resident wants. LVN R stated she was not sure what the negative outcome would be if they did not stop when resident said to or cried out. LVN R stated CNAs notified her of blood in catheter bag when they did their 2 hour check. LVN R stated she notified LVN D and ADON/RN they needed to check the catheter bag and then they went to notify the doctor. LVN R stated the doctor stated to continue to monitor and flush. LVN R stated she heard when she returned from her days off that Resident #2 had been sent out to the hospital and she had not worked in that hall since then. LVN R stated the return at the time of the foley change was light red. LVN R stated resident was not medicated before or after the foley catheter change. LVN R stated catheter was changed every two weeks but since his return from the hospital it is every three weeks. LVN R stated she heard that RNs were the only ones to change Resident #2's foley from now on. In an interview on 12/20/24 T 04:46 pm LVN D stated the DON asked her to assist LVN R with a foley change because two always go in Resident #2's room because the family is particular. LVN D is Medical Records and works the floor and works on call. LVN D stated she had done the foley change on Resident #2. LVN D stated LVN R filled the foley balloon. LVN D stated Resident #2 was not medicated prior to change and did not recall if LVN R gave him something after. LVN D stated Resident #2 did not cry out, say no, or anything. She said he was aware of what was going to happen. LVN D stated she also aided him in breathing when changing the foley. LVN D stated it was not difficult to change the foley catheter. LVN D stated there was yellow urine return when foley catheter was placed. LVN D stated LVN R and a CNA were in the room for the foley change. LVN D stated if a resident says stop or no, we stop. Resident #2 cried out when LVN R inflated the balloon and LVN D told LVN R to stop, deflate the balloon, and get ADON/RN. ADON/RN came in the room and LVN D had pulled catheter out 2-3cm and resident did not react. LVN D stated ADON/RN came in and pushed the catheter in and inflated the balloon. She said the resident did not react. LVN D stated at the end of inflating the balloon, LVN D stated she noticed pin-tinged urine at the connection of the tube to bag. LVN D stated she showed ADON / RN. LVN D stated ADON / RN said that sometimes happens when replacing or changing a foley, you get pink tinged urine. LVN D stated they never pulled the catheter out and in and out and in. LVN D did not say what negative outcome would be if they did not stop when resident said to. LVN D stated she was working when they asked the doctor to come in and check resident. LVN D stated the doctor ordered resident to be sent out to the hospital. LVN D stated they let the RP know the catheter needs changed and she decides who is going to change the catheter. LVN D stated she went on break and when she came back, LVN R told her of blood in the catheter bag. LVN D stated when the doctor came in, ADON / RN did rounds with him. In an interview on 12/20/24 at 05:13 pm ADON/RN stated LVN R came to her and told her LVN D needed her. ADON / RN stated she went to Resident #2's room and LVN D told her when she tried to advance the catheter, she felt resistance and asked for assistance. ADON / RN stated she moved the catheter maybe an inch or two with no resistance and she inflated the balloon. ADON/RN stated the return was yellow with tinge of pink. ADON/RN stated she went back to her office. ADON/RN stated LVN R notified ADON/RN of the hematuria. ADON/RN stated she called the MD and had an order for flush. The ADON/RN stated she flushed the catheter and the resident was not in distress. In an interview on 12/20/24 at 05:28 pm telephone interview with CNA U stating LVN D and LVN R were in Resident #2's room CNA U stated at the end the ADON/RN came in. CNA U stated she was in the room the whole time when the foley catheter was changed. CNA U stated LVN D was doing the Foley change and LVN R was preparing what LVN D needed. CNA U stated LVN R did not do anything. CNA U stated LVN D did everything. CNA U stated at the beginning the resident was asking what they were doing and why. CNA U stated when they were almost done, the resident started complaining. CNA U stated LVN R left the room to get ADON/RN and LVN D stopped what she was doing. CNA U stated ADON/RN came in and asked the resident if he were in pain and he said he was in a little pain. CNA U stated they started assessing the resident. CNU stated ADON/RN checked the foley catheter and said it was in right. CNA U stated ADON/RN asked the resident again if her were in pain and the resident stated no. CNA U stated LVN D and ADON/RN left and LVN R and her stayed to settle the resident. CNA U stated by the time they left, there was no blood. CNA U stated thirty minutes later, she went to drain the bag and it had dark red blood in the bag missed with urine. CNA U stated the bag was 1/4 the way full. CNA U stated the Resident #2 was in his room. CNA U stated she went and told LVN R and they both went back to the room to check the foley bag. CNA U said that was at the end of her shift and when she came back to work, he was in the hospital. CNA U stated Resident #2 never cried out and resident would say he had no pain until the end when they went to get ADON/RN. CNA U stated she was unsure if resident received medication before or after for pain. CNA U stated she asked about resident and the nurses told her he had been sent to the hospital because of bleeding. In an interview on 12/20/24 at 05:45 pm the DON stated she knew about the foley catheter change. DON stated she spoke with RP saying the catheter was leaking. The DON stated LVN R was busy so she asked LVN D to go check his foley catheter. The DON stated one of the LVNs told her the foley was bleeding and the doctor came in and gave orders to send Resident #2 out to the hospital. The DON said RP showed her other videos but she could not remember if she showed her the video of the foley change. The DON stated RP wanted only RNs to change the foley catheter on Resident #2 and the DON told her there were only 2 RNs and if either were at the facility, sure they would, but all the nurses knew how to change a foley catheter. DON stated RP told them it was possibly trauma that caused the bleeding. DON and the administrator were in the administrator's office talking to her and the DON stated if a resident said no or cried out, the nurses should stop because it was the resident's right to say no. In an interview on 12/20/24 at 06:00 pm the administrator stated he was notified of the resident being sent out to the hospital. The administrator said he did not think the Resident #2's RP showed or attempted to show video of foley catheter change. 12/20/24 06:07 pm meeting with DON, LVN R, LVN D, and ADON / RN. Surveyor asked them all if resident cried out, showed discomfort or pain. LVN R and LVN D stated he did not. Surveyor played video where resident was heard yelling, saying no no no, just put a bullet in me, please, please, [NAME], etc. LVNs said nothing. Both LVNs stated that when a resident was in pain or discomfort or calling out, they should stop what they were doing. LVNs would not say anything further. In an interview on 12/21/24 at 02:33 pm The DON stated she had watched/listened to the video FM sent to administrator. She said she was very upset. The DON stated she was not upset with surveyor, she was hurt, disappointed, and upset with her nurses for lying to her (Resident #2's pain and discomfort). In an interview on 12/20/24 at 06:35 pm FM stated she was sending the video to administrator's email. 12/20/24 08:43 pm IJ presented to facility. 12/21/24 12:15 am Facility sent POR to surveyor, ARD, and PM. 12/21/24 09:05 am POR accepted. Observation on 12/21/24 at 05:27 pm of incontinent care of Resident #2 by CNA V and CNA W with no deficiencies cited. In an interview on 12/21/24 at 02:33 pm The DON stated she had watched/listened to the video FM sent to administrator. She said she was very upset. The DON stated she was not upset with surveyor, she was hurt, disappointed, and upset with her nurses for lying to her. 12/21:24 06:05 pm IJ lifted. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2024 at 06:05 PM. The facility remained out of compliance at a severity level of 4 and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Immediate Corrective Action Response: The resident identified as #2 was reassessed on 12/20/24. Resident #2's plan of care reviewed to validate that appropriate intervention is in place and noted on the care plan related to foley insertion and care. Regional Nurse / Director of Nursing provided in-service training LVN D (now LVN R), E (now LVN D), and RN ADON regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Identification Risk Response All residents who require and indwelling foley catheter may be at risk of the alleged deficient practice. Director of Nursing / Assistant Director of Nursing / Designee conducted an audit to identify all residents with indwelling foley catheters to identify any resident having s/s of pain associated with the catheter and/or s/ s of hematuria. Outcome: There were no negative outcomes identified. Date completed: 12/21/24 Director of Nursing / Assistant Director of Nursing / Designee interviewed residents who were identified as interviewable and who require and indwelling foley catheter in order to identify any concerns of pain during the procedure of changing of catheter. Outcome: no negative outcomes identified. Date completed: 12/21/24 Systemic Change Response The Regional Nurse / DNS educated the licensed nurses regarding: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Director of Nursing / Assistant Director of Nursing and Clinical Leadership will conduct training for all newly hired nurses, PRN nurses and agency nurses prior to the nurses working. In-service training: - Abuse Neglect and Exploitation Prevention, Reporting and Protecting - Procedure for insertion of indwelling foley catheter. Monitoring, assessing for s/s of pain prior to procedure, during procedure and responding to any complaints of s/s of pain; to include but not limited to stopping the procedure, providing non-pharmacological and pharmacological interventions in order to relieve the resident's discomfort. Insertion of the indwelling foley catheter and if resistance is noted upon insertion and the catheter is not advancing as usual expect process when inserting the catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, then the nurse should notify the PCP for further instructions. Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP. Date completed: 12/21/24 Director of Nursing / Assistant Director of Nursing will require nurses to perform return demonstration of the procedure for the insertion of the foley catheter in order to establish competency prior to the nurse performing this procedure on the actual resident / patient. Date completed: 12/21/24 The Administrator and Director of Nurses conducted and Ad Hoc QAPI review of this situation and this immediate corrective action plan with the facility's Medical Director. Date completed: 12/21/24 Monitoring response: Director of Nursing / Assistant Director of Nursing / Designee will conduct at least weekly audits / rounds to inspect resident / residents with indwelling foley catheters to identify s/s of hematuria and will observe nurse / nurses during the procedure of placing / changing an indwelling catheter in order to evaluate competency. Director of Nursing / Assistant Director of Nursing / Designee will review the nursing 24hr report, and progress notes to identify and issues placing / changing the indwelling foley catheter and ensure appropriate follow up interventions are in place. All findings will be reported to the QAPI committee for the next 2 months and the committee will then determine compliance or will determine additional training and oversight is required. Verification: Started on 12/21/2024 at 12:30 PM and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 12/20/2024 and 12/21/2024: Head to toe assessments completed on 11 / 11 residents with Foley catheters. 11 /11 resident's foley catheters draining yellow urine. 11/11 residents foley bag with no blood in the urine or bag. 7 verbal residents out of 7 verbal residents denied pain or discomfort. Interviews with 8 nurses verbalizing understanding regarding: - In-services on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, - Education (computer education), and - Return demonstrations of placing an indwelling foley catheter on dummies both male and female. - Documentation for education and return demonstrations for 97% of nursing staff. 3 PRN nurses will not be allowed on the floor until in-service, education, and return demonstration are completed. Documentation for assessment of 11 residents with indwelling foley catheters with no issues, concerns or change in condition. Record review of the licensed nurse's In-Service Program Attendance Record for the following topic Abuse Neglect and Exploitation Prevention, Reporting and Protecting conducted by DON / designee. 15 LVN's and 1 RN were in-serviced between 12/20/2024 and 12/21/2024. Record review of the licensed nurse's computer-based education on catheter insertion. 15 LVN's and 1 RN reviewed computer-based training between 12/20/2024 and 12/21/2024. Record review of the licensed nurse's return demonstration conducted by DON /designee 15 LVN's and 1 RN were in-serviced between 12/20/2024 and 12/21/2024. Interviews on 12/21/2024 between 12:30 PM and 5:00 PM, the survey team interviewed 8 licensed staff (7 LVN's and 1 RN), interviewed licensed staff verbalized understanding of what they learned during in-services they received between 12/20/2024 and 12/21/2024. Interview on 12/21/2024 at 02:35 PM, LVN T was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:13 PM, LVN X was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:26 PM, LVN Y was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 03:43 PM, LVN D was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 04:04 PM, ADON / RN was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Interview on 12/21/2024 at 04:20 PM, LVN Z was able to verbalize understanding of the following: in-service on Abuse Neglect and Exploitation Prevention, Reporting and Protecting, computer-based education on catheter placement / insertion, and return demonstration of placing / insertion of an indwelling foley catheter on males and females. Observation of Timeline on 12/23/24 at 08:30 AM: 12/06/24 11:10 AM LVN D, LVN R, and CNA entered room to do a foley catheter change. LVN D explained to resident #2 what and why they were there. 12/06/24 11:13 AM Resident starts yelling out. LVN D tells him to breathe. 12/06/24 11:21 AM LVN D stopped due to resistance and LVN R went to get RN. 12/06/24 11:25 AM RN enters room and advances / completes F/C change. Resident does not cry out. 12/06/24 11:27 AM RN leaves room. 12/06/24 02:05 PM Doctor #1 first notified of blood in foley bag. 12/06/24 02:27 PM Doctor #2 (Urologist) notified. His MA said to monitor resident for discomfort or pain. MA stated it was normal for bleeding to occur when foley is changed. 12/06/24 02:38 PM Doctor #3 notified. He said to continue to monitor and new order for UA given. 12/06/24 04:09 PM Doctor #4 gave order for IV antibiotics for 1 time a day until 12/13/24. 12/06/24 04:49 PM Doctor #3 went in to see resident. Order for resident to be sent out to hospital. Diagnosis was microscopic Acute Hematuria. 12/06/24 05:08 PM EMS called to transport resident to hospital. 12/06/24 05:30 PM EMS arrives. 12/06/24 09:36 PM resident admitted to hospital diagnosis hematuria (blood in urine). 12/14/24 04:51 PM Resident readmitted to facility. In an interview and observation on 12/23/24 at 12:45 PM The DON stated check off list for POR had 97% of nursing staff signed off. The DON stated the only staff left to be in-serviced, educated, and trained were the PRN staff. The DON stated they would not be allowed on the floor until they completed all. Check off list was reviewed. Review of the facility's policy on Incontinence and Catheterization Assessment and Evaluation Date revised: January 2023 revealed, Indwelling Catheter For a resident who was admitted to the community with an indwelling urinary catheter or who had one placed after admission, the community will: -Recognize and assess factors affecting the resident's urinary function and identified the medical justification for the use of an indwelling urinary catheter. -Define and implement pertinent interventions consistent with resident conditions, goals, and recognized standards of practice to try to minimize complications from an indwelling urinary catheter and to remove it if clinically indicated. -Monitor and evaluate the resident's response to interventions. -Revise the approaches as appropriate. Review of the facility's policy on Pain Management Date Implemented: 03/14/2019, Date Revised: [DATE], revealed: Compliance Guidelines: To assess the resident pain control and management needs at admission/readmission, quarterly, annual and when a change of condition indicates a need for initiating or modifying a pain management program for the residents. The goal of the community Pain Management Program is that pain is identified and treated timely, effectively and consistently. OVERVIEW .Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by team members inquiring if they have pain and observation of the resident for nonverbal signs and symptoms of pain.