Every finding on record at Midtown Manor

Based on observation, interview, and record review, the facility did not ensure an effective pest control program so that the facility was free of pests and rodents. Specifically, an observation was made of a live cockroach in the facility and residents and staff reported that cockroaches were found in the resident rooms. Findings included: On 4/29/25 at 9:32 AM, an observation was made outside room [ROOM NUMBER]. Directly outside of room [ROOM NUMBER] and located between room [ROOM NUMBER] and 113 was a plastic Personal Protective Equipment (PPE) cart. The cart contained three drawers that were filled with reusable gowns. The State Surveyor (SS) observed a cockroach crawling across the top of the PPE cart and then into the top drawer. Certified Nursing Assistant (CNA) 9 was standing in the doorframe of room [ROOM NUMBER]. The SS called CNA 9 over to the PPE cart and opened the top drawer. The SS and CNA 9 observed the cockroach crawling on top of the reusable gowns. CNA 9 informed CNA 10, who was walking by the room, of the cockroach found inside the PPE cart. CNA 10 stated that the housekeeper would come and disinfect the cart. CNA 10 stated that she had seen cockroaches in the facility under the sinks inside resident rooms and she just informed housekeeping and they cleaned the room. On 4/29/25 at 10:17 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that they get bugs in the building sometimes, and she had seen them in the hallway, nurse's station, and in resident rooms. RN 2 stated that they had a pest control that came to the facility one time a week. RN 2 stated that the pest control sprayed the edges of the walkways and under the desk at the nurses station. A picture of a cockroach was shown to RN 2 and she confirmed that was the bug that she sees inside the facility. On 4/29/25 at 10:43 AM, an interview was conducted with CNA 2. CNA 2 stated that they had cockroaches in the building. CNA 2 stated that they had pest control come spray the facility weekly. CNA 2 stated that she had observed the cockroaches in the resident rooms and she killed one downstairs coming out of the dining room last week. On 4/29/25 at 11:37 AM, an interview was conducted with the Administrator (ADM). The ADM stated that they sprayed the inside of the building in the common areas every week and the outside perimeter was sprayed quarterly. The ADM stated that once a month they took all the residents to the dining room and sprayed all the rooms. The ADM stated that pests identified in the past were roaches and wasps. The ADM stated that the regular included all rooms in the building that were not resident rooms, and the outside of all doorways and exits. The ADM stated that a total spray would include all rooms including the resident rooms. On 4/29/25 at 1:13 PM, an interview was conducted with the Housekeeping Supervisor (HS). The HS stated that she obtained the PPE cart next to room [ROOM NUMBER] from the back storage shed near the smoking area. The HS stated that she asked the housekeeper to clean the PPE cart, but she did not get to it immediately. The HS stated that she did not know who stocked the cart with PPE before it was cleaned. The HS stated that she was informed that someone found a cockroach inside of the cart. On 4/29/25 at 11:18 AM, a walk-through was conducted in the kitchen and the dry food storage areas. In the dry food storage area, an observation was made of a small dead bug on the floor in front of the food storage shelf. On 4/29/25 at 12:11 PM, a second observation was made of the dry food storage area. Dietary Aide (DA) 1 accompanied the surveyor. DA 1 confirmed there was a small dead bug on the floor in front of the food storage shelf. DA 1 stated a pest control company came twice a week and sprayed the facility to control bugs. DA 1 stated she had not seen any bugs in the kitchen or observed any bugs in the storage areas prior to this one. On 4/29/25 at 1:48 PM, an interview was conducted with the Dietary Manager (DM) who stated an exterminator came two times a week and sprayed the building. The DM stated she would not tolerate bugs in the kitchen.

Based on observation, interview, and record review, for 14 out of 36 sampled residents, the facility did not 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. Specifically, observations were made of staff not performing hand hygiene during meal service and dining assistance; hand hygiene was not performed during wound care and cross contamination of the wound bed was observed; Enhanced Barrier Precautions (EBP) were not implemented for any residents with wounds, indwelling urinary catheters, enteral feeding, or any other indwelling medical device; and the Personal Protective Equipment (PPE) cart was not sanitized prior to use and a cockroach was observed crawling on the PPE. Additionally, the infection prevention and control program did not have a system of surveillance to identify any possible communicable diseases, and tracking and trending of infections was not completed. Resident identifiers: 6, 8, 11, 14, 18, 26, 35, 47, 54, 64, 65, 70, 76, and 280. Findings included: 1. On 4/27/25, the following dining observations were made in the assisted dining room: a. On 4/27/25 at 12:04 PM, a meal tray was served to resident 47 by Certified Nursing Assistant (CNA) 3. CNA 3 was observed to don gloves and cut resident 47's food. CNA 3 doffed her gloves and donned new gloves. No hand hygiene was performed between glove change. CNA 3 then continued to assist in meal tray delivery. b. On 4/27/25 at 12:06 PM, an observation was made of resident 76 spooning food off of resident 18's plate. Resident 18 yelled out hey and resident 76 pulled their spoon away. No staff were observed to intervene. Resident 18 left the dining room table, leaving the plate and remaining food behind. c. On 4/27/25 at 12:11 PM, an observation was made of resident 280 leaning over and picking something up from the ground. CNA 4 was observed to pick up a fork from the floor and hand it back to resident 280. CNA 4 stated that resident 280 was scooping meat from the floor with the fork. CNA 4 stated that she tried to take the dirty fork from the resident but the resident would not allow her to exchange it for a new one. d. On 4/27/25 at 12:21 PM, an observation was made of resident 76 eating food from resident 18's plate and then drank a beverage from resident 18's tray. Resident 76 then drank a beverage from resident 26's tray. No staff were observed to intervene. Resident 76 then attempted to take a second beverage from resident 26's tray and was stopped by CNA 1. 2. On 4/29/25, the following dining observations were made in the assisted dining room: a. On 4/29/25 at 12:07 PM, a meal tray was served to resident 6 by CNA 5. CNA 5 doffed their gloves and new gloves were donned. No hand hygiene was performed between glove change. CNA 5 then served a meal tray to resident 18. b. On 4/29/25 at 12:09 PM, a meal tray was served to resident 76 by CNA 2. CNA 2 doffed their gloves and new gloves were donned. No hand hygiene was performed between glove change. CNA 2 then served a meal tray to resident 8. c. On 4/29/25 at 12:13 PM, an observation was made of CNA 5 assisting resident 76 with dining. CNA 5 donned gloves and was seated next to resident 76. CNA 5 then assisted resident 65 by touching his drinking glass and attempting to load his spoon with food. CNA 5 returned to a seated position next to resident 76. CNA 5 touched resident 76's spoon with the same gloved hand that touched resident 65's spoon. On 4/29/25 at 12:26 PM, an interview was conducted with CNA 2. CNA 2 stated that they changed gloves after every third resident served unless the gloves were soiled. CNA 2 stated that hand hygiene was performed after every two trays served or when they changed their gloves. On 4/29/25 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should change their gloves and perform hand hygiene when they touch a resident or their utensils, plates, or cups. 3. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of gastrostomy status, dysphagia, folate and iron deficiency anemia, severe protein-calorie malnutrition, stage 2 pressure ulcer, congestive heart failure, ischemic cardiomyopathy, and dementia. On 4/27/25 at 9:26 AM, an observation was made of resident 14's Tube Feed (TF) infusing. A urinary catheter bag was observed on the left side of the bed. No signs were posted for EBP for the TF or catheter, and no PPE cart was located nearby. Resident 14's medical record was reviewed. Resident 14's physician orders revealed the following: a. Wound on Right Shoulder: Clean with wound cleanser, apply skin prep to peri wound, apply Medihoney with collagen followed by Calcium Alginate to wound bed, applying a cover dressing (Non-woven Island Dressing). Change Tuesday, Thursday, Saturday and as needed (PRN). The order was initiated on 4/26/25. b. Left Abdomen around gastrostomy tube (G-tube): Clean with wound cleanser, apply skin prep to peri wound, apply stoma ease powder to peri wound, apply small layer of calcium alginate with silver and cut a hole in it to ensure it can be placed around the tube, apply drain sponge, followed by applying a layer of tape. Change daily and PRN. The order was initiated on 4/25/25. c. Protective dressing to Sacrum; clean with wound cleanser, apply skin prep, and cover with foam dressing. Change Monday, Wednesday, Friday and PRN. The order was initiated on 11/13/24. d. Enteral Feed Order every day and night shift Jevity 1.5 45 milliliters per hour (ml/hr) and water 50 ml/hr for 20 hours with a break from 10:00 AM to 2:00 PM. The order was initiated on 4/24/25 and discontinued on 4/27/25. e. Enteral Feed Order every day and night shift Isosource 1.5 45 ml/hr and water 50 ml/hr for 20 hours with a break from 10:00 AM to 2:00 PM. The order was initiated on 4/27/25. f. Change suprapubic (S-P) catheter on 1st Friday of each month and as necessary. The order was initiated on 4/4/25. On 4/28/25 at 10:25 AM, an observation was made of Registered Nurse (RN) 2 performing wound care. RN 2 was assisted by CNA 6. RN 2 sprayed wound cleanser into a package of 4 x 4 gauze. The old dressing was removed from the wound on the right shoulder when the observation began. Resident 14 was lying on the left lateral side. CNA 6 was positioned in front of resident 14 on the left side of the bed. RN 2 was positioned behind resident 14 on the right side of the bed. The wound on the right shoulder was raised, beefy, red and approximately the size of a quarter. RN 2 stated that the wound started as a scrape on the shoulder and it had been getting progressively worse. RN 2 cleaned the wound bed with the gauze soaked in wound cleaner, moving in a circular motion from the inside of the wound bed working outward. RN 2 applied skin prep to the outside of the wound. RN 2 doffed gloves and applied new gloves, no hand hygiene was performed prior to the new gloves being applied. RN 2 applied Medihoney to the wound bed with a cotton tipped applicator. RN 2 cleaned a pair of scissors with a 2 x 2 alcohol swab, then cut a square of the collagen dressing. RN 2 placed the collagen dressing on top of the wound bed. RN 2 then placed a 2 x 2 dressing of Calcium alginate on top of the collagen. RN 2 covered the dressing with a 4 x 4 bordered foam adhesive dressing. RN 2 signed and dated the dressing. RN 2 doffed her dirty gloves and performed hand hygiene with Alcohol Based Hand Rub (ABHR), and new gloves were donned. Neither RN 2 or CNA 6 wore a gown during the wound care of resident 14. RN 2 doffed their gloves and washed their hands in the sink with soap and water. RN 2 donned new gloves. RN 2 cleaned a pair of scissors with a 2 x 2 alcohol prep pad. RN 2 removed the old dressing around the G-tube. RN 2 stated that there was some discharge on the old dressing. RN 2 doffed their gloves, performed hand hygiene with ABHR, and new gloves were donned. RN 2 cleaned the stoma with a 4 x 4 gauze pad soaked in wound cleanser, then wiped dry the skin surrounding the stoma with a clean 4 x 4 gauze pad. RN 2 stated that the stoma was pink and hyper granulated and scant blood was noted. RN 2 applied stoma powder around the site. RN 2 cut a 2 x 2 calcium alginate pad to fit around the G-tube and a drain sponge was applied over it. RN 2 secured the dressing with tape. RN 2 doffed their gloves and cleaned the scissors with a 2 x 2 alcohol prep pad. RN 2 performed hand hygiene at the sink with soap and water. Neither RN 2 or CNA 6 wore a gown during resident 14's G-tube care. On 4/28/25 at 11:09 AM, an interview was conducted with RN 2. RN 2 stated that she typically did not don a gown for wound care. RN 2 stated that hand hygiene should be performed prior to the start of wound care, after removal of the dirty dressing, and upon completion of the wound care. RN 2 stated that she cleaned the scissors prior to use with a purple top Sani Cloth. RN 2 stated she did not know what EBP were and which residents needed to be on them. RN 2 stated that she disconnected resident 14's TF at 10:00 AM. RN 2 stated that she donned gloves only when disconnecting the TF and that she typically did not don a gown for any TF or G-tube care. 4. Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, resistance to multiple antibiotics, carrier of suspected carrier of methicillin resistant staphylococcus aureus, pressure ulcer of left buttocks stage 3, neuropathy, non-pressure ulcer of left and right foot, venous insufficiency, cardiac defibrillator, type 2 diabetes mellitus, atrial fibrillation, mild intellectual disability, and heart failure. On 4/27/25 at 11:57 AM, an observation was made of resident 18 seated in his wheelchair in the assisted dining room. Resident 18 was wearing bilateral orthotic shoes and both feet had dressings intact. Resident 18's medical record was reviewed. Resident 18's physician orders revealed the following: a. Right and Left Heel: Cleanse with wound cleanser, apply skin prep to peri wound and wound bed, followed by applying a heel protector held in place by loose layer of Kerlix and Coban and held in place by loose fitting sock. - if either heel wound starts to open up or drain, apply small amount Calcium Alginate. Change Tuesday-Thursday-Saturday and PRN. The order was initiated on 4/12/25. b. Left Buttock: Clean with wound cleanser, apply skin prep to peri wound, apply small amount of Santyl to wound bed followed by applying a layer of calcium alginate with silver, then apply cover dressing. Change Tuesday-Thursday-Saturday and PRN. The order was initiated on 4/12/25. On 4/29/25 at 8:46 AM, an observation was made of RN 3 performing wound care. RN 3 was assisted by CNA 7 and CNA 8. RN 3 opened a package of 4 x 4 gauze and sprayed wound cleanser inside the packaging onto the dressing. RN 3 donned gloves and squeezed a small amount of Santyl cream into a medication cup. RN 3 cleaned the scissors with a purple top sani wipe and cut a square of allgenate and placed it into the cup with the cream. RN 3 doffed their gloves, gathered the dressing supplies, and entered resident 18's room. CNA 7 and CNA 8 were located in resident 18's room. CNA 7 and CNA 8 donned a reusable gown and disposable gloves and transferred resident 18 to the bed using a mechanical lift. Resident 18's soiled brief was changed by CNA 7 and CNA 8 and resident 18's dressing on the buttocks was observed soiled with stool. RN 3 donned a gown and gloves. RN 3 removed the old dressing from the left buttocks located at the gluteal cleft. RN 3 doffed gloves and new gloves were donned, no hand hygiene was performed. RN 3 cleaned the open wound with a 4 x 4 gauze pad, wiping downward to upward repeatedly. It should be noted that the method used to clean the wound bed was not from the inside of the wound bed working outwards, but rather outside crossing over the area where stool was observed and then crossing over the wound bed repeatedly. RN 3 doffed gloves and new gloves were donned, no hand hygiene was performed. RN 3 applied skin prep to the surround wound bed. RN 3 doffed gloves and new gloves were donned, no hand hygiene was performed. RN 3 scooped the Santyl cream with the allgenate square and applied the dressing to the wound bed with their gloved finger. RN 3 applied a bordered foam dressing over the top of the wound bed. RN 3 doffed their gown and gloves upon completion of the wound care to resident 18's buttocks. On 4/29/25 at 9:21 AM, an interview was conducted with RN 3. RN 3 stated that hand hygiene should be performed before wound care began, with each glove change, after doffing dirty gloves, and upon completion of the wound care. RN 3 stated that the wound bed should be cleaned in a circular motion from the inside outward. RN 3 was asked why the wound bed was cleaned in an upward/downward motion instead, and RN 3 stated it should have been cleaned from the inside out. On 4/29/25 at 11:26 AM, a follow-up interview was conducted with the DON. The DON stated that nurses should perform hand hygiene before and after dressing changes and each time they doffed their gloves before donning new ones. The DON stated that when cleaning a wound bed it should be cleansed with wound cleaner working from the inside of the wound outwards to avoid any cross contamination. The DON stated that it would not be appropriate to clean a wound in an upward and downward motion, moving back and forth over the wound bed. 5. Resident 54 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of anoxic brain damage, gastrostomy status, Parkinsonism, aphasia, dysphagia, and severe protein-calorie malnutrition. On 4/28/25 at 7:40 AM, an observation was made of resident 54's TF infusing. No signs were posted for EBP for the TF or catheter, and no PPE cart was located nearby. Resident 54's medical record was reviewed. Resident 54's physician orders revealed the following: a. Enteral Feed Order every day and night shift Jevity 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/18/25, and discontinued on 4/27/25. b. Enteral Feed every day and night shift Isosource 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/27/25. c. Monitor Percutaneous endoscopic gastrostomy tube site for any signs of infection and cleanse with normal saline and open to air every day and night shift. The order was initiated on 8/19/24. On 4/28/25 at 12:50 PM, an interview was conducted with the DON. The DON stated that she did not currently have any residents on no EBP. The DON stated they used universal precaution of hand hygiene and donning gloves for resident care. The DON stated that staff were not implementing precautions for EBP. 6. Resident 11 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic venous hypertension with ulcer of right and left lower extremity. Resident 11's medical record was reviewed on 4/28/25. On 4/24/25, a wound care note documented . Wound #1 Wound Location: Left anterior shin Wound Diagnosis: Venous Stasis Ulceration (VSU) Wound Duration: 12/5/2024 reported to be recurrent over the last year Wound Progression: Improving, as expected Current Measurement: L [length] 1.8 cm [centimeters] x W [width] 2.9 cm x D [depth] 0.1 cm multiple small sites Previous Measurement: L 2.9 cm x W 4.0 cm x D 0.1 cm multiple small sites Wound Bed Tissue: Hypogranular 15%, Epithelialization 75%, Excoriation 10% Wound Edge: Attached, Well Defined, Demarcated Peri-Wound Tissue: Intact, Edematous, Hemosiderin Staining, Other: Drainage Amount: Small Drainage Type: Serosanguineous Wound Odor: None Indication(s) of Infection: None. will continue to monitor closely. Wound Care Orders: Wound Bed Preparation: Remove cover dressing (if applicable), cleanse wound bed with saline or wound cleanser, then apply the following: Left Anterior Shin: Apply layer of calcium alginate to wound bed, apply two layer wrap extending from the BASE OF TOES TO TWO FINGER WIDTHS BELOW HIS KNEE. Treatment Frequency: 3X/WEEK [three times per week] & PRN Bilateral lower extremities: Apply moisturizer followed by applying tubigrips extending from base of toes to two fingerwidths below knee. Treatment Frequency: Ensure in place daily. On 4/27/25 at 11:39 AM, resident 11 was observed with heal protectors bilateral. Resident 11 stated that he was unsure why he had the heal protectors. Resident 11's room was observed without an EBP signage or PPE. 7. Resident 64 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cystostomy status, chronic kidney disease, and neuromuscular dysfunction of bladder. Resident 64's medical record was reviewed on 4/28/25. A physician's order dated 11/18/22, documented S-P Cath. [catheter] insertion site; cleanse with NS [normal saline], cover with drain sponge, and secure with tape. Change daily and PRN. every day shift. A physician's order dated 12/15/22, documented Change urine leg bag daily. every day shift. A physician's order dated 1/29/25, documented Change S-P catheter on 1st Friday of each month. every day shift starting on the 7th and ending on the 7th every month If a urologist changed, please hold an order. A physician's order dated 1/29/24, documented Change urine down drain bag on Fridays. every day shift every Fri [Friday]. A physician's order dated 11/28/24, documented Check urine output QShift [every shift]. every day and night shift. A physician's order dated 3/14/25, documented Irrigate S-P Catheter once daily at night. 1.Mix 5ml [milliliters] of white vinegar into 360ml of sterile water or distilled water. 2.Instill 60cc [cubic centimeters] of vinegar mixed sterile or distilled water into the bladder and irrigate/aspirate 3-4times. 3.Discard the last aspirate solution. 4.Re-instill 60cc more of vinegar mixed sterile or distilled water. 5. Place catheter to down drain. every night shift for Preventing infection. On 4/27/25 at 1:53 PM, resident 64's room was observed without an EBP signage or PPE. 8. Resident 35 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizoaffective disorder and carrier or suspected carrier of methicillin resistant staphylococcus aureus. Resident 35's medical record was reviewed on 4/27/25 through 4/30/25. An Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed resident 35 had a wound infection and a Multidrug-resistant Organism (MDRO). An Extended Care Facility/Rehab Unit Order and Nursing Care Referral dated 11/25/24, revealed Multiple Drug Resistant Organism (MDRO) Assessment-Current infection or colonization, or history within the past year: Yes MRSA (Methicillin/Oxacillin-resistant Staphylococcus aureus). Current Isolation precautions: Contact precautions . It should be noted that upon entry to the facility, there was no indication outside of resident 35's room that he was on enhanced barrier precautions and no PPE was available outside the door. 9. Resident 70 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with psychotic disturbance, carrier or suspected carrier of methicillin resistant staphylococcus aureus, type 2 diabetes, Parkinsonism, Post Traumatic Stress Disorder, and pain. Resident 70's medical record was reviewed on 4/27/25 through 4/30/25. An admission MDS assessment dated [DATE], revealed resident 70 did not have a MDRO, but had a wound infection. On 4/29/25 at 8:19 AM, an observation was made of CNA 2 placing EBP signs on two of the doors on the secured unit. When CNA 2 was asked why she was putting up the signs she stated she did not know why the residents were on enhanced barrier precautions. CNA 2 stated the supervisor provided staff with a list off residents who should be on enhanced barrier precautions the night before and instructed the staff to put the signage up. Shortly after, a cart was observed in the hallway with gowns and gloves outside the door between the two rooms with the EBP signage. 10. On 4/29/25 at 9:32 AM, an observation was made outside room [ROOM NUMBER]. Directly outside of room [ROOM NUMBER] and located between room [ROOM NUMBER] and 113 was a plastic PPE cart. The cart contained 3 drawers that were filled with reusable gowns. The State Surveyor (SS) observed a cockroach crawling across the top of the PPE cart and then into the top drawer. CNA 9 was standing in the doorframe of room [ROOM NUMBER]. The SS called CNA 9 over to the PPE cart and opened the top drawer. The SS and CNA 9 observed the cockroach crawling on top of the reusable gowns. CNA 9 informed CNA 10, who was walking by the room, of the cockroach found inside the PPE cart. CNA 10 stated that the housekeeper would come and disinfect the cart. CNA 10 stated that she had seen cockroaches in the facility under the sinks inside resident rooms and she just informed housekeeping and they cleaned the room. CNA 9 then turned the PPE cart around so the drawer was facing the wall. On 4/29/25 at 9:46 AM, an observation was made of CNA 9 removing the PPE cart from outside room [ROOM NUMBER]. CNA 9 took the PPE cart to the utility room and placed all of the reusable gowns into a dirty laundry sack. The laundry sack was then placed into a dirty laundry bin. CNA 9 stated that she removed the gowns so that they were not used. The PPE cart was left inside the dirty utility room. On 4/29/25 at 1:07 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the Housekeeping Supervisor (HS) obtained the PPE cart from outside the facility in a storage unit in the backyard area. On 4/29/25 at 1:13 PM, an interview was conducted with the HS. The HS stated that she obtained the PPE cart next to room [ROOM NUMBER] from the back storage shed near the smoking area. The HS stated that she asked the housekeeper (HK) to clean the PPE cart, but she did not get to it immediately. The HS stated that she did not know who stocked the cart with PPE before it was cleaned. The HS stated that she was informed that someone found a cockroach inside of the cart. 11. On 4/30/25 at 11:46 AM, an interview was conducted with the Infection Preventionist (IP). The IP provided the infection control tracking and trending log from January 2024 through March 2025. The IP stated that he had been in charge of the tracking and trending log but it was not all there or complete. The tracking and trending logs were reviewed. No documentation could be found of a facility map with locations and types of infections identified each month. The log contained a monthly list of resident names with a date, type of infection and any antibiotics that were prescribed. On 4/30/25 at 1:05 PM, an interview was conducted with the DON. The DON stated that the list of residents and infections was filled out by her. The DON stated that the IP was responsible for the tracking and trending of the facility infections. On 4/30/25 at 1:14 PM, a follow-up interview was conducted with the IP. The IP stated that he kept track of the antibiotics prescribed to the residents. The IP stated that he did not have any maps for 2024 or 2025. The IP stated that the purpose of the maps was to see where the resident was located in relation to the infections and it helped to track and identify infectious trends. The IP stated that they had not been identifying trends or outbreaks for 2024 or 2025. The IP stated that he had noticed a lot of pneumonia in the building. The IP stated that when a resident was diagnosed with pneumonia they were placed on droplet/contact precautions. The IP stated that it was difficult to maintain the droplet/contact precautions because the residents slept 4 to a room. The IP stated that it was tricky to protect the other residents in the room. The IP stated that they asked the resident on droplet/contact precautions to wear a mask outside of the room, but they did not have any rooms available to isolate the residents by themselves. Review of the facility policy and procedure for Isolation Procedure documented in Standard Precautions under Hand hygiene that hand hygiene was one of the most important measures to prevent and control the spread of disease. The policy documented that hand hygiene should be performed with alcohol-based hand rub or by washing the hands with soap and water. The policy documented Perform hand hygiene: *before and after any direct contact with patients; *immediately after removal of gloves; * before handling an invasive device not requiring a surgical procedure, including central intravacular catheters, urinary catheters or peripheral vascular catheters; *after touching blood, body fluids, secretions, excretions, non-intact skin or contaminated items, even if gloves are worn; *after contact with inanimate objects in the immediate vicinity of the patient; and *after using the lavatory. The policy further documented that gloves were to be changed between tasks and procedures on the same patient after contact with potentially infectious material. The policy documented that hand hygiene should be performed immediately after removing gloves. The policy was obtained from the World Health Organization 2014. Review of the facility policy and procedure for Infection Prevention and Control Program documented that the Infection Preventionist was responsible to Conduct surveillance for facility associated infections and/or communicable diseases. The policy documented that Facility wide surveillance will be performed to identify opportunities to prevent and/or reduce the rate of infection in our residents, employees, and visitors. The policy documented that the IP would communicate to leadership issues specific to facility associated and community acquired infection surveillance and compliance with hand hygiene and use of PPE.

Based on interview and record review, for 3 out of 36 sampled residents, the facility did not ensure that the antibiotic stewardship program included antibiotics use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed an antibiotic to treat an infection and the organism was resistant to that antibiotic, and two residents were prescribed antibiotics to treat an infection without a culture and sensitivity report to indicate if the antibiotic was susceptible to the organism. Resident identifiers: 1, 33, and 64. Findings included: On 4/30/25 at 11:46 AM, an interview was conducted with the Infection Preventionist (IP). The IP provided the infection control tracking and trending log from January 2024 through March 2025. The IP stated that he had been in charge of the tracking and trending log but it was not all there or complete. The tracking and trending logs were reviewed for February and March 2025. 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included benign prostatic hyperplasia, cystostomy status, chronic kidney disease, and neuromuscular dysfunction of the bladder. On 2/2/25, the log of resident infections documented that resident 64 had a Urinary Tract Infection (UTI). The log documented that resident 64 was prescribed Cefuroxime 500 milligram (mg) by mouth two times a day for 7 days. Resident 64's medical record was reviewed. On 2/2/25, resident 64's urinalysis (UA) documented abnormal findings for urine appearance Turbid, white blood cell (WBC) Esterase 3+, Protein 2+, Occult Blood 3+, positive Nitrite, WBC greater than 30, Red Blood Cells greater than 30, crystals present, and many bacteria. The urine culture and sensitivity (C & S) report documented, Greater than 2 organisms recovered, none predominant. Please resubmit another sample if clinically indicated. Greater than 100,000 colony forming units per ml [milliliter]. The report was signed on 2/4/25, and documented on ABX [antibiotics]. On 2/2/25, resident 64's physician ordered, Cefuroxime Axetil Oral Tablet 500 MG (Cefuroxime Axetil), Give 1 tablet by mouth two times a day for UTI for 7 Days. The order summary documented that the order was completed and discontinued on 2/9/25. Resident 64's February 2025 Medication Administration Record (MAR) revealed no documentation to demonstrate that the Cefuroxime was administered. 2. Resident 1 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic subdural hemorrhage, retention of urine, cystostomy status, chronic kidney disease, persistent proteinuria, and malignant neoplasm of the bladder. On 2/11/25, the log of resident infections documented that resident 1 had a UTI. The log documented that resident 1 was prescribed Bactrim double strength (DS) 1 tablet by mouth two times a day for 7 days. Resident 1's medical record was reviewed. On 2/11/25, resident 1's UA documented abnormal findings for WBC Esterase 2+, Protein 1+, Occult Blood trace, and WBC greater than 30. The urine C & S documented Mixed bacterial flora. Less than 10.000 colonies/ml. The report did not contain a sensitivity report or organisms that were identified. On 2/11/25, resident 1's physician ordered, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 7 Days. The order summary documented that the order was completed and discontinued on 2/18/25. Resident 1's February 2025 MAR documented that Septra DS was administered on 2/11/25 through 2/18/25, for a total of 14 doses administered. 3. Resident 33 was admitted to the facility on [DATE] with diagnoses which consisted of chronic kidney disease, benign prostatic hyperplasia, and cognitive social or emotional deficit following cerebral infarction. On 3/30/25, the log of resident infections documented that resident 33 had a UTI. The log documented that resident 33 was prescribed Nitrofurantoin 100 mg by mouth two times a day for 7 days. Resident 33's medical record was reviewed. On 3/29/25, resident 33's UA documented abnormal findings for WBC Esterase 2+ and WBC 11-30. The C & S report documented that the organism was proteus mirabillis and the organism was resistant to Nitrofurantoin. On 3/30/25, resident 33's physician ordered Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI for 7 Days. The order summary documented that the order was complete and discontinued on 4/6/25. Resident 33's March and April 2025 MAR documented that the Macrobid was administered on 3/30/25 through 4/6/25, for a total of 14 doses administered. On 4/30/25 at 1:14 PM, an interview was conducted with the IP. The IP stated that he kept track of the antibiotics prescribed to the residents. The IP stated that he made sure that the proper labs were obtained and followed-up on for any infections that were treated with an antibiotic. The IP stated that he followed up on the prescribed antibiotics by reviewing the monthly pharmacy review. The IP stated that he thought the pharmacist checked to see if the antibiotic that was ordered was appropriate to treat the infectious organism. The IP stated that the pharmacy would let them know if they needed to change the antibiotics. The IP stated that he did not look at the urine C & S report to verify that the antibiotic was susceptible to the organism identified. The IP stated that the purpose of the C & S report was to identify the organism and to see which antibiotic treatment the organism was susceptible to. On 4/30/25 at 2:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the IP was responsible for ensuring that the antibiotics ordered were appropriate. The DON stated that the IP should identify the organism and ensure that the antibiotic ordered was susceptible to determine if it was appropriate to treat the infection. Review of the facility policy and procedure for Infection Prevention and Control Program documented under ANTIBIOTIC STEWARDSHIP PROGRAM that the program included protocols to monitor antibiotic use and resistance including: *Optimizing the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic * Reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and * Implementing a facility-wide system to monitor the use of antibiotics.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. Specifically, for 3 out of 36 sampled residents, a resident taking an antidepressant for skin picking did not have behavior tracking for the medication and residents taking an antidepressant for insomnia did not have their hours of sleep tracked. Resident identifiers: 14, 41, and 55. Findings included: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, paranoid schizophrenia. Resident 55's medical record was reviewed on 4/28/25. A physician's order dated 8/12/21, documented traZODone HCl [hydrochloride] Tablet 50 MG [milligrams] Give 1 tablet by mouth at bedtime for Sleep related to PARANOID SCHIZOPHRENIA. A physician's order dated 4/28/23, documented clomiPRAMINE HCl Oral Capsule 50 MG Give 1 capsule by mouth at bedtime related to EXCORIATION (SKINPICKING) DISORDER. A care plan Focus initiated on 5/3/23, documented that resident 55 had the potential or actual impairment to skin integrity of head and arms related to picking on skin. The interventions included, but were not limited to, identify and document potential causative factors and eliminate or resolve where possible. The March 2025 Behavior Monthly Flow Sheet was reviewed. Resident 55 was not being tracked for hours of sleep and skin picking. On 4/28/25 at 1:13 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she would document on the weekly assessment and in the progress note if resident 55 was picking his skin. RN 2 stated that she would also note in the progress note if the wounds needed cleaning. RN 2 stated that insomnia would be a behavior that staff were monitoring and some residents had that monitor on the behavior monitoring sheets. RN 2 stated if the night shift noticed the resident was not sleeping well they would document on the behavior sheet. RN 2 stated the night shift would also pass it on to the day shift if they noticed anything. RN 2 confirmed that staff were not tracking hours of sleep for resident 55. On 4/28/25 at 1:44 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the skin picking should be a behavior on the tracking sheet and staff should add that. 2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, schizophrenia. Resident 41's medical record was reviewed on 4/28/25. A care plan Focus initiated on 4/2/24, documented that resident 41 had congestive heart failure. The interventions included, but were not limited to, monitor and document sleeping pattern, inform physician of any insomnia or anxiety, and give sedatives as ordered. A physician's order dated 4/2/24, documented traZODone HCl Oral Tablet 100 MG Give 100 mg by mouth at bedtime for Insomnia. The March 2025 Behavior Monthly Flow Sheet was reviewed. Resident 41 was not being tracked for hours of sleep. On 4/28/25 at 11:52 AM, an interview was conducted with RN 2. RN 2 confirmed that resident 41 was taking trazodone for insomnia and hours of sleep were not being tracked. RN 2 stated when the medication was a new medication to the resident she would do tracking but if the medication was establish she might not continue to do the tracking. RN 2 stated that without the tracking they would not be able to track if the medication was effective or not. 3. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, insomnia, and dementia. Resident 14's medical record was reviewed. A physician order dated 2/20/25, documented, traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg by mouth at bedtime related to INSOMNIA. A physician order dated 2/21/25, documented, Melatonin Oral Tablet 3 MG (Melatonin) Give 3 mg by mouth at bedtime related to INSOMNIA. The April 2025 monitoring monthly flow sheet was reviewed. Resident 14 was not being monitored for hours of sleep. On 4/28/25 at 11:34 AM, an interview was conducted with the DON. The DON stated that they did not document hours of sleep for hypnotics or medications to aide in sleep. The DON stated that the nursing staff would pass off in report to the next shift if a resident was not sleeping. The DON stated that they only documented for episodes of behaviors and adverse side effects of medications.

Based on interview and record review, the facility failed to complete transmitting annual and quarterly Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) for 4 out of 36 sampled residents. Specifically, resident's MDS assessments were not accepted by the facility after being exported. Resident identifiers: 32, 38, 62, and 71. Findings included: 1. Resident 71 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, major depressive disorder, and post-traumatic stress disorder. An annual MDS assessment had an assessment reference date (ARD) of 3/22/25. The MDS assessment was exported on 3/28/25, but not accepted by the facility and not submitted to CMS. 2. Resident 62 was admitted to the facility on [DATE] with diagnoses which included cardiorespiratory condition, schizophrenia, and thyroid disorder. A quarterly MDS assessment had an ARD of 3/23/25, and was completed on 3/28/25. The MDS assessment was not accepted by the facility and not submitted to CMS. 3. Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, osteoarthritis, and paranoid schizophrenia. A quarterly MDS assessment had an ARD of 3/27/25, and was completed on 4/9/25. The MDS assessment was exported on 4/14/25, but not accepted and not submitted to CMS. 4. Resident 38 was admitted to the facility on [DATE] with diagnoses which included dementia, dysphagia, and mental health disorder due to known physiological condition. A quarterly MDS assessment had an ARD of 3/22/25, and was completed on 3/22/25. The MDS assessment was exported on 3/28/25, and was not accepted and not submitted to CMS. On 4/30/25 at 9:17 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she completed the MDS assessments and then exported them to CMS. The MDS Coordinator stated after the MDS assessment was exported, then she needed to accept the MDS assessment. The MDS coordinator confirmed she did not accept the above MDS assessments.

Based on interview and record review, the facility did not ensure that each residents drug regimen was free from unnecessary drugs. Specifically, for 2 out of 36 sampled residents, a resident taking an anticoagulant medication did not have adequate monitoring and a resident taking a vasodilator for high blood pressure did not have that medication held per the physician's ordered parameters. Resident identifiers: 7 and 41. Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diastolic congestive heart failure, chronic atrial fibrillation, essential hypertension, and venous insufficiency. Resident 41's medical record was reviewed on 4/28/25. A care plan Focus initiated on 4/2/24, documented that resident 41 was on anticoagulant therapy related to atrial fibrillation. The interventions initiated included, but were not limited to, a. Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness every shift. b. Monitor, document, and report as needed adverse reactions of anticoagulant therapy to include blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. A physician's order dated 4/1/24, documented Apixaban Oral Tablet 5 MG [milligrams] Give 5 mg by mouth two times a day related to CHRONIC ATRIAL FIBRILLATION. The Side Effects Monthly Flow Sheet was reviewed for March 2025. Apixaban was not listed as a medication that was being monitored. On 4/28/25 at 11:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated when the medication was a new medication to the resident she would do tracking but if the medication was established she might not continue to do the tracking. RN 2 stated that without the tracking they would not be able to track if the medication was effective or not. RN 2 stated if a resident was on apixaban she would do a weekly assessment. RN 2 stated the weekly assessment would include a skin check and everything in a basic assessment and would be documented in a progress note. RN 2 stated if a resident was on an anticoagulant she would look for discoloration on the skin that could indicate bleeding and she would check vital signs. RN 2 stated that a weekly and monthly skin assessment was completed. On 4/28/25 at 12:04 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that anticoagulants were care planned for monitoring. On 4/28/25 at 1:44 PM, a follow up interview was conducted with the DON. The DON stated for an anticoagulant medication she would add it to the care plan but not on the tracking paper. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which consisted of chronic kidney disease, hypertension, and dementia. Resident 7's medical record was reviewed. On 2/13/24, resident 7 had an order initiated for Hydralazine hydrochloride Oral Tablet 25 mg, give 1 tablet by mouth three times a day related to hypertension. Hold if systolic blood pressure was less than 110. Resident 7's April 2025 Medication Administration Record documented that the medication was given when it should have been held on the following dates and times: a. On 4/11/25 at 10:00 PM, BP was 107/88; b. On 4/17/25 at 9:30 AM, blood pressure (BP) was 102/56; c. On 4/19/25 at 9:30 AM, BP was 100/60; d. On 4/24/25 at 10:00 PM, BP was 100/68; e. On 4/25/25 at 4:00 PM, BP was 108/58; f. On 4/25/25 at 10:00 PM, BP was 108/not legible. On 4/30/25 at 8:08 AM, an interview was conducted with the DON. The DON confirmed that the Hydralazine was given when it should have been held per the physician ordered parameters.

Based on interview and record review, for 1 out of 36 sampled residents, the facility did not ensure that residents were free from abuse. Specifically, a resident with a history of aggressive behavior,who required supervision, struck another resident. Resident identifiers: 18 and 33. Findings included: An entity 358 incident report was submitted to the State Survey Agency on 5/15/24. The report revealed that a smoking aid was taking resident 33 out to assist him to smoke. The smoking aid turned to open the door and resident 33 struck resident 18. The incident happened in the Foyer of the nursing home at approximately 5:35 PM. No serious bodily injury was reported. The report stated that resident 33 had a history of aggressive behaviors and required supervision. The report stated both residents were redirected, with resident 33 being redirected to his room. Resident 33's legal guardian was at the facility at the time of the incident and was informed. Law enforcement and Adult Protective Services were notified. It should be noted that a second incident report was submitted to the State Survey Agency on 5/29/24, where resident 33 struck resident 18 in the back of the head. Resident 33 was sent out for behavior management. The report was closed with no action needed. 1. Resident 18 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease, intellectual disabilities, and schizoaffective disorder. Resident 18's medical record was reviewed between 4/27/25 and 4/30/25. A Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed that resident 18 had a Brief Interview for Mental Status (BIMS) score of 00 suggesting significant cognitive impairment. His assessment also revealed resident 18 had physical behavior symptoms directed toward others 4 to 6 days of the look-back period, but less than daily, verbal behavior symptoms daily and behavioral symptoms not directed toward others that occurred daily. Resident 18's progress notes revealed: a. On 5/15/24 at 6:00 PM, an Incident note revealed, Resident sitting in geri-chair in foyer waiting to smoke; staff observed another resident punch [resident 18] in the R [right] knee but was unable to intervene in time; resident assessed by nurse, no injuries apparent, resident reports mild pain to R knee and rates at a 3/10; ADON [Assistant Director of Nursing], MD [Medical Doctor] and administrator notified. b. On 5/29/24 at 4:20 PM, an Incident note revealed, Resident sitting in geri-chair in day room talking to staff member; staff observed another resident punch [resident 18] on the R side of the head but was unable to intervene in time; resident assessed by nurse, redness noted to the R ear, resident reports pain to R ear as a 5/10; administrator, DON [Director of Nursing], resident advocate, MD, and police notified. 2. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia, anxiety disorder, major depressive disorder, and cognitive social or emotional deficit following cerebral infarction. On 4/27/25 at 9:42 AM, an interview was conducted with resident 33 who stated he felt he was able to get along with everyone at the facility. Resident 33 stated that the staff may not say that he gets along with everyone. Resident 33's medical record was reviewed between 4/27/25 and 4/30/25. A quarterly MDS assessment dated [DATE], revealed resident 33 had a BIMS score of 10 suggesting moderate cognitive impairment. This assessment also revealed that resident 33 had behaviors directed toward others on 4 to 6 days, but not daily, had verbal behaviors daily toward other residents, and had other behaviors not directed toward others on a daily basis. The assessment revealed resident 33 had mood symptoms of trouble concentrating and sleeping. Physician orders included: a. Depakote extended release Oral tablet; 500 milligrams (mg) by mouth. b. Clozapine Oral tablet 100 mg by mouth. Resident 33's care plan was reviewed. There were no care areas to address resident 33's behaviors directed toward other residents or for monitoring resident 33 for incident prevention. Resident 33's progress notes revealed: a. On 5/15/24 at 5:56 PM, an incident note revealed, Resident escorted from room to smoking room, staff turned to open smoke room door for resident to enter room, when staff turned back resident was observed punching another resident in the R knee; staff unable to intervene in time; guardian, ADON, MD and administrator notified. b. On 5/17/24 at 10:20 PM, an alert note revealed, Resident needs to be reminded to stay away from hallways and high traffic areas and wait for smoke aid to take him to smoke instead of coming out looking for him and to refer to his smoking schedule posted in his room. No further altercations. c. On 5/24/24 at 6:46 AM, a Health Status note revealed, Resident is A & O [alert and oriented] x 2 [person and place], delusional thinking, will act up on paranoia at times, has had restrictions to not smoke around other residents as he has the tendency to strike out without being provoked .Plan of care ongoing. d. On 5/28/24 at 11:43 AM, a No Type Specified note revealed, Resident returned from the Clozaril clinic with the following note, continued delusions and physical altercations, . Invega 234 mg IM [intramuscular] due 6424 [6/4/24], continue medications as ordered, return June 25th. e. On 5/29/24 at 2:00 PM, a Plan of Care Note revealed, IDT [interdisciplinary team] and the legal guardian reviewed and discussed about current plan of care. f. On 5/29/24 at 4:20 PM, an Incident Note revealed, Resident wheeled up to another resident in his W/C [wheelchair] while other resident was talking to staff and unprovoked stood up and punched other resident in the side of the head. staff observed incident but was unable to intervene in time; nurse assessed resident; no apparent injures [sic]; Administrator, DON, resident advocate, guardian, MD, and police notified. g. On 5/29/24 at 6:05 PM, an Order note revealed, New order: transfer to [name of facility redacted] ED [emergency department] via ambulance for danger to others. h. On 5/29/24 at 6:30 PM, a Transfer to Hospital Summary revealed, Resident 33 was transferred to [name of facility redacted] ED via [name redacted] ambulance. Paramedics accompanied. On 4/30/25 at 3:31 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2 who stated staff checked on resident 33 multiple times per day. CNA 2 stated resident 33 had calmed down quite a bit. CNA 2 stated resident 33 used to go outside to smoke with other residents, but he started smoking by himself, then started smoking alone in the smoking room, and now he does not smoke at all. CNA 2 stated resident 33 and resident 18 did not get along. CNA 2 stated resident 33 and resident 18 no longer interacted with each other. CNA 2 stated resident 33's behaviors had improved. CNA 2 stated she was not aware of any particular interventions that had been put into place to prevent altercations between resident 33 and resident 18, but the residents did not interact with each other and there had been no problems. On 4/30/25 at 3:56 PM, an interview was conducted with Registered Nurse (RN) 1 who stated resident 33 was a quiet resident. RN 1 stated resident 33 spent a lot of time in his room. RN 1 stated staff monitored resident 33 closely and she and the Resident Advocate (RA) spent a lot of time with resident 33, taking him for walks, and taking him shopping. RN 1 stated resident 33 did not verbalize his feelings and when things would build up it would just all come out. RN 1 stated resident 18 was very loud and had behaviors constantly. RN 1 stated resident 18 wanted to go out and smoke constantly and aggravated other residents constantly. RN 1 stated when resident 33 hit resident 18 it was intentional. RN 1 stated the RA was constantly going to resident 33's room, and taking him to activities. RN 1 stated the nurses notes should state how residents were being monitored. RN 1 also stated she was not sure if there was a care plan for resident 33's behaviors.

Based on observation, interview, and record review, for 1 out of 36 sampled residents, that the facility did not ensure that the resident had the right to communicate with individuals and entities within and external to the facility with reasonable access to a telephone, including the right to privacy of such communications. Specifically, a resident on the secure unit was not provided access to a private area to make phone calls. Findings included: Resident 47 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, morbid obesity, avoidant personality disorder, chronic kidney disease, and schizoaffective disorder. On 4/27/25 at 2:30 PM, an observation of resident 47 was made sitting on a chair in the hallway talking on the phone. There were other residents and staff in the hallway. A staff member came and stood by resident 47. Resident 47 looked up at the staff member and stated, do you mind I am talking to my mom. The staff member left and walked down the hallway. On 4/28/25 at 9:03 AM, an interview was conducted with resident 47 who stated residents had to use the phone in the hallway. Resident 47 stated it bothered him that he had to talk on the phone in the hallway and he stated he was only allowed to use the phone for 15 minutes. On 4/28/25 at 12:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2 who stated residents on the unit could use the phone. CNA 2 stated resident 47 called his mom all the time and another resident received a call from a family member every day at 4:30. CNA 2 stated the phone was kept in a room where the cigarettes were kept so they could not allow the resident to sit in that room for phone calls. CNA 2 stated a chair was placed in the hallway outside the room so the residents could talk on the phone. CNA 2 stated there was not really an area on the unit where residents could make private phone calls. On 4/29/25 at 8:40 AM, an observation was made of a resident standing at the nurses station talking on the phone. There were several residents in the area as well as staff members. The resident's conversation was clearly heard by the surveyor from across the hall. On 4/30/25 at 1:32 PM, an interview was conducted with Registered Nurse (RN) 2 who stated the phone at the nurses station was the resident's phone. RN 2 stated the residents could go to the resident advocate's office if they wanted privacy. On 4/30/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON) who stated staff could take residents from the secure unit to the Resident Advocate's (RA) office to make private phone calls. The DON stated the RA also had a tablet that residents could use to make calls to loved ones. The DON stated she would talk to the staff and to resident 47 so that he would know he had the ability to make private phone calls and a staff member could assist him if needed. The DON acknowledged it was a resident right to have private conversations.

Based on interview and record review, for 1 out of 36 sampled residents, the facility did not provide or obtain laboratory services only when ordered by a physician. Specifically, a lab was obtained for a Valproic acid level without a physician order. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, insomnia, dementia, post-traumatic stress disorder, major depressive disorder, and alcohol abuse. A physician order dated 2/20/25, documented, Valproic Acid Oral Solution 250 MG [milligram]/5ML [milliliter] (Valproate Sodium) Give 15 ml by mouth two times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE. On 12/18/24, resident 14 had a laboratory result obtained for a Valproic Acid level. No documentation could be found for a physician order for the lab. On 4/28/25 at 1:06 PM, an interview was conducted with the Charge Nurse (CN). The CN stated he was not able to locate the lab order for the Valproic acid that was obtained on 12/18/24. The CN stated the process was to obtain a telephone order, document the order in a nurse note, fill out the order, place the lab in the requisition book for the laboratory to obtain, and then he would follow-up with the results.

Based on interview and record review, the facility did not ensure that the individual working in the facility as a nurse aide was not employed for more than 4 months unless that individual had completed a training and competency evaluation program approved by the State and had been deemed competent to provide nursing related services. Additionally, the facility may not use a temporary, per diem, or any other than a permanent employee who does not meet the competency evaluation program. Specifically, a staff member who did not complete the nurse aide competency evaluation program within 4 months continued to provide nursing related services to residents. Staff identifier: Nurse Assistant (NA) 1. Findings included: On 4/28/25, the facility provided a current employee contact list with job title and date of hire. The list did not contain information for NA 1. On 4/29/25 at approximately 3:45 PM, an interview was conducted with the Administrator (ADM). The ADM provided the telephone number for NA 1. The ADM stated that NA 1 worked as needed and had initially been hired as a dietary aide. The ADM stated that the employee then transitioned into a NA position at the facility. The ADM stated that NA 1 did not complete their certification program within the 4 months of working as a NA and was transitioned back to dietary services. The ADM stated that the employee was now currently enrolled in a Certified Nursing Assistant (CNA) program. The ADM stated that the employee worked on 4/27/25, as a NA and they should not have been working in that capacity and providing nursing services. The ADM stated that NA 1 was called into work and the staff who contacted her did not know that they were not allowed to work as a NA. On 4/30/25 at 11:08 AM, a telephone interview was conducted with NA 1. NA 1 stated that she worked on 4/27/25 from 6:00 AM to 6:00 PM, to cover for another NA. NA 1 stated that she provided nurse aide services on 4/27/25, and was assigned to rooms 106, 105, 108, 109, 112, and 113. NA 1 stated that she had worked at the facility for 3 years and had started working as a NA from August 2024 through September 2024 and then switched back to the the kitchen in October 2024. NA 1 stated that she had finished the CNA coursework on 4/9/25, and needed to take the test.

Based on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, residents oxygen tubing was not properly labeled. Resident identifiers: 33 and 37. Findings included: 1. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, major depressive disorder, and sleep apnea. On 4/27/25 at 9:48 AM, an interview was conducted with resident 33. During the interview resident 33 was asked about his use of oxygen. Resident 33 stated he had just started using the oxygen the day before. An observation was made of the concentrator in resident 33's room. There was no labeling on the tubing or the concentrator. Resident 33's medical record was reviewed on 4/27/25 through 4/30/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident 33 was on oxygen therapy while a resident at the facility. A review of resident 33's physician orders revealed, Change oxygen tubing and clean filter on Sundays. Every day shift, every Sunday. On 4/10/25 at 3:50 PM, a progress note revealed, Oxygen 2-5 Liters via nasal cannula, keep saturations greater than 90% every day and night shift, change oxygen tubing and clean filter on Thursdays, day shift. Resident 33's care plan included, [Resident 33] has emphysema/COPD [chronic obstructive pulmonary disease] r/t [related to] smoking. The care plan was initiated on 5/24/23. The goal was, [Resident 33] will be free of s/sx [signs and symptoms] of respiratory infections through review date. and [Resident 33] will display optimal breathing patterns daily through review date. Interventions included, .Oxygen settings: O2 [oxygen] via nasal prong//mask @ 2-5L [liters]. Keep oxygen saturation greater than 90%. 2. Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, heart disease, and anxiety disorder. On 4/27/25 at 12:49 PM, an interview was attempted with resident 37. An oxygen concentrator was observed to be running and next to his bed. The cannula was laying on the bed. Resident 37 was asked if he used oxygen 24 hours a day or only at night and the resident refused to answer. The oxygen tubing was observed to have no labeling on the tubing. Resident 37's medical record was reviewed on 4/27/25 through 4/30/25. A Quarterly MDS assessment dated [DATE], revealed that resident 37 was on oxygen therapy while at the facility. A review of physician orders included: a. Oxygen 3-4 L via nasal cannula continuously. Keep oxygen saturation greater than 90% (except smoking). Every day and night shift. Start date: 6/23/23. b. Clean oxygen filter and change oxygen tubing on Thursday. Every day shift every Thursday. Start date: 1/4/24. A review of resident 37's care plan revealed the following: a. [Resident 37] has coronary artery disease (CAD) r/t Atherosclerosis. The care plan was initiated on 8/17/17. The goal was, [Resident 37] will be free from s/sx of complications of cardiac problems through the review date. Interventions included, .Oxygen settings: O2 via nasal prongs @ 2 L. Keep oxygen saturation greater than 90%. b. [Resident 37] has emphysema/COPD r/t smoking. The care plan was initiated on 11/29/17. The goal was, [Resident 37] will display optimal breathing patterns daily through review date. and [Resident 37] will be free of s/sx of respiratory infections through review date. Interventions included, .Oxygen settings: O2 via nasal prongs @ 3L. Keep oxygen saturation greater than 90%. On 4/29/25 at 8:47 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5 who stated water on the oxygen concentrators was checked every day to ensure it was changed and the CNAs on the night shift changed the oxygen tubing every two weeks. CNA 5 stated they do not need an order to change the oxygen tubing. CNA 5 also stated she had not changed it because she worked on the day shift. On 4/30/25 at 8:14 AM, an interview was conducted with the CNA Supervisor who stated the CNAs on the day shift do the cleaning on the oxygen concentrators and change the cannulas. The CNA Supervisor stated usually the whole water bottle was changed out, but occasionally they would wash out the bottles and re-use them. The CNA Supervisor stated the CNAs were supposed to put tape on the tubing and date it so staff would know when it was changed. The CNA Supervisor stated the CNAs were hurried and did not label the tubing. The CNA Supervisor stated the nurses have the orders for when the tubing needs to be changed and tell the CNAs who need to have the tubing changed and the concentrator cleaned.

Based on observation, interview, and record review, for 1 out of 36 sampled residents, the facility did not ensure that the resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. Specifically, a resident was observed lying flat during an enteral tube feed infusion. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of anoxic brain damage, gastrostomy status, Parkinsonism, aphasia, dysphagia, and severe protein-calorie malnutrition. On 4/28/25 at 7:40 AM, an observation was made of resident 54's tube feed (TF) infusing. Resident 54 was lying flat in bed on the left lateral side. The head of the bed was not elevated. A bag of Isosource 1.5 calorie was infusing at a rate of 72 milliliters per hour (ml/hr) with 200 milliliters (ml) remaining in the bag. The water flush bag was infusing at a rate of 70 ml/hr with 400 ml remaining in the bag. The formula bag was dated 4/27/25 at 6:00 PM, and was labeled with the resident name. Resident 54's medical record was reviewed. Resident 54's physician orders revealed the following: a. Enteral Feed Order every day and night shift Jevity 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/18/25 and discontinued on 4/27/25. b. Enteral Feed every day and night shift Isosource 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/27/25. On 10/20/22, resident 54 had a care plan initiated for required a tube feeding related to dysphagia, swallowing problem, and weight loss. Interventions identified on the care plan included: See Medical Doctor orders for current feeding orders; check tube placement and gastric contents/residual volume and hold feed if greater than 100 ml aspirate; discuss with resident any concerns about tube feeding, advantages, disadvantages, and potential complications; monitor for aspiration, tube dislodgement, infection, self-extubation, constipation/diarrhea, nausea and vomiting and dehydration; provide care to gastrostomy tube site as ordered; and Registered Dietician to evaluate caloric intake and estimate needs. On 10/20/22, resident 54 had a care plan initiated for had a swallowing problem related to coughing or choking during meals or swallowing medications, and loss of food/liquids from mouth while eating. Interventions identified on the care plan included: all staff to be informed of the resident's dietary and safety needs; alternate small bites and sips; use a teaspoon for eating; do not use straws; check mouth after meals for pocketed food and provide oral care to remove debris; keep head of bed elevated 45 degrees during meal and thirty minutes afterwards; monitor for shortness of breath, choking, labored respirations, and lung congestion; oral suction as needed; and oral intake with supervision only. On 4/30/25 at 7:31 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the risk for aspiration increased during TF infusion if the head of the bed was not elevated. RN 1 stated that the head of bed should be elevated to 45 degrees. RN 1 stated that resident 54 had a history of aspiration and that was why he needed to be seated upright when eating and required supervision when eating. RN 1 stated that resident 54's head of bed should be elevated when the TF was infusing to prevent aspiration. On 4/30/25 at 9:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident's head of bed should be elevated to 30 to 45 degrees when the TF was infusing. The DON stated that if the head of the bed was not elevated it could cause reflux, vomiting or aspiration. Review of the facility policy for Enteral Feedings - Safety Precautions documented under Preventing aspiration .3. Always elevate the head of the bed (HOB) at least 30 - 45 degrees during tube feeding and at least 1 hour after. If elevating the HOB is medically contraindicated, use the reverse Trendelenburg position.

Based on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls without continued attempts at interventions to prevent additional falls and a cognitively impaired resident had access to cleaning chemicals. Resident identifiers: 37 and 76. Findings included: 1. Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, heart disease, and anxiety disorder. Resident 37's medical record was reviewed between 4/27/25 and 4/30/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident 37 had a Brief Interview for Mental Status (BIMS) score of 8 suggesting moderate cognitive impairment. It also revealed that resident 37 required supervision for most self care activities, was dependent for showering/bathing, and required supervision with mobility. Resident 37's progress notes were reviewed: a. On 1/11/25 at 5:16 PM, an incident note revealed, Resident stated that he rolled out of bed last night and got himself up. He didn't tell night shift nurse. He complained more pain on Rt. [right] leg. able to perform ROM [range of motion] and No injury. b. On 4/6/25 at 5:11 PM, an incident note revealed, was notified that resident had fall in the room. resident stated that he was standing by the sink and fell onto the floor while turning around towards his bed. he complained pain at his left back of his head. no visible bruises or injuries noted at this time. ROM was intact. ADON [Assistant Director of Nursing], MD [medical doctor], and guardian notified. Neuro [neurologicals] initiated. A review of resident 37's assessments revealed post fall assessments on 1/12/24, 1/11/25, and 4/6/25. A review of resident 37's care plan revealed he was a high fall risk related to psychoactive drug use, wandering, shortness of breath, and fatigue. Interventions dated 8/16/17, included, Anticipate and meet needs, ensure call light was within reach and encourage use, educate resident and guardian about safety and what to do if fall occurs, encourage resident to participate in activities, follow facility fall protocol, and ensure resident was wearing appropriate footwear. An intervention dated 1/12/24, included, Medically clear-hypoxia, respiratory infection and edema. An intervention dated 1/15/24 included, Pt [physical therapy] evaluate and treat as ordered or PRN [as needed]. An intervention dated 4/6/25 included, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter [sic] remove any potential causes if possible. Educate resident/family/caregivers/IDT [interdisciplinary team] as to causes. On 4/30/25 at 8:18 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5 who stated if they see that a resident had fallen, they call the nurse right away, they do not leave the resident alone. CNA 5 stated the nurse would assess the resident and pass the information on to the supervisor. CNA 5 stated if she were to witness the fall, she would provide a witness statement of what happened so the staff could determine how to prevent a fall again. On 4/30/25 at 3:03 PM, an interview was conducted with the Director of Nursing (DON) who stated after a resident had a fall, she would review the care plan to see if there were any possible new interventions that could be put in. The DON stated if she did not put any new interventions in after a fall it would be because she felt she had tried everything. The DON stated she had tried to educate resident 37, but she was unsure he remembered everything and was forgetful. The DON stated the IDT would meet and review resident 37's situation to see what happened and to see if there was an intervention that could help prevent a fall. The DON stated resident 37 did not use his call light and was a very difficult person. The DON stated physical therapy and occupational therapy had been used a few other times. 2. Resident 76 was admitted to the facility on [DATE] with diagnoses that included dementia with moderate agitation, type 2 diabetes, iron deficiency anemia and myalgia. On 4/29/25 at 9:46 AM, an observation was made on the secure unit of resident 76 holding a cleaning bottle in her hand from a serving cart being used as a cleaning cart outside of the hallway bathroom. The housekeeping staff was inside the bathroom cleaning and the cart was in the hallway with the cleaning products accessible on the cart. Resident 76 had been wandering up and down the hallway. After a couple of minutes, the housekeeper came out of the bathroom and took the spray bottle from the resident. Resident 76's medical record was reviewed between 4/27/25 and 4/30/25. An admission MDS assessment dated [DATE], revealed resident 76 could not be scored on the BIMS suggesting significant cognitive impairment. The assessment also revealed that resident 76 had wandering behaviors on a daily basis. A review of resident 76's care plan included impaired safety awareness with an intervention of Monitor location every 60 min. [minutes] Document wandering behavior and attempted diversional interventions in behavior log. Resident 76's progress notes were reviewed: a. On 4/10/25 at 11:51 PM, a Health Status Note revealed, Resident oriented to self only, has been showing increasing aggression specially when constipated, requires frequent redirection by staff, tends to wander into other resident's room and grab their things, med [medication] changes done recently to better manage behaviors and concerns, skin presently intact and no falls or injuries, taking medications crushed in pudding, good appetite. b. On 4/17/125 at 1:38 PM, a Health Status Note revealed, Resident is A & O [alert and oriented] to self only; wanders into other residents rooms, believes she is a CNA; ambulates independently without falls/injury at this time; dependent on staff for ADLs [activities of daily living] and cares, needs frequent cueing and redirection; skin WNL [within normal limits]; continent of B & B [bowel and bladder] with episodes of stress incontinence; good appetite, eats in dining room with set-up assist, needs frequent reminders and redirection, wanders around dining room; difficulty making basic wants and needs known to staff, staff anticipates wants and needs. On 4/29/25 at 12:41 PM, an interview was conducted with a facility housekeeper (HK) who was observed with the serving cart on the secured unit earlier in the day. A bucket of water was observed on top of the cart. The HK stated she was cleaning the bathrooms on that day. The HK stated she disinfected the whole building one day per week. An observation was made of the HK spraying the toilet and the sink in a hallway bathroom with a cleaning solution and then putting the spray bottle on the second shelf of the cart before going back into the bathroom and wiping down the toilet and the sink. On 4/29/25 at 12:59 PM, a second interview was conducted with the HK with the assistance of an interpreter. The HK stated she disinfected the building once per week, but it could be twice per week depending on how dirty the building was. The HK stated while she was cleaning the bathrooms in the building she kept the cleaning supplies on the cart, and stated she always kept the cleaning supplies covered. The HK acknowledged that resident 76 had taken the spray bottle off of the cart while she was cleaning the bathroom on the secure unit and that she had taken it from her. The HK stated she did not know about having a locked cart to use while cleaning and would have to ask the housekeeping manager. The HK stated going forward she would bring the cart into the bathroom with her so resident's did not have access to the chemicals on the cart. On 4/30/25 at 1:35 PM, an interview was conducted with the Housekeeping Supervisor (HS) who stated the HK filled in for other housekeepers who were off. The HS stated the HK was an extra staff member on 4/29/25. The HS stated HK used a serving cart, but did not know why. The HS stated she should not have been using that cart. The HS stated the carts for housekeepers have a compartment for the chemicals so the resident's would not have access to them. The HS stated she checked on the housekeepers to ensure the carts had the compartments facing the cleaning staff because the door was only on one side. The HS stated she had meetings with the cleaning staff to educate them about how to thoroughly clean.

Based on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that the services provided met professional standards of practice. Specifically, two residents did not have their tube feed formula bag labeled with the formula name, the administration route, rate, and duration, and the initials of who prepared, hung and checked the enteral formula against the order. Resident identifiers: 14 and 54. Findings included: 1. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of gastrostomy status, dysphagia, folate and iron deficiency anemia, severe protein-calorie malnutrition, stage 2 pressure ulcer, congestive heart failure, ischemic cardiomyopathy, and dementia. On 4/27/25 at 9:26 AM, an observation was made of resident 14's Tube Feed (TF) infusing. A bag of Isosource 1.5 calorie was infusing at a rate of 45 milliliter/hour (ml/hr) and the water flush was infusing at a rate of 50 ml/hr. The formula bag had approximately 400 milliliter (ml) remaining and the water flush bag was observed empty. The formula bag was dated 4/26/25 at 6:00 PM, and was labeled with the resident's name. No other documentation was observed on the formula bag or water bag. On 4/28/25 at 7:40 AM, an observation was made of resident 14's TF infusing. A bag of Isosource 1.5 calorie was infusing at a rate of 45 ml/hr with 450 ml of formula remaining in the bag. The water flush was infusing at a rate of 50 ml/hr with 500 ml of water remaining in the bag. The formula and water bags were dated 4/27/25 at 3:00 PM, and were labeled with the resident name. No other documentation was observed on the formula bag or water bag. Resident 14's medical record was reviewed. Resident 14's physician orders revealed the following: a. Enteral Feed Order every day and night shift Jevity 1.5, 45 ml/hr and water 50 ml/hr for 20 hours with a break from 10:00 AM to 2:00 PM. The order was initiated on 4/24/25 and discontinued on 4/27/25. b. Enteral Feed Order every day and night shift Isosource 1.5 45 ml/hr and water 50 ml/hr for 20 hours with a break from 10:00 AM to 2:00 PM. The order was initiated on 4/27/25. On 4/21/23, resident 14 had a care plan initiated for required a tube feeding (Gastrostomy-tube) related to resistant to eating and weight loss. Interventions identified on the care plan included: check tube placement and gastric contents; discuss with resident and family concerns with TF and potential complications; monitor for aspiration, tube dislodgement, infection, self-extubation, constipation/diarrhea, nausea and vomiting and dehydration; provide care to Gastrostomy-tube (G-tube) site as ordered; and Registered Dietician to evaluate caloric intake and estimate needs. On 4/28/25 at 12:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the TF formula bag label should contain the date and time the infusion was started, the resident's name, the rate of infusion, and the initials of who started it. 2. Resident 54 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of anoxic brain damage, gastrostomy status, Parkinsonism, aphasia, dysphagia, and severe protein-calorie malnutrition. On 4/28/25 at 7:40 AM, an observation was made of resident 54's TF infusing. A bag of Isosource 1.5 calorie was infusing at a rate of 72 ml/hr with 200 ml remaining in the bag. The water flush bag was infusing at a rate of 70 ml/hr with 400 ml remaining in the bag. The formula bag was dated 4/27/25 at 6:00 PM, and was labeled with the resident name. Resident 54's medical record was reviewed. Resident 54's physician orders revealed the following: a. Enteral Feed Order every day and night shift Jevity 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/18/25 and discontinued on 4/27/25. b. Enteral Feed every day and night shift Isosource 1.5 72 ml/hour with water 70 ml/hr for 15 hours per day, off at 9:00 AM to 6:00 PM. The order was initiated on 4/27/25. On 10/20/22, resident 54 had a care plan initiated for required a tube feeding related to dysphagia, swallowing problem, and weight loss. Interventions identified on the care plan included: See Medical Doctor orders for current feeding orders; check tube placement and gastric contents/residual volume and hold feed if greater than 100 ml aspirate; discuss with resident any concerns about tube feeding, advantages, disadvantages, and potential complications; monitor for aspiration, tube dislodgement, infection, self-extubation, constipation/diarrhea, nausea and vomiting and dehydration; provide care to G-tube site as ordered; and Registered Dietician to evaluate caloric intake and estimate needs. On 4/28/25 at 7:40 AM, an interview was conducted with RN 3. RN 3 stated that the TF should be labeled with the resident name, date, time, formula, and should be signed by the nurse preparing the TF. RN 3 stated that the rate was preprogrammed into the infusion pump and did not need to be on the label. RN 3 confirmed that the formula bag did not have a nurse's signature and stated, it should have. On 4/30/25 at 9:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the TF formula bag should contain the date and time that it was hung and the initials of the staff starting the infusion. The DON stated that the bag should also have the formula type on the label. Review of the facility policy for Enteral Feedings - Safety Precautions documented under Preventing errors in administration 1. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID [identification] and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); and g. Rate of administration (ml/hour). 2. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. The policy was last revised May 2014. Review of the Lippincott Nursing Procedures documented under Enteral Gastric, Duodenal, and Jejunal Tube Feedings for implementation to Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of who prepared, hung and checked the enteral formula against the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY--NOT FOR IV [intravenous] USE. Wolters Kluwer. Lippincott Nursing Procedure. Ninth Edition. Philadelphia, PA. (2023), pp. 297.

Based on interview and record review, for 1 out of 36 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, a care plan was not developed for the treatment, monitoring, and assessment of a resident's arteriovenous fistula (AVF). Resident identifier: 32. Findings included: Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic kidney disease, hypertension, and AVF. Resident 32's medical record was reviewed. Resident 32's physician orders revealed the following: a. On 2/4/25, an order was initiated for check blood was flowing through the fistula properly (thrill) every day and night shift. b. On 2/4/25, an order was initiated for no lifting more than 5 pounds for 12 weeks. c. On 2/4/25, an order was initiated for Do not use Lt. [left] Arm for I.V. [intravenous]/I.M [intramuscular], Blood Pressure, Phlebotomy -AV [arteriovenous] fistula. Resident 32's progress notes revealed the following: a. On 1/30/25 at 5:52 PM, the Health Status Note documented, Resident returned from appointment with [name omitted] for fistula placement, no new orders. b. On 2/4/25 at 3:06 PM, the note documented, Don't use left arm for IV, IM, BP [blood pressure], Phlebotomy-AV fistula Q [every] shift, check blood is flowing through the fistula properly (thrill) Q shift, no lifting more than 5 lbs. for 12 weeks. c. On 2/4/25 at 3:13 PM, the note documented, If wound on left arm is dry, and not oozing, leave open to the air x [times] 2 weeks, if wound has any oozing or drainage, cover the wound with a dry gauze dressing PRN [as needed] x 2 weeks (Do not put any ointment on). d. On 2/11/25 at 12:05 PM, the note documented, Resident returned from [name omitted] Nephrology with the following note, kidney function at 16% most recently, repeat labs in two weeks including renal function panel, no med [medication] changes, no blood pressure or blood draws from left arm, labs in two weeks. e. On 3/4/25 at 6:30 PM, the note documented, Resident returned from his Vascular Surgery appointment this afternoon with the following doctor's observations: Left BC [brachiocephalic] fistula created 1/30/25, patent AVF could be accessed by end of March if needed. If not used greater than 4 months, send for follow up Ultrasound before use. Re-image sooner if any loss of thrill. On 8/17/22, resident 32 had a care plan initiated for renal insufficiency related to chronic kidney disease. The care plan was last revised on 1/2/25. The care plan did not contain any interventions for the care, treatment, assessment, or monitoring of the AVF. All care plan focus areas for resident 32 were reviewed and none contained interventions specific to the AVF. On 4/28/25 at 1:58 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 32 did not currently receive dialysis, but that he had a AVF. RN 3 stated that she assessed resident 32's fistula for a thrill or bruit to determine if it was patent. RN 3 stated that she also assessed the site for signs and symptoms of infection. RN 3 stated that she informed the Certified Nursing Assistants to not use the arm with the AVF for blood pressure readings and the resident was on a weight restriction for heavy lifting. RN 3 stated that resident 32 should have a care plan for the AVF. RN 3 reviewed resident 32's care plan and confirmed that the resident did not have a care plan that included the care and treatment of the AVF. RN 3 stated that resident 32's care plan needed to be updated to include this care. RN 3 stated that the Director of Nursing (DON) was responsible for creating the care plans. On 4/28/25 at 2:08 PM, an interview was conducted with the Charge Nurse (CN). The CN stated that resident 32 had an AVF and he would expect to see it care planned. The CN stated that the care plan should address not taking a blood pressure in the arm with the AVF, checking for signs and symptoms of infection, dressing changes if needed, and any restrictions for the use of that arm. The CN stated that resident 32 had orders that stated no blood pressure readings, blood draws, intravenous access, intramuscular injections, or phlebotomy from the left arm. The CN stated that the purpose of the care plan was to discuss potential problems, give appropriate care, and make adjustments to that care. The CN stated that the DON was responsible for creating the care plan. On 4/28/25 at 2:12 PM, an interview was conducted with the DON. The DON stated that she was responsible for the care plan development. The DON confirmed that resident 32 had a new AVF, but they were not actually using it. The DON stated that resident 32 had orders for monitoring of the AVF in the Treatment Administration Record. The DON stated that the nursing staff were to assess the AVF every shift for blood flow by determining if there was a bruit or thrill. The DON stated that resident 32 was not receiving dialysis so there was no care plan for the AVF. The DON stated that the purpose of the care plan was to guide staff on interventions, treatment, and monitoring for care areas.

Based on interview and record review, for 1 out of 36 sampled residents, the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, a resident was admitted to the facility and his baseline care plan was not developed until 10 days after his admission. Resident identifier: 70. Findings included: Resident 70 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with psychotic disturbance, carrier or suspected carrier of methicillin resistant staphylococcus aureus, type 2 diabetes, Parkinsonism, Post Traumatic Stress Disorder, and pain. Resident 70's medical record was reviewed on 4/27/25 through 4/30/25. An admission screening dated 1/31/25, revealed resident 70 was oriented to person only upon admission, had normal gait, was confused, had a flat affect, 3+ edema bilaterally in both lower extremities, was incontinent of bowel and bladder, was independent with transfers, but needed assistance with dressing, bathing, and personal hygiene. An Interim Care Plan assessment dated [DATE], revealed under safety/risk: UTD [unable to determine] for skin integrity at admission; No for resident smoking; No for resident using restraints; No for discharge initiated. Under Functioning: Yes for cognitively impaired; No for visual impairment; UTD for wearing glasses; No for hearing impaired; No for hearing aids; Yes for ability to communicate with staff; Yes for ability to understand staff. For ADL [activities of daily living] Function-independent; Transferring-independent; ambulating; Locomotion-independent; dressing-independent; personal hygiene- assistance; eating-assistance; toilet use-independent; bathing-assistance. For Bladder function: Yes for continent of bladder; No for catheter; Yes for continent of bowel. For Mobility-No for using an assistive device for locomotion. Under Medications/Treatments-antipsychotics is checked as resident is currently taking. For Medical conditions-no conditions are noted. It should be noted that the instructions on this Interim Care Plan assessment state that it should be used as a tool for the purpose of building the interim care plan. Resident 70's care plan was reviewed. Care plan focus areas were initiated on 2/21/25, which was 10 days after the resident's admission. On 4/30/25 at 10:07 AM, an interview was conducted with Registered Nurse (RN) 2 who stated when a resident was admitted , basic assessments were done by the charge nurse in a progress note. RN 2 stated the initial care plan was completed by the Director of Nursing (DON). On 4/30/25 at 10:25 AM, an interview was conducted with the DON who stated she completed the baseline care plan for the residents. The DON stated she completed the baseline care plan in less than 14 days. The DON stated the baseline care plan could be found in the assessment area of the resident's medical record. The DON stated she considered the International Classification of Diseases the baseline care plan and she had 14 days to complete it. The DON stated it was similar to the MDS assessment.

Based on interview and record review, for 1 out of 36 sampled residents, the facility did not ensure that the transfer was documented in the resident's medical record and that the appropriate information was communicated to the receiving provider. Specifically, the documentation did not include contact information of the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; a copy of the discharge summary; and all other necessary information to ensure a safe and effective transition of care. Resident identifier: 6. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, carrier Methicillin Resistant Staphylococcus Aureus, dysphagia, hypertension, anxiety disorder, schizoaffective disorder bipolar type, post-traumatic stress disorder, lactose intolerant, hyperlipidemia, glaucoma, asthma, chronic kidney disease, type 2 diabetes mellitus, vascular dementia, and pain. On 4/27/25 at 1:17 PM, an interview was conducted with resident 6. Resident 6 stated that he was hospitalized two times recently for pneumonia. Resident 6's medical record was reviewed. On 3/25/25 at 4:33 PM, resident 6's order note documented to send the resident to the emergency department for evaluation related to complaints of shortness of breath. The note did not document the information that was sent to the receiving provider for the continuity of care. On 4/29/25 at 8:15 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when they transferred a resident to the hospital they obtained a doctor's order to transfer and they send a copy of the face sheet, Physician Order for Life Sustaining Treatment (POLST), and medication list with the resident to the hospital. RN 1 stated that they documented in the nurses notes that the resident was transferred. RN 1 stated that the progress note should also contain the vital signs, communication with Emergency Medical Services (EMS) and the resident's guardian, the resident's change in condition and reason for transfer, assessment, and any treatment that was provided. RN 1 stated that the charge nurse usually documented all the progress notes, gathered the paperwork, and communicated with the provider and EMS. RN 1 stated that on weekends the nursing staff was responsible for completing the discharge paperwork. RN 1 stated that when she entered a discharge progress note she did not document what paperwork was sent to the receiving provider. On 4/29/25 at 1:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when they transferred a resident to the hospital they notified the Medical Director and family member of the need to transfer. The DON stated she gave EMS a copy of the face sheet, medication list, POLST form, and a copy of the guardianship. The DON stated the nurse should document the resident condition and reason for transfer, notification to the physician and family, and location being sent to. The DON stated that the nurses were not charting what documentation was sent to the receiving provider.

Based on interview and record review, for 2 out of 36 sampled residents, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS); report to law enforcement any reasonable suspicion of a crime; and report the results of the investigation to the SSA within 5 working days of the incident. Specifically, the facility did not report an allegation of abuse to APS or law enforcement and the facility final investigation results were not submitted to the SSA. Resident identifiers: 61 and 79. Findings included: Resident 79 was admitted to the facility on [DATE] with diagnoses which consisted of unspecified symptoms and signs involving cognitive functions and awareness, surgical aftercare following surgery on the nervous system, chronic pain, and insomnia. The resident was discharged from the facility on 8/15/24. Resident 61 was admitted to the facility on [DATE] with diagnoses which consisted of chronic respiratory failure, spinal stenosis, post-traumatic stress disorder, major depressive disorder, bipolar disorder, and anxiety disorder. The resident was discharged from the facility on 4/20/25. On 8/13/24 at 8:09 PM, the facility initial report, Form 358, to the SSA reported that on 8/13/24 at 6:50 PM, resident 79 punched resident 61 on the back of the head and upper back, resident 61 turned around and hit resident 79's left ear with the cane. Form 358 documented that APS was notified on 8/13/24 at 7:40 PM. No other documentation could be found of the APS notification with an intake verification number. No documentation could be found that the facility submitted the results of the investigation to the SSA within 5 working days of the incident. On 4/29/25 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was responsible for reporting all incidents to the SSA. RN 1 stated that she submitted the initial report and the 5 day follow-up report to the SSA. RN 1 stated she did not have access to print those reports from the SSA. RN 1 stated that all the facility abuse documentation was contained within Form 358 and Form 359, and she did not have copies of any of the facility investigations. On 4/30/25 at 2:02 PM, a follow-up interview was conducted with RN 1. RN 1 stated that the process was to notify the Administrator of the incident and then she conducted the investigation and informed him of the findings. RN 1 stated that when there was an incident she wrote up the investigation in a notebook and then summarized the information in Form 358 and Form 359. RN 1 stated that she did not keep copies of the forms or any other investigation documentation. RN 1 stated that she did not notify the police about the incident between resident 79 and resident 61. RN 1 stated that she thought that if an assault happened they were to send the resident out for medical treatment and then notified the police. RN 1 stated that if the resident did not need medical treatment at the hospital it was just two residents fighting and she did not have to notify the police. RN 1 stated that she notified APS by phone and they gave her an intake number. RN 1 stated for the incident between resident 79 and resident 61, she left a phone message for APS and did not have an intake number or verification of the notification. Review of the facility policy on Abuse/Neglect Reporting, Prevention, and Investigation documented, If an employee witnesses abuse and/or neglect, in any form, he/she is required to report it immediately. All reports of abuse and/or neglect must be reported to the RCA [Resident Care Advocate], DON [Director of Nursing], ADON [Assistant Director of Nursing], or Administrator who in turn will report it to the resident's representative (sponsor), the State Survey and Certification Department, and Adult Protective Services or local law enforcement within 24 hours of the occurrence of such incident. The reporting tine [sic] may be less depending on what occurred or what procedure dictates. An immediate investigation will be conducted by the Administrator and/or his designee. The findings of such an investigation will be reported to the State Survey and Certification Department within 5 working days of the occurrence of such incidents. The policy did not have a date that it was developed or any revisions/updates.

Based on observation and interview it was determined, for 1 out of 36 sampled residents, that the facility did not ensure that residents were treated with respect and dignity and cared for in a manner that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, a staff member was observed standing next to a seated resident while assisting them with dining. Resident identifier: 70. Findings included: Resident 70 was admitted to the facility on [DATE] with diagnoses which consisted of dementia, cataracts, type II diabetes mellitus, and Parkinsonism. On 4/27/25 at 12:13 PM, an observation was made of the lunch meal service in the assisted dining room. Resident 70 was seated at the dining table with his meal tray in front of him. Certified Nurse Assistant (CNA) 1 was observed to assist resident 70 with dining. CNA 1 stood next the the resident while feeding him bites of his food. The CNA did not sit down next to the resident while providing the dining assistance. Resident 70's medical records were reviewed. Resident 70 had a diet order for reduced concentrated sugar diet, mechanical soft texture, regular consistency. On 4/29/25 at 12:26 PM, an interview was conducted with CNA 2. CNA 2 stated that when they provided dining assistance to a resident they needed to be seated next to the resident. CNA 2 stated that they could not stand next to the resident while providing dining assistance. On 4/29/25 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should be seated next to the resident and interact with the resident while assisting them with dining.

Based on interview and record review, for 2 out of 36 sampled residents, in response to allegations of abuse the facility did not have evidence that all alleged violation were thoroughly investigated. Specifically, the facility did not have evidence that an incident of physical abuse between two residents was thoroughly investigated. Resident identifiers: 61 and 79. Findings included: Resident 79 was admitted to the facility on [DATE] with diagnoses which consisted of unspecified symptoms and signs involving cognitive functions and awareness, surgical aftercare following surgery on the nervous system, chronic pain, and insomnia. The resident was discharged from the facility on 8/15/24. Resident 61 was admitted to the facility on [DATE] with diagnoses which consisted of chronic respiratory failure, spinal stenosis, post-traumatic stress disorder, major depressive disorder, bipolar disorder, and anxiety disorder. The resident was discharged from the facility on 4/20/25. On 8/13/24 at 8:09 PM, the facility initial report, Form 358, to the SSA reported that on 8/13/24 at 6:50 PM, resident 79 punched resident 61 on the back of the head and upper back and resident 61 turned around and hit resident 79's left ear with the cane. The form documented that the incident was witnessed by Nursing Assistant (NA) 1. The form documented that resident 79 sustained a laceration to the left ear. The form documented that the immediate steps taken were to separate the residents. Resident 79 was removed from the locked unit and then sent to the hospital for evaluation. On 4/29/25 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was responsible for reporting all incidents to the State Survey Agency (SSA). RN 1 stated that she submitted the initial report and the 5 day follow-up report to the SSA. RN 1 stated she did not have access to print those reports from the SSA. RN 1 stated that all the facility abuse documentation was contained within Form 358 and Form 359, and she did not have copies of any of the facility investigations. RN 1 stated that she gathered the documentation from incident reports and nurse documentation in the progress notes. On 4/30/25 at 11:08 AM, a telephone interview was conducted with NA 1. NA 1 stated that resident 79 and resident 61 were roommates on the locked unit. NA 1 stated that when she entered the room she witnessed the incident between the residents. NA 1 stated that resident 61 was complaining that resident 79 was taking his belongings and was trying to take his computer. NA 1 stated that resident 79 got up and hit resident 61 in the head. NA 1 stated that resident 61 responded by hitting resident 79 in the ear with his cane. NA 1 stated that resident 79's ear was red but no skin was broken. NA 1 stated that she reported the incident to the Director of Nursing and the residents were separated. On 4/30/25 at 2:02 PM, a follow-up interview was conducted with RN 1. RN 1 stated that the process was to notify the Administrator of the incident and then she conducted the investigation and informed him of the findings. RN 1 stated that when there was an incident she wrote up the investigation in a notebook and then summarized the information in Form 358 and Form 359. RN 1 stated that she did not keep copies of the forms or any other investigation documentation. Review of the facility policy on Abuse/Neglect Reporting, Prevention, and Investigation documented that the facility policy was to report incidents of abuse or neglect to all pertinent parties and agencies and that each incident would be thoroughly investigated. The policy further documented, The Administrator and/or the RCA [Resident Care Advocate] will be responsible for collecting and reporting findings. The report must include, but is not limited to: A. The name of the resident(s) involved. B. The date and time incident occurred. C. The circumstances surrounding the incident. D. Where the incident took place. E. The name of any witnesses. F. The name of the person(s) charged with committing the act. G. Recommendations for corrective action. H. Other information that may be requested or appropriate. The policy did not have a date that it was developed or any revisions/updates.

Based on interview and medical record review it was determined, for 3 of 28 sample residents, that the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one resident who had a change in condition did not have timely interventions and adequate monitoring and was sent to the hospital [MEDICAL CONDITION], one resident who had been pushed accidentally by another resident and fell , sustained a fractured ankle that was not called into the physician timely and one resident who had orders for a hemoccult test, did not have the hemoccult test timely. The deficient practice identified for resident 78 was found to have occurred at a harm level. Resident identifiers: 32, 46 and 78. Findings include: HARM 1. Resident 78 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/19/18 resident 78's medical record was reviewed. Nursing progress notes revealed the following entries: a. 6/19/18 at 18:05 (6:05 PM), Rcvd (received) order to obtain UA (urinalysis) c (with) C&S (culture and sensitivity) r/t (related to) frequency et (and) urgency et CXR (chest x-ray) r/t cough et chest congestion. b. 6/20/18 at 7:25 AM, Labs recived (sic). Faxed results to (Physician 1). Will follow. c. 6/21/18 at 18:00 (6:00 PM), Resident spike temp (temperature), BP (blood pressure 190/130, T (temperature) 105.6, P (pulse) 118, 02 (oxygen) sat (saturation) RA (room air) 85%, emisis (sic), called (Physician 1), stated to send to ER (emergency room ) (Name of Hospital) for eval (evaluation) high BP 190/130, (increase) temp, low 02 85% RA. Will follow. d. 6/21/18 at 18:10 (6:10 PM), Called daughter (Name of daughter) - no awnser (sic) left message concerning sending resident to (Name of Hospital) ER. Will follow. e. 6/23/18, Patient cont (continues) at hospital. UA results back. physician's orders [REDACTED]. CXR for cough, chest congestion. A chest x-ray result form dated 6/19/18 at 17:59 (5:59 PM), revealed the following: FINDINGS: Lungs/Pleura: Normal aeration. No effusion. No [MEDICAL CONDITION]. No pneumothorax. Heart/Mediastinum: No significant abnormalities. Normal size. Bones/Soft Tissues: No significant abnormalities. Support Lines/Tubes: None. IMPRESSION: No radiographic evidence of significant cardiopulmonary abnormality. A culture and sensitivity report form for resident 78 revealed that resident 78's UA had been collected on 6/20/18 at 4:45 PM. (NOTE: The UA had been collected by the lab approximately 23 after the physician's orders [REDACTED]. The hospital History and Physical (H&P) dated 6/21/18 at 22:33 (10:33 PM), revealed the following: CC (Current Condition): [MEDICAL CONDITION] and fever History of Present Illness: (Resident Name) is a [AGE] year old female with a history of [MEDICAL CONDITION], basal ganglia stroke, left [MEDICAL CONDITIONS](hypertension)[REDACATED], and hx (history) of acute [MEDICATION NAME] deemed inoperative, who presents as a transfer form (sic) her care facility for fever, [MEDICAL CONDITION], and concern [MEDICAL CONDITION]. She has been resident at (Care Facility Name) and was reported to be more somnolent, febrile, and confused when evalauted (sic) today by the facility staff. She is unable to provide a history, and per EMS (emergency medical services) she was febrile to 105.6, and this decreased to 103 on the way to the ED (emergency department). She was also noted to have foul smelling urine per both the care facility and the ED following straight cath (catheterization). In addition, she was noted to be hypoxic with saturations reportedly in the 80's on RA, and she was initially started on a NRB (non rebreather) (mask) before being placed on a simple mask with improvement in her saturations to the mid 90's. In the ED, she was found to be encephalopathic, hypoxic, requiring 4 L (liters) (oxygen) simple mask, and in mild distress UA remarkable for infection with pyuria and bacteruria, + (positive) LE (Leukocyte Esterase), + [MEDICATION NAME]. CXR remarkable for mild retrocardiac opacity that may reflect subsegmental atelectasis or developing consolidation. She was given 1 L NS (normal saline), 1 g (gram) CTX (Ceftrioxone), 500 (milligrams) [MEDICATION NAME], and admitted to medicine for management. On exam she was incoherently mumbling I want some water. She was unable to convey her thought clearly, and was noted to be fairly confused and in mild distress. At one point she did say that it 'burned to pee.' ASSESSMENT AND PLAN: #Sepsis. Secondary to likely UTI (Urinary Tract Infection) and PNA (pneumonia) Reported fever per EMS to 105.6 down to 103 in route. [MEDICAL CONDITION] on admission to 98, BP stable, increased 02 requirement UA indicative of infection, CXR with possible consolidation/opacity. Continue Cefepine 1 g Q (every) 8 (hours). Azithroymcin (sic) 500 mg QD (every day). S/P (status [REDACTED]. #[MEDICAL CONDITION]: Likely multifactorial in setting of presumed urosepsis with questionable PNA, in conjunction with polypharmacy. Patient incoherent, and unable to provide history. #UTI: Suspected as the primary source [MEDICAL CONDITION] given her presentation, remarkable UA and intermittent complaints of dysuria. #Acute hypoxic [MEDICAL CONDITION]: No baseline 02 demand, and patient needed 4-6 L NC (nasal cannula) with up to 4 L simple mask. ABG (arterial blood gases) WNL (within normal limits). Likely in setting of possible PNA, aspiration, and [MEDICAL CONDITION]. The Attending Attestation dated 6/21/18 at 21:21 (9:21 PM), revealed, I personally examine and evaluated the patient on 6/21/18. I reviewed the documentation of (Physician Name) and I agree with the findings of history, physical exam, assessment and care plan Continue [MEDICATION NAME] and [MEDICATION NAME] started in ED for treatment of [REDACTED].She has wet sounding cough and mild bibasilar crackles in bases. Patient's current [DIAGNOSES REDACTED]. Review of the Weights and Vitals Summary for resident 78 revealed that the last entry for vital signs (VS) by facility staff was on 6/15/18. No documentation could be located in the medical record to show that there had been an increase in monitoring for a change in condition regarding resident 78's lung sounds, level of consciousness nor for VS by facility staff. On 7/19/18 at 10:10 AM, an interview was conducted with the facility Charge Nurse (CN). The facility CN stated that he did not know when the urine sample was actually collected, since there was no documentation as to the time that it was collected. The facility CN stated that the lab comes only in the afternoon and so the urine could have sat in the refrigerator prior it being collected by the lab company. The facility CN stated that they should have increased the monitoring of resident 78 since there had been a change in condition. On 7/19/18 at 10:30 AM, an interview was conducted with the facility Director of Nursing (DON) and the facility Assistant Director of Nursing (ADON). The facility ADON stated that they should have increased the monitoring of resident 78 since they had obtained orders for a CXR and UA and knew that she had had a change in condition. The facility DON stated that there was no further documentation regarding an increase for monitoring resident 78. NOT HARM 2. Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/17/18 resident 46's medical record was reviewed. Nursing progress notes revealed the following entries: a. 5/22/17 at 12:30 PM, Resident was pushed by another resident. Resident fell down. Another resident (resident 46) kicked resident several times. T - 97.9, P - 82, R (respirations) - 24, BP - 118/70. Right swelling ankle. Guardian notified. Left message. Will follow. b. 5/22/17 at 16:30 (4:30 PM), X-ray right ankle Dx (diagnosis) pain. Will follow. c. 5/22/18 at 3:00 AM, X-ray + for lateral malleoles fx (fracture) s (without) displacement. (Physician 1) notified. No new orders. He will asses (sic) in AM on weekley (sic) visit. (NOTE: The note was documented by the graveyard shift and the date was incorrect. The date should have been 5/23/18.) A physician's orders [REDACTED].>An x-ray report dated 5/22/17 at 5:22 PM, revealed There is a fracture involving the lateral malleolus with no displacement. The joint alignment is maintained. There is associated soft tissue swelling. The x-ray report revealed that it had been faxed to the facility on [DATE] at 5:24 PM. The x-ray report was noted by facility staff and resident 48's physician was notified on 5/22/17 at 23:00 (11:00 PM). (NOTE: Resident 48's physician was not notified of the swelling in the ankle until four hours after the fall. Additionally, resident 48's physician was not notified of the fractured ankle for five hours and 36 minutes after the report was sent to the facility.) On 7/17/18 at 2:40 PM, an interview was conducted with the facility DON and the facility ADON. The facility DON stated that resident 48's physician should have been notified immediately when there was a change in condition after a fall and notified as to what that change was. The facility ADON stated that the x-ray should have been called into the physician immediately as well. 3. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/17/18, resident 32's medical record was reviewed. A review of resident 32's Nurse's Notes revealed the following entries: a. On 3/10/18 at 9:00 AM, Patient had bloody like emesis. MD notified . Patient had KUB (an abdominal x-ray) and hemoccult (a test to check stool samples for blood) ordered. b. On 3/14/18 at 8:10 AM, Hemoccult test dx (diagnosis). Bloody emesis. Will follow. c. On 3/16/18 at 6:18 AM, Received labs. Faxed to MD. A review of resident 32's lab results revealed that a sample for a hemoccult test was collected on 3/14/18 at 11:15 PM. The report indicated that blood was present in the resident's stool and that the final result was approved on 3/15/18 at 1:11 PM. The signature of resident 32's physician was visible in the bottom right corner of the report. There was no date or time documented with the physician's signature. A review of resident 32's physician orders [REDACTED]. The fax stated, (Resident 32) - on 3/14/18 occult blood stool lab came back positive. It is noted he has lost another 5 lbs. Do you want any follow up? Thank you! (see attached lab). Resident 32's physician responded with an order to check the resident's ferritin, total iron binding capacity (TIBC), and complete blood count (CBC). No date or time was documented for the physician's response. (NOTE: There was no documentation regarding the positive hemoccult test results for 40 days following MD notification on 3/16/18.) On 4/30/18 at 8:15 AM, the following entry was documented under resident 32's Nurses Notes: CBC, iron, TIBC, ferritin. Dx positive occult blood. Will follow. The reports for resident 32's iron, TIBC, ferritin, and CBC test indicated that the blood samples were collected on 4/30/18. (NOTE: The samples for the labs were collected 4 days after the fax was sent to the MD.) On 7/17/18 at 2:50 PM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that hemoccult labs were ordered when there was a concern for a [MEDICAL CONDITION]. RN 3 stated that a hemoccult lab should be ordered as soon as possible and she would be concerned if there was a delay in calling it in. RN 3 stated waiting a couple of days is not OK. On 7/18/18 at 7:49 AM, the Director of Nursing (DON) was interviewed. The DON stated that she was working on resident 32's Care Plan when she noticed that there had been no follow-up regarding the positive hemoccult test. The DON stated that resident 32's physician didn't say one way or the other after he signed the hemoccult results. The DON stated that she expected that the RN who reported the lab result to the physician to re-check and remind him again.