Every finding on record at Mission Nursing and Rehabilitation Center

Based on observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #13) reviewed for pharmacy services. The facility failed to ensure Resident #13 received the correct dose of:Amiodarone HCI oral tablet 200 mg, Apixaban oral tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 25 mg. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #13's admission record, dated 03/18/26, reflected a [AGE] year-old female with an admit date of 02/16/26 and an initial admission date of 02/03/24 with diagnoses that included encephalopathy ( any condition that disrupts normal brain function), dependence on renal dialysis (a life-sustaining need regular hemodialysis due to end-stage renal disease or acute kidney failure where the kidneys cannot adequately filter waste or remove fluid), angina pectoris (chest pain or discomfort caused by reduced blood flow and oxygen to the heart muscle), hypertension (a chronic condition where blood forces against artery walls too strongly), paroxysmal atrial fibrillation (an irregular, rapid heart rhythm that starts and stops on its own, usually lasting from minutes up to seven days), unspecified combined systolic and diastolic heart failure ( a serious condition where the heart cannot properly pump (systolic) and cannot effectively fill (diastolic), often leading to high filling pressure, pulmonary congestion, systemic edema) and depression (a mood disorder causing persistent sadness, loss of interest, and physical symptoms like fatigue or sleep disturbances, affecting daily life). Record review of Resident #13's 5-day admission MDS assessment, dated 02/19/26 reflected a BIMS score of 12, which indicated her cognition was moderately impaired. Record review of Resident #13's quarterly care plan, dated 03/05/26 reflected the following:Focus: [Resident #13] is on anticoagulant therapy r/t atrial fibrillation, date initiated/revised on 02/17/26. Interventions included to administer med as ordered, date initiated/revised 02/17/26. [Resident #13] has the potential for respiratory distress r/t CHF, date initiated/revised on 02/17/26. Interventions included to give medications as ordered, date initiated/revised on 02/17/26. Record review of Resident #13's physician's order summary, dated 03/18/26 reflected: Amiodarone HCI oral tablet 200 mg, at 6:00 a.m. and 6:00 p.m., give one tablet by mouth two times a day related to paroxysmal atrial fibrillation, hold if HR is below 60 or SBP is below 110, start date 03/10/26. Apixaban oral tablet 2.5 mg, at 6:00 a.m. and 6:00 p.m., give one tablet by mouth two times a day related to paroxysmal atrial fibrillation, start date 02/17/26. Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol tartrate) at 6:00 a.m. and 6:00 p.m., give one tablet by mouth two times a day for htn hold if SBP is less than 110 or pulse less than 60, start date 02/17/26. Record review of Resident #13's February 2026 electronic medication administration record reflected: Amiodarone, Apixaban, and Metoprolol were not administered on 02/18/26 at 6:00 a.m. for a total of 3 missed doses. Record review of Resident #13's March 2026 electronic medication administration record reflected: Amiodarone, Apixaban, and Metoprolol were not administered on 03/04/26, 03/09/26, 03/13/26, 03/18/26, and 03/21/26 for Amiodarone and Metoprolol on 03/21/26 at 6:00 a.m. for a total 14 missed doses. February 2026Metoprolol Tartrate (25 MG) 2/18/2026 absent dialysis day Apixaban (2.5mg) 2/18/26 absent dialysis days Amiodarone (200 MG) 2/18/26 absent dialysis days March 2026Amiodarone (200 MG) 3/4/26 absent dialysis day3/9/26 absent dialysis day3/13/26 absent dialysis day3/18/26 absent dialysis day3/21/26 absent dialysis day Metoprolol Tartrate (25 MG) 3/4/26 absent dialysis days 3/9/26 absent dialysis day3/13/26 absent dialysis day3/18/26 absent dialysis day3/21/26 absent dialysis day Apixaban (2.5 mg)3/4/26 absent dialysis day3/9/26 absent dialysis day3/13/26 absent dialysis day3/18/26 absent dialysis dayIn an interview on 03/19/26 at 9:26 a.m., LVN E said Resident #13 had dialysis on Mondays, Wednesdays, and Fridays. She said she would leave the facility by 5:45 a.m. and would return at noon. LVN E said the facility's Med-Aides were responsible to administer Resident #13's medications. She was said if a resident was not in the facility at the time of their medication administration, the Med-Aide would enter a code 3 which meant the resident was not in the facility. She said the Med-Aides had a window of 4 hours to administer a mediation from the scheduled time. She said by the time Resident #13 returned from dialysis it was past the 4-hour window, so the morning medication(s) were not administered on the days she went out for dialysis. She was not able to say what the negative outcomes to Resident #13 were for not being administered her morning medications as ordered. In an interview and observation on 03/19/26 at 10:01 a.m., Med Aide A said her responsibility as a Med- Aide was to administer medications. She said her morning shift started at 7:00 a.m. and the first thing she did when she clocked in was to assist in the dining room with breakfast. She said she would start medication administration between 8:30 a.m. and 9:00 a.m. Med Aide A said she had been assigned to administer medications to Resident #13's hall on 03/04/26, 03/09/26, 03/13/26, and 03/18/26. She said Resident #13 was a dialysis patient and she was not in the facility on when she administered the morning medications on 03/04/26, 03/09/26, 03/13/26, and 03/18/26. She said the facility's protocol for when a resident was not in the facility when medication was being administered was to enter code 3 on their electronic medical administration record. Med Aide A said she had a window of four hours to administer medication(s) from the scheduled time and if a resident was not in the facility during the 4-hour window, the medication would not be administered. Med-Aide A said a negative outcome to Resident #13 not being administered medications as ordered would be that she would not be getting the full effects of the medications. During an interview on 03/19/26 at 10:35 a.m., the DON said Resident #13 went to dialysis on Mondays, Wednesdays, and Fridays at 6:30 a.m. She said Resident #13 would leave the facility before 6:00 a.m. and return between 12 and 1:00 p.m. The DON was observed as she reviewed Resident #13's electronic medical record and said Resident #13 had a code 3 for the following medications at 6:00 a.m., Amiodarone, Apixaban and Metoprolol on 2/18/26, 03/04/26, 03/09/26, 03/13/26, and 03/18/26. She said code 3 indicated the resident was not in the facility at the time the medication was being administered. She said the facility had a four-hour window to administer medication from the scheduled time and if the resident was not in the facility during the four window, the medication would not administer. The DON said she was not aware Resident #13 was not being administered her morning medications on the days she was scheduled dialysis and her physician had not been notified. She said it was the Med-Aide's responsibility to notify her that Resident #13 was not being administered her morning medication the days she had dialysis. She said, what we should have done is called Resident #13's physician to let him know that she was not in the facility during morning med pass the days she had dialysis. if he wanted to change the time or leave as is. The DON said the negative outcomes to Resident #13 not being administered Amiodarone, Apixaban, and Metoprolol was not getting the full effects of the medications, but she had not had any change of conditions the month of February 2026 or March 2026. The DON said the facility had 6 dialysis residents but only Resident #13 had missed doses of ordered medications. During an interview on 03/19/26 at 11:45 a.m., the NP said Resident #13 had been ordered Amiodarone, twice a day to control her heart rhythm. The NP said if Resident #13 was not administered Amiodarone as ordered it could possibly exacerbate her arterial fibrillation but since she had received at least 1 dose, it was ok. She said Resident #13 had been ordered Apixaban for her atrial fibrillation, twice a day and if she missed a dose, she was risk of forming a blood clot, but since she received at least one dose a day the negative outcome was not too severe she that mean that Resident #13 received 1 of 2 doses of medication so the chances of her experiencing any negative outcome were minimal. The NP said the facility should have notified her or the doctor that Resident #13 was not in the facility when the medications were ordered, she said at that point they would have changed the time or discontinue the medication. The NP said she had not been notified of any change in condition for Resident #13 during the month of February or March 2026. In telephone interview on 04/02/2026 at 3:30 p.m., the Dr. said when he called in an order for a resident, he would give the name of the medication, frequency, dosage, and route. He said it was the nurse's responsibility to set the time when the medication would be administered. He said if the resident was not at the facility during that time, the facility should have called him to let him know. The Dr. said there were no negative outcomes to Resident #13 for missing 17 doses of Amiodarone Apixaban, and Metoprolol. He said he had not received any calls from the facility reporting any change of conditions for Resident #13. He said the likelihood of any negative outcomes were unlikely because Resident #13 was administered 1 of 2 daily doses. Record review of the facility's Administering Mediations policy revised on December 2012, reflected: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation: 3. Medications must be administered in accordance with the orders, including any required time frames. Record review of the facility's Adverse Consequences and Medication Errors policy, revised April 2024 reflected: Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy interpretation and implementation: 5. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include a. omission-a drug is ordered but administered.

Based on interview and record review, the facility failed to complete the baseline care plan for one (Resident #89) of three residents reviewed for base line care plans. The facility failed to provide Resident #89 a written summary of his baseline care plan completed within 48 hours of admission. This failure placed three newly admitted residents reviewed at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Finding include: Record review of Resident #89's face sheet, dated 3/18/26 reflected she was a [AGE] year-old female with an admission date of 3/4/26. Her diagnoses included chronic obstructive pulmonary disease (a progressive, treatable, but incurable lung disease that causes chronic airflow restriction, making it hard to breath). Record review of Resident #89's MDS revealed that was still in progress. Record review of Resident #89's baseline care plan reflected it had not been completed as of 3/17/26. During an interview with MDS Coordinator on 3/18/26 at 4:00 p.m., she stated that now the facility does an assessment instead of the baseline care plan. She stated that she was responsible for the comprehensive care plan. MDS Coordinator stated that she had until 3/18/26 to complete the comprehensive care plan. She stated that she does not see the negative outcome. During an interview on 3/19/26 at 9:27 a.m., RN B stated that she was the nurse that admitted Resident #89. RN B stated that she was responsible to do the baseline care plan but she forgot. RN B stated that the negative outcome could be the lack of communication between staff. During an interview and record review on 3/19/26 at 11:00 a.m., DON stated that the baseline should be done within 48 hours after admission. DON did record review and confirmed that the baseline care plan was not in the electronic chart. DON stated the admitting nurse was in charge to initiate the baseline care plan. DON stated that the care plan was a way of communication between the nursing team. DON stated that the risk to residents who do not have care plans entered timely was inaccurate care being provided by staff. The DON stated that care plans were a process that began with the MDS nurse and admitting nurse entering the baseline care plan. The DON stated she did not know what happened to Resident #89's baseline care plan. Record review of the facility's policy, Care Plans-Baseline with a revision date December, 2016, reflected, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #38) of 6 residents reviewed for comprehensive care plans. The facility failed to include Resident #38's enhanced barrier precautions in his care plan. This failure could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.Findings included: Record review of Resident #38's face sheet, dated 03/17/2026, reflected a 57 -year-old male admitted [DATE]. Resident #38's diagnoses included peripheral vascular disease (a slow, progressive circulation disorder where blood vessels outside the heart and brain) and wound to left heel. Record review of Resident #38's Quarterly MDS assessment, dated 10/10/2026, reflected BIMS of 2 indicating severely cognitively impaired. Record review of Resident #38's most recent Care Plan, 03/06/2026, reflected enhanced barrier precautions were not addressed on his care plan and there were no interventions. Record review of Resident #38 Physician's Order, dated 03/13/2026, reflected cleanse with normal saline, apply betadine then cover with gauze and wrap with roll gauze and secure with tape once daily for wound on left heel. During an interview on 03/19/2026 at 9:36 a.m., MDS D stated she was responsible for developing care plans for Resident #38. MDS D stated the wound care nurse developed the care plans for wound care orders. She stated the care plan needed to be completed within 48-72 hours from receiving the new order. MDS D stated it was important for wound care to be care planned for infection control and to ensure protection for staff as well. During an interview on 03/19/2026 at 10:38 a.m., the WCN stated she was responsible for developing the care plan for the wound care orders. She stated she was not aware she needed to care plan Resident #38's wound treatment order since treatment was being done as a preventative. The WCN stated it was important for wound orders to be care planned to ensure they were doing the right preventative measures to help heel the wound. During an interview on 03/18/2026 at 3:40 p.m., the DON stated enhanced barrier precautions needed to be care planned. She stated MDS staff was responsible for developing the care plans. The DON stated that EBP was implemented for residents with wounds, urinary catheters, PEGS (soft, flexible tube placed directly into the stomach through the belly skin to deliver food, liquids, or medication when someone cannot eat enough by mouth), IV's (a method to deliver fluids, medicine, or nutrients directly into a vein using a small, flexible tube), and dialysis ports (a surgically created, dedicated entry point into your bloodstream, usually in the arm or chest, acting as a highway for blood to flow out, get cleaned by the machine, and return, acting as a substitute for failing kidneys). The DON stated these residents have a blue curtain hanging on the door with PPE. During an interview on 03/19/2026 at 1:37 p.m., the DON stated enhanced barrier precautions should have been care planned for Resident #38 and were to be completed as soon as they got the order. The DON stated it was important for it to be completed to protect Resident #38 from getting infection and to let staff know about the interventions that needed to be provided for the resident. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, date revised December 2016 revealed:Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation: 8. The comprehensive, person centered care plan will: Include measurable objectives and timeframes;Describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being;13. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 resident (Resident#10) reviewed for indwelling catheters. The facility failed to prevent Resident#10's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#10's face sheet with a date 3/18/26 revealed a [AGE] year-old male originally admitted on [DATE]. Resident#10 had admitting diagnosis of neuromuscular dysfunction of the bladder, unspecified (a loss of bladder control caused by nerve damage from diseases or injuries like stroke, diabetes or spinal cord damage). Record review of Resident #10's care plan dated 3/3/2026 revealed Resident #10 has a indwelling catheter due to obstructive uropathy kidney neoplasm(a blockage in the urinary tract) Date initiated 3/17/26 and revised on 3/17/26, Interventions listed the the resident #10 position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #10's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #10 had a BIMS score of 3 which indicated Resident #10 had intact cognition. Section H-Bladder and bowel revealed resident #10 has an indwelling catheter. Record review of Order Summary has order printed 3/18/26 revealed order to Change Foley Catheter 16 # French with 10milliliters balloon as needed for obstruction or if closed system is compromised. Order Foley catheter care every shift and as needed start dated 03/3/26. During an observation conducted on 03/17/26 at 12:20 PM, Resident #10's indwelling catheter bag was noted dragging on the floor while resident was in wheelchair. During interview with LVN A on 03/17/26 at 12:20 PM, LVN A was informed catheter bag was dragging on the floor. She stated it should not be touching the floor. She replied that a negative outcome of foley catheter bag being on the floor the catheter wouldn't drain well and pick up bacteria from floor. During interview with DON on 03/19/26 at 11:06 AM, she stated that no, it should not be touching the floor, if on the floor, the tubing and the bag should be change immediately. She stated the negative outcome was that Resident #10 could get an infection or the bag could get ripped. Record Review of Policy Titled Catheter Care, Urinary with revised date April 2010, revealed: Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 7 residents (Resident #71) reviewed for pharmacy services. The facility failed to compare the instructions written on Resident #71's blister pack with the physician's order for Gabapentin before it was administered on 03/19/2026. This deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.Record review of Resident #71's face sheet, dated 03/19/26, revealed a [AGE] year-old female admitted on [DATE] and readmitted [DATE]. The diagnoses included Cirrhosis of the liver (chronic condition of the liver in which the normal functioning tissue is replaces with scar tissue and regenerative nodules as a result of chronic liver failure), Bipolar Disorder (a chronic mental health condition characterized by intense, long-lasting shifts in mood, energy, and activity levels, ranging from extreme highs to lows), and Type 2 Diabetes Mellitus (a chronic metabolic condition where the body develops insulin resistance and fails to produce enough insulin, leading to high blood sugar levels). Record review of Resident #71's MDS Assessment, dated 03/04/26, revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #71's care plan, dated 2/24/2024, revealed the focus area, The resident is on pain medication therapy related to disease process. An intervention listed for the problem stated, Administer medications as ordered (morphine, baclofen, and gabapentin). Record review of Resident #71's Physicians order, dated 8/27/2025, revealed an active order in PCC (electronic health record) for gabapentin 800 MG to give 1 tablet by mouth three times per day. Record review of the blister pack containing Resident 71's Gabapentin 800 MG revealed the order stated, TAKE 1 TABLET BY MOUTH TWO TIMES PER DAY. During an observation of medication administration at 10:00 a.m., on 03/19/26, CMA A prepared morning medications for administration. CMA A popped the medications she needed to administer to Resident #71 out of their blister packs, including the Gabapentin 800 MG. Observation revealed and noted on the blister pack was, Gabapentin 800 MG, give 1 tablet by mouth two times per day. During an interview on 3/19/2026, at 11:45 am, CMA A stated before administering any medication she confirmed the right person, dose, drug, route and time. CMA A stated she was supposed to compare the order on the blister pack to what the order stated in the electronic health record and ensured there were no discrepancies. CMA A stated there was a difference in how many times the medication was administered. CMA A stated the physician orders were for three times a day, but the blister pack indicated two times a day. CMA A stated she gives all medication according to the physicians' order and not according to the blister pack. During an interview on 3/19/2026 at 1:20 p.m., the DON stated it is her expectation that blister packs match the physicians order in the electronic health record. The DON stated the CMA A should have notified the nurse about the blister pack not matching the physicians order in the electronic health record. The DON stated Resident #71 was taking Gabapentin for pain and took other medication for pain as well. The DON stated Resident #71 was not without her medication at any time. During an interview on 3/19/2026 at 2:10 p.m., Resident #71 stated her pain was controlled well with her medications. Resident #71 stated when she was in pain, she requested medication and it was given to her, and all medications are given appropriately. Resident #71 stated she had no issues or concerns with her medication.Record review of the facility policy titled, Administering Medications, dated April 2019, stated the following: .7. The individual administering the medication checks must check the label to verify the right resident, right medication, right dosage, right time and the right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 3 residents (Resident #28) reviewed for labeling and storage. The facility failed to put an open date for Resident #28's Trelegy inhaler. This failure could have placed residents at risk of not receiving the therapeutic effects of the medication. The findings included: Review of Resident #28's admission Record, dated 3/19/26, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnosis including Chronic obstructive pulmonary disease with exacerbation (a sudden worsening of symptoms typically increased shortness of breath, cough, and thicker or discolored mucus). Review of Resident #28's Care Plan dated 1/7/26 revealed: Revised on 5/9/25 Focus: Resident #28 has Emphysema/ Chronic obstructive pulmonary disease related to Physiological atrophy. Review of Resident #28's quarterly MDS Assessment, dated 1/9/26 revealed her BIMS was 12 meaning she was moderate cognitive impaired. Further review revealed she had a diagnosis of Chronic obstructive pulmonary disease. Review of Resident #28's Order Summary Report, dated 3/19/26, revealed Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 mcg/act (Fluticasone-Umeclidinium-Vilanterol) 1 inhalation inhale orally one time a day for Chronic obstructive pulmonary disease. An observation on 03/18/2026 at 10:32 a.m., of the 600 Hall Medication Cart with LVN C , revealed Resident #28's Trelegy inhaler did not have an open date. During an interview on 03/18/26 at 10:32 a.m., LVN C stated that the inhaler should be labeled with an open date. She stated that the person responsible for labeling the bottles was the person who initially opened them. LVN C stated that they need to know when the inhaler was opened, so they know when it expires. During an interview on 03/19/2026 at 11:20 a.m., the DON stated that trelegy inhaler should have an open date. DON stated that it was important to have an open date because the medications had a life span and without an open date could not track when the inhaler was opened. Record review of the facility's Labeling of Medications Containers policy, with a revision date April/07, revealed All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #38) residents reviewed for infection control. The facility failed to ensure Resident #38 had an EBP sign on the door. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.Findings included: Record review of Resident #38's face sheet dated 03/17/2026 reflected a 57 -year-old male, admitted on [DATE]. Resident #38's diagnoses of Peripheral Vascular Disease (a slow, progressive circulation disorder where blood vessels outside the heart and brain) and wound to left heel. Record review of Resident #38's Quarterly MDS assessment, dated 10/10/2025, reflected he scored a 2 on his BIMS which reflected severely cognitively impaired. Record review of Resident #38 most recent Care Plan, 03/06/2026, reflected Resident #38 did not have enhanced barrier precautions developed on his care plan or interventions. Record review of Resident #38 Physician's Order, dated 03/13/2026, reflected cleanse with normal saline, apply betadine then cover with gauze and wrap with roll gauze and secure with tape one time a day for wound on left heel. During an observation on 03/17/2026 at 9:42 a.m. revealed there was no EBP sign posted on Resident #38's door. During an interview on 03/17/2026 at 10:15 a.m., CNA H stated she was Resident #38's CNA. She stated Resident #38 should have an EBP sign. CNA H stated the nurse was responsible for putting the sign up. She stated she did not notice that the sign was not there. She stated she wore PPE every time she went into his room to provide care. CNA H stated it was important for the EBP sign to be posted so that other staff were aware of the type of precautions in place and to prevent spread of infection. During an interview on 03/17/2026 at 10:33 a.m., LVN G stated she was Resident #38's nurse. She stated she was responsible for posting the EBP sign on Resident #38's door. LVN G stated she did not know the sign was missing. She stated the sign was there this morning, 03/17/2026. She stated the staff was to wear PPE when coming into close contact and doing patient care. She stated the required PPE for EBP consisted of gloves and gowns. LVN G stated that it was important for the sign to be posted to prevent the transmission of infection and ensure the safety of the patient. She stated an infection control in-service was done two weeks ago. During an interview on 03/18/2026 at 3:40 p.m. the DON, stated the residents in the secured unit were there for a reason and they grabbed everything including the EBP sign. She stated they were working on a better system to keep the sign in place. She stated the person responsible for placing the EBP sign on the door would be their part time infectious disease nurse, but they did not wait for her to show up because all their staff were educated on that. The DON stated the signs at the door were important to alert visitors and staff of the type of precaution that was in place. She stated they also had a blue curtain in place that made staff aware that they were on precautions. During an interview on 03/19/2026 at 1:37 p.m., the DON stated Resident #38 was not in isolation but only on enhanced barrier precautions. The DON stated this means that whatever Resident #38 had, it was contained. The DON stated the staff would have to physically touch the wound for contamination. The DON stated the negative outcome would be getting an infection. Record review of the facility policy, titled Enhanced Barrier Precautions, revised April 1, 2024, revealed,Purpose: This policy outlines the guidelines and procedure to implement enhanced barrier precautions to prevent the spread of infectious disease among residents and staff.Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles in 1 of 4 medication carts (700 hall medication cart) reviewed for medication storage. The facility failed to ensure the medication aide medication cart for 700 hall was secured by a lock when it was left unattended by MA A. This failure could place residents at risk of injury if medication left unsecured was consumed. Findings include:Findings include: During an observation on 1/2/2026 at 5:00 PM the 700 Hall medication aide medication cart was left unlocked and unattended on 700 hallway. MA A approached the medication cart and noticed it was unlocked and secured the cart by locking it. There was no one around the medication cart while MA was inside a room. During an interview on 1/2/2026 at 05:05 PM MA A revealed she was responsible for the medication cart that was left unlocked. She stated she was expected to lock the medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them or medications could get stolen. She stated she forgot to lock the cart. During an interview on 1/3/2026 at 02:18 PM the DON revealed numerous staff, which included her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walked away from the medication cart was to lock it. The DON stated the negative outcome for leaving the cart unlocked was a resident or visitor could grab the medication from the cart, and it could harm them. She stated she provided in-services to the staff, and she visually monitored daily. Record review of the facility's, undated, policy Security of Medication Cart: revealed The medication cart shall be secured during medication passes. Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room

Based on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (R#22) of 4 residents whose records were reviewed for OOH-DNR Order forms: The facility failed to have the physician sign at the bottom of R#22's Out of Hospital Do Not Resuscitate (OOH-DNR) order, which mad the advance directive invalid. This failure could place residents at risk for not having their end of life wishes honored. The findings included: Record review of R#22's admission record dated 01/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and an initial admitted [DATE]. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Crohn's disease (inflammatory bowel disease that causes swelling and irritation of the tissues in the digestive tract). Record review of R#22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1, indicating R#22 cognition was severely impaired. Record review of R#22's quarterly care plan dated 10/23/24 reflected a focus of: [R#22] had a code status of OOH-DNR. Date Initiated: 05/02/24 Revision on: 09/10/24. Interventions included: A copy of the OOH-DNR would be kept in the R#22's medical chart readily available for all to see. Date Initiated: 09/10/2024, and in the event that [R#22] arrested no efforts to resuscitate would be provided in accordance with the Resident wishes. Date Initiated: 09/10/24 Record review of R#22's medical orders reflected an OOH-DNR order dated 10/05/24. Record review of R#22's Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) dated 04/06/24 reflected there was no physician signature at the bottom section stating, all persons who have signed above must sign below, acknowledging that this document has been properly completed. An interview on 01/07/24 at 11:05 a.m., SW said part of her duties was to assist the facility's residents and or their representatives understand their end of life wishes. She said if a resident or their representative opted to be a DNR, she would initiate the process by first making sure they understood what a DNR meant and to assist them in completing the OOH-DNR form. She said the form required the resident or their representative, 2 witnesses and their physician signature. She said once the resident or representative and the 2 witnesses signed the OOH-DNR form she would email the form to the resident's PCP and the hard copy would be kept in the facility in case the PCP would visit the facility. The SW said after the resident/representative and 2 witness signed the OOH-DNR form, she would notify the resident's charge nurse so they could obtain a verbal order from their PCP and code the resident appropriately on their electronic medical record. She said that she would give the original OOH-DNR form to the medical records personnel for her to assist in obtaining the primary care PCP signature. The SW said once the facility received the OOH-DNR form signed by the resident's PCP, it would be given to the medical records department to make sure it was completed correctly. If it were correctly completed it would be uploaded to the resident's electronic medical record, a copy would be kept in the nurse's station, and in her office in case of a power outage. She said as long as the form had the physician's signature under physician's statement and the date it was signed it would be considered valid. She said the physician did not have to sign the bottom portion of the OOH-DNR form that stated, All persons who have signed above must sign below, acknowledging that this document has been properly completed. The SW said if a resident were to code, nursing staff would check their electronic medical record under face sheet to check their code status. She said if a resident were coded a DNR, the nursing staff would also check the uploaded DNR form to make sure the form had been signed by the resident/representative, 2 witnesses, and their PCP to be considered a valid form. If the form were missing any of the required signatures, the resident would be considered full code. An interview and observation on 01/07/25 at 11:37 a.m., Medical Records specialist said she would assist the facility's SW in obtaining the resident's PCP signature on their OOH-DNR form. She said as soon as the SW gave her the OOH-DNR form she would walk the form over to the PCP for their signature. She said she once she obtained the PCP's signature, it would the SW's responsibility to make sure the form had been completed correctly. The Medical Records Specialist said as long as the resident's PCP had singed under the physician's statement it would be considered valid. She was observed checking R#22's medical file and pulled out the OOH-DNR form and said it was considered valid because her PCP had signed under physician's statement. She said the OOH-DNR form did not need the physician's signature on the bottom portion of the form that stated, All persons who have signed above must sign below, acknowledging that this document has been properly completed. An interview and observation on 01/07/25 at 1:05 pm, LVN B was observed checking R#22's electronic medical record and said R#22 had a code status of DNR. She said if a resident coded, she would first check their electronic medical record for their code status under their face sheet and then proceed to check the actual OOH-DHR form under miscellaneous tab to ensure the form had all required signatures. She said R#22's DNR was considered valid because it had a physician's signature. LVN B said had been in-serviced in resident's code status when she was first hired and as needed. She said if the OOH-DNR form was missing a required signature, it would be considered invalid, and the resident would be a full code. An interview on 01/08/25 at 8:35 a.m., LVN C said if a resident were to code, he would immediately check their electronic medical record under their face sheet to see what their code status was. He said he would then check the resident's miscellaneous tab to ensure the OOH-DNR form had the resident/RP, 2 witnesses, and physician's signature. He as long as the physician singed under the physician's statement it would be considered a valid form. LVN C said he had been in-serviced in DNR protocols. He said if the OOH-DNR form was missing a required signature, it would be considered invalid, and the resident would be a full code. An interview on 01/08/25 at 8:41 a.m., ADON she said if a resident were to code, nurses would check their electronic medical record under profile to check what their code status was and then check the resident's OOH-DNR form to ensure all required partied had signed. The LVN/ADON said as long as the OOH-DNR had the physician's under Physician's statement it would be considered valid. She said staff have been in-serviced on the topic of DNR quarterly or as needed. She said if the OOH-DNR form was missing any of the required signature they would be considered full code. An interview on 01/08/25 at 8:50 a.m. DON said the facility's SW was responsible to assist the resident or their representative with their code status decisions. She said if a resident or their representative opted to be a DNR, an OOH-DNR form was required. A completed OOH-DNR form was uploaded to the resident's electronic medical record for nursing staff to have easy access to the form. She said the OOH-DNR form required to have the signatures of the resident or representative, 2 witnesses signatures and the PCP's signature under physician's statement to be considered valid. The DON said if a resident were to code, nursing staff would check their electronic medical record face sheet to check what their code status was. They would next need to check the miscellaneous tab to ensure the actual OOH-DNR form had all required signatures. She said if the OOH-DNR form was missing any of the required signatures, it would be considered invalid, and the resident would be a full code status. She said the OOH-DNR form did not need the physician's signature on the bottom portion of the form that stated, All persons who have signed above must sign below, acknowledging that this document has been properly completed. Record review of the facility's Do Not Resuscitate Order (revised April 2017) reflected: Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain like functions on a resident when there is a Do Not Resuscitate Order in effect . Policy Interpretation and Implementation: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. 2. A do not resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and place in the front of the resident's medical record .

Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #34) reviewed for respiratory care. The facility failed to ensure Resident #34 received oxygen at the prescribed rate. This failure could place residents at risk for respiratory distress. The findings included: Record review of Resident #34's face sheet dated 1/6/25 reflected the resident was an 81 -year-old male admitted to the facility on [DATE]. Resident #34 had diagnoses which included the following: acute (rapid onset) and chronic (persistent and long-lasting) respiratory failure, acute bronchitis (inflammation of the bronchial tubes in the lungs), and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). Record review of Resident #34's MDS assessment, dated 12/16/24, reflected the resident had a BIMS score of 15 which suggests cognitively intact. Special treatments, procedures, and programs reflected resident received oxygen therapy. Record review of the most recent Care Plan for Resident #34, dated 12/18/24, reflected the resident had Oxygen Therapy r/t CHF, Respiratory illness Date Initiated: 12/13/2024. Interventions reflected: Give medications as ordered by physician. Oxygen Settings: O2 via nasal cannula at 3L continuously. Record review of the Doctor's Order Summary dated 1/6/25 reflected Resident #34 was prescribed O2 3L via nasal cannula every shift start date 12/20/24. Record review of the MAR for January 2025 reflected the resident was prescribed O2 3L via nasal cannula every shift -Start Date- 12/20/2024. Observation on 01/06/25 10:05 AM Resident #34 observed in room sitting up in bed head of bed elevated and receiving O2 at 4Lpm via NC. Resident #34 verbalized that was the rate he received at home and that he has informed staff the same. Resident denied any headache, dizziness, or other not normal symptoms. Observation on 01/06/25 at 5:58 PM Resident #34 observed in room sitting up in bed with head of bed elevated and receiving O2 at 4 Lpm via NC. Resident denied any headache, dizziness, or other not normal symptoms. Observation on 01/07/25 10:32 AM Resident #34 observed in room sitting up in bed with head of bed elevated and receiving O2 at 3.5 Lpm via NC. Resident denied any headache, dizziness, or other not normal symptoms. In an interview on 1/7/25 at 10:45 am with LVN J she said the orders for Resident #34's oxygen say he should receive 3L of oxygen via nasal cannula. She said they must check rate every 2 hours when check on resident or as needed. She said she checked on O2 and that call light was in reach every time she went in the room. She said she went into Resident #34's room about 15 minutes ago and the O2 was set at 3L and that she did not have to adjust the flow rate. She said LVN K, the charge nurse also checked prior told her it was set at 3L. She said they also checked on O2. She said Resident #34 was not able to change the setting himself because the concentrator was too far from him, and that he was aware he was not to be moving the rate. LVN J said Resident #34 does get visitors. The family member was very supportive. LVN J said she had not witnessed Resident #34's family member changing the oxygen setting. LVN J said that if a Resident was receiving more oxygen than prescribed, they could have hyper oxygen and that could damage the lungs. LVN J entered Resident #34's room to check the oxygen settings with surveyor. O2 setting was at 3L at that time. In an interview on 1/7/25 at 11:05 am LVN K. She said she went into Resident #34's room a few minutes ago. She said she adjusted the O2 setting when she went in his room and made sure it was at 3L. LVN K said Resident #34 was non-compliant on certain things but did not know if the resident moved the setting or not because she had never witnessed. She said they usually check the O2 settings every time they go into a Resident's room. She said if the oxygen was set higher than prescribed, it could affect a Resident's overall condition with their lungs depending on their diagnosis. LVN K said she believed nursing staff got checked-off yearly on oxygen administration. LVN K said they used to have an RT provide in-services but now ADON/LVN or DON in-service nursing staff. In an interview on 1/7/25 at 11:17 am ADON/LVN. She said if an order reads for 3L of oxygen to be administered, it should be followed. If oxygen was bumped up, would have to get an MD order. ADON/LVN said if a resident received too much oxygen and had COPD (Chronic Obstructive Pulmonary Disease - a chronic lung disease caused by damage to the lungs that leads to inflammation and swelling in the airways which limits airflow and makes breathing difficult) as a diagnosis, it could be a problem. ADON/LVN said they could get acidosis. She said if a resident was given 4 L of oxygen and the order reads 3L and there was no order for the increase, then it was considered a medication error. The ADON/LVN said they do in-services on oxygen therapy frequently and skills checkoffs were also done by the DON. In an interview on 1/7/25 at 12:00 pm the DON stated that LVN K called the family member of Resident #34, and family member said that she adjusted the resident's oxygen rate at times. The DON said the family member was informed that was not allowed. The DON said they started in-servicing staff and will complete care plan to include family adjusts O2 rate. In an interview on 1/8/24 at 7:00 pm DON, she said the order for Resident #34's oxygen was for 3L. She said the frequency for checking oxygen settings is case by case depending on what the order said. DON said that for Resident #34, the order said check every shift. The DON said the adverse effect for a resident receiving more O2 than prescribed could be hyperoxemia (a condition in which there is too much oxygen in the blood usually caused by high levels of oxygen) if receiving more oxygen than prescribed. The DON said Resident #34's original order that he received from hospital was 2-4 Lpm. The DON said the resident was not over oxygenated. She said his O2 saturations were not over oxygenated and there were no signs of distress while under their care. She said if any signs of distress had been noticed a change in condition would have been completed and they would have notified the doctor. The DON said the nurses were following the orders, they did not change it and they do not check the prescribed rate frequently because he is not one-on one care. Record review of the facility's Oxygen Therapy skills check-off reflected: Purpose: Validation of skills associated with administering oxygen therapy: 1. Oxygen is a medication and should not be adjusted without a physician's order. 4. Attach oxygen deliver device (e.g., cannula, mask to oxygen tubing) and attach to humidified oxygen source adjusted to prescribed flow rate, usually between 1 and 6 L/min. 8. Assess flow meter and oxygen source for proper setup and prescribed flow rate. Record review of the facility's record of in-service dated 10/24/24 reflected: Objectives of the In-Service . Brief evaluation of the participants' responses to the in-service: Oxygen policy (Administration, Assessments, etc.) . Record review of the facility's most recent Record of in-service dated 1/7/24 reflected In-service of oxygen settings: Objectives of the In-Service: 1. Always assess all residents for the need of oxygen 2. Follow O2 orders as stated from MD 3. Us of O2 for emergencies doesn't require an order 4. Therapy can adjust momentarily if needed for SOB, but must notify charge nurse to contact MD. 5. All changes to O2 will dictate a change of condition and need MD Notification 6. Always check concentrator vs orders with each entry. Record review of facility's Oxygen Administration policy revised March 2004, reflected: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Procedure . 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 (CNA D) of 4 CNAs reviewed for competent nursing care. The facility failed to ensure CNA D communicated R#22's change of condition to the charge nurse on 12/23/2024. This failure could place residents at risk of not having change in conditions assessed immediately resulting in delayed treatment and a decreased in quality of life. The findings included: Record review of R#22's admission record dated 01/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and an initial admitted [DATE]. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Crohn's disease (inflammatory bowel disease that causes swelling and irritation of the tissues in the digestive tract). Record review of R#22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1, indicating R#22 cognition was severely impaired. Record review of R#22's weekly skin review dated 12/24/2024 at 7:53 a.m., reflected: redness to her right upper arm, chest, and abdomen. RP and physician had been notified on 12/24/2024. Record review of R#22's progress note on 12/26/2024 at 5:44 a.m., authored by LVN A reflected: CNA D stated that since Monday she has noticed a small rash on her left side. Since then, the rash has progressed all over her upper chest down to her abdomen and both of her arms. The resident states no discomfort but you can tell she visibly has been scratching herself nonstop. I gave the patient Hydrocortisone for the itchiness during the night. I let NP know about the situation and am awaiting new orders. Record review of R#22's change in condition evaluation effective 12/26/2024 reflected: signs and symptoms identified as other change in condition ( red bump rash all over upper body) and change in skin color or condition. Date stated signed 12/23/2024. Vitals were within normal range. R#22's primary care clinician notified on 12/26/2024 at 5:55 a.m. and he recommended for R#22 to be applied Permethrin cream neck below x1 for dermatitis. An interview on 01/07/24 at 2:46 p.m., CNA D, said her regular work schedule was the overnight shift. She said on 12/23/24, she went into R#22's room and noticed she was scratching her chest. She said she noticed R#22 had a rash which she described being red bumps on her chest. She said the rash looked like an allergic reaction. She said she told herself she was not going to report it to her charge nurse until the following day and see if it went away. She said on 12/24/24, she checked the resident's chest again and noticed the rash had already run down to her breast area and at that point she told herself she needed to report it immediately to her charge nurse but got occupied with other residents and forgot to report it. She said on 12/25/24 she was assigned a different hall and did not reported it. CNA D said on 12/26/24 she was assigned R#22's hall and went to check on R#22 and noticed it was really bad, like if she had chicken pox, a lot of red dots from her chest down to her belly, and her back. She said R#22 was non-verbal but did not display any facial grimacing. She said after seeing R#22's rash had gotten worse, she immediately reported it to LVN A. She said she and LVN A went back to R#22's room and observed LVN A assess the resident. She said LVN A took a picture of the rash and sent it to R#22's NP. CNA D said she had been in-serviced in recognizing changes in residents and reporting them to their charge nurse immediately. CNA D was not able to say how her not reporting R#22's rash to her charge nurse immediately could have negatively impacted her. A telephone interview on 01/07/24 at 3:37 p.m., LVN A said on 12/26/24, CNA D communicated to her that R#22 had a rash on her chest, belly, and back and had been seen scratching nonstop. LVN A described the rash as being pinkish/red bumps. She said she took a picture and notified R#22's NP. She said while she was waiting for NP's response, she applied hydrocortisone to alleviate the itchiness during the night (which she had a standing order). She the NP responded the same day and prescribed Permethrin cream to be applied from the neck down, one time only for dermatitis. She said she did a change of condition on 12/26/24. She said, resident was not in pain or any discomfort just itchy. She said CNA D told her she had first noticed the rash on R#22 on 12/23/24. LVN A said any skin discolorations, skin tears and or rashes should be reported to the charge nurse immediately. An interview on 01/08/25 at 9:19 a.m., CNA E said that on 12/24/24 she had given R#22 a bed bath and noticed the resident had a rash on chest, stomach, arms and back. She said she immediately notified LVN E and she informed the treatment nurse. She said she was in-serviced in recognizing change in conditions and to report any changes to her charge nurse immediately upon being hired, quarterly, or as needed . An interview on 01/08/25 at 9:25 a.m., LVN L said on 12/25/24 she was R#22's charge nurse. She said R#22 had a standing order for hydrocortisone cream to be applied every morning to her arms and legs due to dry and itchy skin. She said couple of months ago, R#22 broke her right arm and required to wear sling. She said R#22 did not like the sling and constantly tried to remove it. She said R#22 would use her left hand to try to remove the sling and while doing so, she would scratch her chest and abdomen area in the process. She said CNA E had told her she had noticed a rash on R#22's chest and abdomen on 12/24/24. She said she assessed R#22 and determined that the rash was due to R#22 trying to remove the sling. LVN L said she immediately informed the wound care nurse who told her to just monitor R#22 since she already had scheduled orders for hydrocortisone. She said if a CNA noticed any skin discoloration, they need to let their charge nurse know immediately. She said the charge nurse would advise the resident's PCP, RP, ADON/DON and do a change in condition evaluation. She said nursing staff, and CNA 's have received in-services on what to do when change of condition skin occur and what steps to follow. An interview on 01/08/25 at 10:05 am, Treatment nurse/LVN said she was responsible for conducting weekly skin assessments on R#22. She said she had done a skin assessment on 12/24/24 and noticed a slight redness on her chest and abdomen, she said no blisters or open areas. She said R#22 required to wear a sling on her right arm and would constantly try to remove it. She said R#22 would pull down the sling and the movement of her trying to remove it caused the redness to her chest and abdomen area. She said it was reported to RP and PCP on 12/24/24. She said the PCP recommended for R#22 to be monitored. An interview on 01/08/25 at 10:56 a.m., NP said he received a call from the facility on 12/26/24 to inform him R#22 had a rash to her chest, abdomen, and back. The NP said the facility's nurse sent him a picture of R#22's chest and abdomen area. He said he prescribed a 1-time application of topical ointment called Permethrin to be applied to her neck and below for the diagnosis of dermatitis. He said the ointment he prescribed was for a 1 time use only. He said 12/26/24, he had not been updated on R#22 skin condition. An interview on 01/08/25 at 3:35 pm, DON said the CNA 's have been in-serviced to report any change in condition to their charge nurse as soon as possible. She said CNA 's can bathe residents but are not supposed to diagnose residents because they do not have a license to assess. She said CNAs were in-serviced on the topic of change of conditions and what to report. The DON said there were no negative outcome for R#22 since CNA E had previously reported her rash on 12/24/24 and the facility had already acted on treating the rash. The DON said the facility did not have a policy that indicated how long the CNA had to report a change in condition but were in-serviced on reporting it immediately to their charge nurse.

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that ensure accurate administering of all drugs and biologicals to meet the needs for 2 of 10 (Resident #5 and Resident #22) residents reviewed for pharmacy services. 1. The nursing staff did not administer Resident #5's Tramadol as prescribed by her physician. This failure could place resident s with pain at risk of not receiving the intended therapeutic benefit of their medications. 2. MA documented she had administered Resident #22 a frozen nutritional treat on 01/07/2025 when the facility did not have the frozen nutritional treat available on 01/07/2025. This failure could place residents at risks of not receiving the intended therapeutic benefit of their medications. The findings were: Record review or Resident #5's Admission Record dated 01/08/25 revealed an [AGE] year-old female with an initial admitted [DATE] with diagnoses of Alzheimer's disease (a progressive irreversible brain disorder that destroys memory ad thinking skills), Heart failure, and Type 2 Diabetes mellitus with unspecified complications (a disease that occurs when your blood glucose, also called blood sugar, is too high). Record review of Resident #5's Physician's Orders for January of 2025 revealed an order for Tramadol HCl oral tablet 50 mg (Tramadol HCl) give two tablets by mouth every 8 hours as needed for Pain. Give 2 tablets of 50 mg to equal 100 mg prn q8h, start date of 04/09/24. Record Review of Resident#5's Quarterly MDS assessment dated [DATE] revealed Resident #5 had a BIMS of 07 that indicated Resident #5 had severe cognitive impairment and had received scheduled pain medication regimen within the past five days. Resident #5 replied to no to having had pain or hurting at any time withinn the past five days. The question for pain intensity was blank. Record review of Resident#5's Care Plan revised on 04/18/24 stated Resident #5 had the potential for pain r/t Depression, wound (admitted with stage 3 PU to sacrum) with interventions to anticipate resident's need for pain relief and respond immediately to any complaint of pain and to observe/record/report to nurse resident complaints of pain or requests for pain treatment. Record review of Resident #5's e-MAR dated July of 2024 revealed an order for tramadol HCl Oral tablet 50 mg, give 2 tablets by mouth every 8 hours as needed for pain. Give 2 tablets to equal 100mg prn q8h, start date 04/09/24. Record review of Control Drug Administration Record dated 06/05/24 for Resident #5 revealed Tramadol 50 mg tab give 1 tab by mouth every 8 hours as needed. The Control Drug Administration record revealed only 1 tablet was administered on the following dates: *06/09/24 at 9:52 p.m., *06/10/24 at 11:00 a.m., *06/11/24 at 9:45 p.m., *06/17/24 at 8:05 p.m., *06/22/24 at 9:41 p.m., *06/30/24 at 1:52 a.m., *07/04/24 at 5:54 p.m., *07/06/24 at 1:16 a.m., *07/07/24 at 7:41 a.m., and *07/11/24 at 5:50 a.m. In an interview on 01/07/24 at 2:30 p.m., the DON said there might be a difference in the order on the blister pack/Controlled Drug Administration log and the e-MAR because the physician called the pharmacy directly. The DON said when that happens the facility does not get the orders. The DON said the nurse should have called the physician to clarify the order. In an interview on 01/08/25 at 6:43 p.m., LVN J said she administered the tramadol on dates 07/07/24 and 07/20/24.LVN J said when passing out medications she verified that the medication was accurate by checking the resident's name, the right route, the right dosage, right time, and right medication. LVN J said she checked the PCC under the MARS tab. The medication was tramadol 50mg every eight hours, one tablet as needed. On 07/07/24 LVN J said she gave one tablet to Resident #5 and on 07/20/24 she gave Resident #5 two tablets. LVN J said if there was a PRN order, she would check the MAR for PRN orders and would compare the blister pack with the sheet. If there were any changes to the order, there would be a sticker on the blister pack indicating a change. LVN J said if they made an error, they would call the doctor and the DON. Then they would get a new blister pack, or they put in the new information in electronic medical record for other staff to follow. LVN J said the negative effect was that the resident would not have the correct dosage to relieve her pain. LVN J said they received the sealed pack from the pharmacy, and she would open it and compare the blister pack to the orders in the MAR. If the order is incorrect, they would call the doctor to ask for a new prescription. LVN J said she did not call the doctor to verify the orders. In an interview on 01/08/25 at 7:00 p.m., LVN C said he administered the tramadol medication on 07/09/24 for two tablets and on 10/26/24 it was one tablet. LVN C said to verify if administering the correct medication, he would check the MAR to make sure it was the right route, right resident, right time, and right dosage. He would check the order and the log. LVN said he would then take the blister pack and pop the medication out. The LVN said if there was a change in direction there would be a sticker with a change in direction or to refer to the MAR. LVN C said he did notice a discrepancy on the log and noticed that the order said one tablet. LVN said on the time that he administered one tablet he looked at the order on the blister pack and when he gave the two tablets, he probably looked at the MAR. LVN C said if he had caught the mistake, he would have called the doctor and he would not have administered the medication. LVN C said he did not call the doctor to clarify the orders. LVN C said they did have an in-service on medication administration conducted by the DON. LVN C said the negative outcome of one tablet would be that the resident's pain would not be relieved but if he gave the two tablets the resident would just be sedated and relaxed. An interview on 01/08/25 at 7:10 p.m., The DON said nursing staff were responsible to sign off any medication given or not given to residents. She said nursing staff and med aides were supposed to check the e-MAR and label to make sure they matched. The DON said nursing staff and med aides are in-serviced quarterly or as needed on the topic of medication administration. The DON said if a medication was signed off on the resident's e-MAR when it was not administered it could cause them to not get the full effects of the medication. The DON said she had called the physician and he had clarified the order. In an interview on 01/08/25 at 07:15 p.m., the Administrator said he did not have very much to do with the nursing procedures. The Administrator said they had the daily clinical meetings, and they went over the 24-hour report and any other concerns. There was follow through throughout the day. The nursing department followed through with concerns such as orders, treatments, and resident care. They also had managers on duty during the weekend and they had an RN that also worked during the weekend for any issues that came up. Record review of facility's policy for Medication and Treatment Orders revised in July 2016 revealed: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon written order of a person duly licensed and authorized to prescribe such medication in this state. 9. Orders for medications must include: a. number and strength of drug b. Number of doses, start and stop date, and/or specific duration of therapy. c. Dosage and frequency of administration d. Route of Administration e. Clinical condition or symptoms for which medication is prescribed; and f. Any interim follow-up requirements (pending culture and sensitivity reports, repeat labs therapeutic medication monitoring, etc.) Record review of facility's policy for Administering Medications revised in December 2012 revealed: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 3. Medications must be administered in accordance with he orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method, (route) of administration before giving the medication. 18. If a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial, circle the MAR space provided for that drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered. b. The dosage. c. The route of administration. d. The injection site (if applicable). e. Any complaints or symptoms for which the drug was administered, and f. Any results achieved and when those results were observed, and g. The signature and title of the person administering the drug. 2. 2. Record review of Resident #22's admission record dated 01/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and an initial admitted [DATE]. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and Crohn's disease (inflammatory bowel disease that causes swelling and irritation of the tissues in the digestive tract). Record review of Resident #22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1, indicating Resident #22 cognition was severely impaired. Record review of Resident #22's quarterly care plan dated 10/23/204 reflected a focus of unintended weight loss on 01/05/2024 of 6 months trigger with 7-pound loss, 4 pounds in 3 months with BMI of 13.2. Date initiated 11/28/2022 and revised on 05/14/2024. Interventions included to provide a frozen nutritional treat daily as a supplement .continue with current care plan per registered dietician. Record review of Resident #22's MAR for the month of January 2025 reflected an order for a frozen nutritional treat one time a day for supplement, start date of 03/09/2022. Med-Aide had signed off on 01/07/2024 at 12 noon. Record review of Resident #22's meal ticket dated 01/07/2025 reflected a regular-puree diet. She was served pureed classic baked ziti-8 oz, pureed parmesan and herb roasted cauliflower, pureed garlic bread, pureed chocolate brownie, pudding, tea, and for frozen nutritional treat was scratched off with a note saying, not available. An observation and interview on 01/07/25 at 1:17 p.m., CNA E was observed feeding Resident #22 in her room during her lunch meal. Resident #22 had been served pureed ziti, pureed parmesan & herb roasted cauliflower, pureed garlic bread, pureed brownie, and a cup of chocolate pudding. CNA E said Resident #22 had eaten about 75 % of her meal. CNA E said Resident #22 had not received her frozen nutritional treat and didn't know why. CNA E said Resident #22 would get a frozen nutritional treat daily with her lunch tray. An observation and interview on 01/07/25 at 1:30 pm, Dietary Manager Trainer said the DM had stepped out of the facility, but she was willing to answer any questions. She was observed reviewing Resident #22's medical orders on her electronic medical record and said Resident #22 had an order for a frozen nutritional treat with her lunch tray every day. She was shown a picture of resident's meal ticket for 01/07/25 where it showed the frozen nutritional treat had been scratched off and a note saying not available had been written on the bottom portion of the meal ticket. The Dietary Manager Trainer was observed checking the freezer and said they were out of the frozen nutritional treats. She was then observed calling the DM on the phone to inquire on the frozen nutritional treats and was told by the DM that the facility was out of the frozen nutritional treats, but she had already placed an order and were due to be delivered on 01/08/2024. An interview on 01/07/25 at 4:00 p.m., Med-Aide was observed when she checked Resident #22's MAR on electronic medical record and said she had signed off a frozen nutritional treat for Resident #22 on 01/07/2024 at 12 noon. She said she had not physically checked Resident #22's tray to make sure the frozen nutritional treat had been included in her lunch tray. She said she trusted the kitchen staff to include it in her lunch tray. The Med-Aide said she was supposed to check if the frozen nutritional treat had been included before signing if off on Resident #22's MAR. She Resident #22 could be negatively affected in that she was not getting the added nutritional treat that she was ordered to receive. The Med-Aide said she said had been in-serviced on medication administration when she was first hired and as needed and felt confident in performing her job duties. An interview on 01/07/25 at 4:25 pm, DM said the facility had run out of frozen nutritional treats on 01/05/25. The DM said on 01/06/25 they had substituted the frozen nutritional treat with regular ice cream. She said on 01/07/25, regular ice cream should have been included but the kitchen staff failed to put it on Resident #22's lunch tray. The DM said she had borrowed frozen nutritional treats from a sister facility to be able to administer Resident #22 until their order comes in. She said no negative outcome to Resident #22 because aside from her regular menu she had been given pudding as a supplement. An interview on 01/07/25 at 5:00 p.m., the Dietician said Resident #22 was on a 2300 calorie diet. He said Resident #22 also had orders for a frozen nutritional treat (290 calories) and pudding (150 calories) to be administered during with her lunch tray. The Dietician said Resident #22 was on a high caloric diet but was not gaining weight. He said her age and medical diagnoses were a contributing factor in her no gaining weight. The Dietician said Resident #22 had not sustained any negative effects for not receiving the frozen nutritional treat on 01/07/2025. An interview on 01/07/25 at 5:25 p.m., DON said Nurse's and Med Aides were responsible to administer residents their medication(s) and sign them off on the residents MAR after the medication(s) had been administered. The DON said if the medication was not administered for whatever reason they were to use the chart codes listed on the bottom of the MAR to indicate the reason why a medication had not been administered. She said Resident #22's frozen nutritional treat should not have been signed off by the facility's Med-Aide because it had not been administered to her. She said she and the ADON have conducted in-services to all nursing staff and med-aides on the topic of medication administration upon hire, quarterly, and or as needed. The DON said she and the facility's Dietician had discussed that on 01/07/2024, Resident #22 had not been administered a frozen nutritional treat and had agreed that there were no negative effects to Resident #22 because she had been served, he regular diet plus pudding for lunch. Record review of the facility's Documentation of Medication Administration policy revised on April 2007 reflected: Policy Statement: The facility shall maintain a medication administration record to document all medications administered . Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: e. reason(s) why a medication was withheld, not administered, or refused (as applicable 47828

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 5 residents (Resident #32) observed for infection control issues in that: CNA F and CNA G revealed CNA F used wipes to cleanse the perineal area, folding it, and using the wipes again and CNA G noticed not sanitizing between glove changes. This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices. The findings were: Record review of Resident #32's electronic face sheet dated 1/8/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included unspecified sequelae of cerebral infarction (long-term complications from a stroke where specific nature cannot be clearly identified), muscle weakness, muscle wasting and atrophy (decrease in size or wasting away of muscle), and unspecified lack of coordination. Record review of Resident #32's comprehensive person-centered care plan, dated 10/23/24, reflected Resident #32 has an indwelling Catheter: neuromuscular dysfunction of bladder. Interventions included: Change catheter as indicated and observe/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Care plan also reflected Resident #32 has bowel incontinence r/t loss of bowel control. Interventions included Check resident during rounds and assist with toileting as needed, provide loose fitting, easy to remove clothing, and provide pericare after each incontinent episode. Monitor for and report to MD s/sx (signs and symptoms) of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Care plan also revealed Resident #32 has an ADL Self Care Performance Deficit. Interventions included: TOILET USE: The resident requires total assist of 1-2 staff for incontinent care. Record review of Resident #32's Quarterly MDS dated [DATE] reflected Resident #32 was dependent for self-care of toileting hygiene, had a catheter for urinary incontinence, and was always bowel incontinent. During an incontinent care observation for Resident #32, on 1/7/25 at 4:50 PM., CNA F and CNA G performed incontinent care on Resident #32. CNA G changed gloves twice and did not sanitize hands between glove changes. CNA F used a wipe to sanitize between labia of vaginal area wiped from clean to dirty, folded it and used the wipe again, then disposed of wipe. CNA F proceeded to wipe, fold, and wipe again 2 more times. CNA F completed cleansing vaginal area, she did not change gloves and sanitize hands prior to assisting resident on her side. CNA G applied sanitizer to gloves and assisted resident on side. She did not change gloves and sanitize hands. Resident #32 was on her other side, CNA G removed soiled diaper, then pulled clean diaper out from under resident using same gloves. CNA G then changed gloves without sanitizing between glove change. CNA F and CNA G left resident in comfortable position with call light in reach. In an interview on 1/7/25 at 5:30 pm., CNA F stated while using wipes during incontinent care, she should wipe, fold over the wipe, wipe again then dispose of wipe. She said she had never been told to only use one wipe per swipe or that she cannot fold over a wipe and use again. She said she had never been told that she must sanitize hands between glove changes. CNA F stated she had been doing this since she started working as a CNA. She said that the nurses at times assisted her when she performed pericare and had never been told she was doing anything wrong. In an interview on 1/7/25 at 5:35 pm CNA G stated that she had been performing pericare the same way since she remembered and had never been told that she must sanitize between glove changes. CNA G said she did not recall sanitizing her gloves. In an interview on 1/8/25 at 6:00 pm, DON stated she completed incontinence care check offs upon hire of staff and annually. She stated she also included in the monthly meetings and as needed. She said hand hygiene must be completed before and after care of residents, between glove changes and after every time they wipe a resident when performing incontinent care. She said CNAs were instructed to only use one wipe per swipe. DON said protocols must be followed to prevent cross contamination. Record review of Clinical Skills Checklist (CMAs and CNAs) for CNA F and CNA G dated 11/21/24 Perineal Care (Female Resident) indicated Procedure . 9. For a female resident: . a. using toilet tissue removes excess soiling as needed. b. discard soil gloves, sanitize hands and apply clean gloves c. Using the pre-moisten disposable/non disposable washcloth wash perineal area, wiping from front to back . 2. Continue to wash the perineum .Do not reuse the same pre-moistened disposable/non disposable washcloth to clean the urethra or labia 4. If needed gently dry perineum of excess moisture . b. Discard soil gloves, sanitize hands and apply clean gloves c. Using the pre-moisten disposable/non disposable washcloth wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same pre-moisten disposable washcloth to clean the labia. Disposal a. Discard brief and other disposable items in plastic bag b. Discard soil gloves, sanitize/wash hands and apply clean gloves c. Apply clean brief on resident Record review of facility's Handwashing/Hand Hygiene policy revised August 2015, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; . m. After removing gloves; . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not r3eplace hand washing/hand hygiene. Integration of glove use along with routine hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: a. Before aseptic procedures; b. When anticipating contact with blood or body fluids; .

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 4 residents (Resident#2) reviewed for abuse and neglect, in that: Facility staff member, CNA A did not implement their abuse policy related to reporting suspected abuse when Resident #2 was observed to be crying while Resident #2's family member was rubbing her forehead. This failure could place residents at risk of abuse and neglect. The findings were: Record review of Resident #2's face sheet, dated 09/06/24, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer disease, unspecified (progressive disease that destroys memory and other important mental functions), essential (primary) hypertension (high blood pressure), functional quadriplegia (a condition that causes complete immobility due to a severe disability or frailty, but is not caused by spinal cord damage or stroke), peripheral vascular disease, unspecified (narrowed blood vessels reduce blood flow to the limbs), schizoaffective disorder, unspecified (a mental health condition including schizophrenia and mood disorder symptoms). Record review of Resident #2's discharge minimum data set assessment (MDS), dated [DATE], revealed Resident #2 had a BIMS score of 99, indicating the resident was unable to complete the interview. The hearing, speech and vision section of the MDS did not include if resident was able to make herself understood by others. Record review of Resident #2's care plan with an initiated date of 06/28/24 revealed 08/31/2024 discoloration to middle of forehead. Record review of Resident #2's nursing note dated 08/31/24 at 12:33pm by LVN B stated, Nurse noted discoloration to middle of the forehead. Nurse assess [sic] the patient no facial grimace or discomfort noted at this time. Also nurse observe the [family member] of [Resident #2] is touching and rubbing the skin Record review of Resident #2's pain assessment in advanced dementia dated 08/31/24 completed by LVN B did not identify any negative vocalization and identified facial expression as smiling or inexpressive. Record review of CNA A's statement dated 09/03/24 about Resident #2's on 08/31/24 did not include any verbiage regarding Resident #2 crying. Record review of Resident #2's physician orders on 09/06/24 revealed an order for Xarelto 2.5MG to be given once daily for peripheral vascular disease with a start date of 06/17/24 and an indefinite end date. Record review of Resident #2's physician orders on 09/06/24 for Xarelto revealed it was classified as an anticoagulant. During an interview with LVN B on 09/05/24 at 5:03pm she stated on 08/31/24 either Resident #2's family member or CNA A notified her of the discoloration to Resident #2's forehead but she could not recall. She stated when she went to assess Resident #2 she noted family member for Resident #2 rubbing her forehead, and stated it was like friction to the forehead. LVN B stated Resident #2's family member was telling her to look at the discoloration which LVN B stated she did note to the middle of her forehead. LVN B stated at the time the discoloration was identified there were no allegations of abuse made. LVN B stated she made notifications to Resident #2's responsible party, DON and the Administrator. During and interview with LVN C on 09/05/24 at 5:30pm he stated on 08/31/24 Resident #2 was not his patient but he went with LVN B to assess Resident #2. LVN C stated Resident #2's family member was doing a swiping motion to Resident #2's forehead. LVN C stated Resident #2 had no signs of pain, no grimacing, no moaning and states she was just sitting in her chair. During an interview with CNA A on 09/06/24 at 3:32pm she stated on 08/31/24 at around 11:00AM Resident #2's family member requested for Resident #2 to be taken out of bed and brought to her in the common area. CNA A stated when she took Resident #2 to her family member in the common area she did not have any discoloration to her forehead. CNA A stated Resident #2's family member then requested a pillow and CNA A went to get it and when she returned she noted Resident #2's family member standing over Resident #2 rubbing Resident #2's forehead while Resident #2 was crying. CNA A stated Resident #2 was not verbal, and her crying could have meant she was in pain. CNA A stated she went to report to LVN B that Resident #2 was crying and that her family member was rubbing her forehead. CNA A stated shortly after that Resident #2's family member went to tell the nurses that Resident #2 had a bruise. CNA A stated she felt it was abuse because Resident #2's family member was hurting Resident #2. CNA A stated she told LVN B about Resident #2 crying and making voices but did not mention she thought Resident #2's family member was abusing her because she did not want to assume things. CNA A stated she had been trained over abuse and neglect at the facility via in-services by the DON and stated she was trained to immediately report any suspected or witnessed abuse to the nurse, ADON, DON and Administrator. CNA A stated she did not report to the Administrator because she did not know the Administrators personal phone number and did not know she was supposed to go to the Administrator. CNA A stated she thought she had to follow the chain of command when reporting and thought LVN B would report to the Administrator. CNA A stated on 09/04/24 she spoke to the Administrator and told him she felt like Resident #2's family member was abusing Resident #2. CNA A stated she told the Administrator she thought Resident #2's family member was hurting Resident #2 because she was crying, and the family member was telling her not to cry. CNA A stated it was important to report abuse for the patient's safety. CNA A stated she did not know the facility policy for reporting before but had since learned it. CNA A stated not reporting abuse could negatively impact residents because if they don't report the abuse then they will keep getting abused. During an interview with the DON on 09/06/24 at 6:02pm she stated staff had been trained over abuse and had been trained to report suspected abuse to the Administrator right away. The DON stated Resident #2 was identified with a bruise to her forehead on 08/31/24. The DON stated LVN B called her and told her that Resident #2's family member was rubbing Resident #2's forehead and after that she went and told the nurses that Resident #2 had a bruise. The DON stated Resident #2 had no signs of crying, pain, no facial grimacing and no other injuries or bruises noted by the nurse. The DON stated there were no allegations of abuse when the discoloration was noted and stated she did not think it was abuse because the patient was not crying. The DON stated CNA A had not reported Resident #2 crying to LVN B and stated ADON D got a statement from CNA A on 09/04/24 that did not include verbiage about Resident #2 crying. The DON stated CNA A spoke to the Administrator on 09/04/24 and did not mention Resident #2 crying. The DON stated her, and the Administrator did not know about Resident #2 crying until 09/06/24. The DON stated she asked LVN B if Resident #2 was crying, and she stated she was not. The DON stated the allegation of abuse was made by CNA A to Surveyor E on 09/06/24 unless CNA A told the Administrator something on 09/04/24. The DON stated CNA A should have reported the suspected abuse to the Administrator. The DON stated CNA A had been trained over reporting abuse on 08/29/24 and 09/04/24 and had been given a 1:1 counseling for not reporting possible physical abuse. The DON stated it was important to report abuse to make sure the residents were well taken care of. The DON stated the facility policy stated to report to the Administrator right away when abuse was suspected or witnessed. The DON stated CNA A did not follow the facility policy when she initially reported because she did not say anything about Resident #2 crying or being in pain. The DON stated not reporting abuse could negatively impact residents because it could affect their care, quality of life, and stated patients could get hurt physically and emotionally. During an interview with the Administrator on 09/06/24 at 6:33pm he stated staff were trained over abuse and were expected to notify him immediately if abuse was suspected or witnessed. The Administrator stated on 08/31/24 Resident #2 was identified with discoloration to her forehead by a family member who reported it to LVN B. The Administrator stated LVN B went to assess Resident #2 after she was notified on 08/31/24 and noted discoloration to forehead. The administrator stated the nurse had not noted any signs or symptoms of pain, no crying, and no distress from Resident #2 at that time. The Administrator stated at the time the discoloration was identified on 08/31/24 there were no allegations or suspicions of abuse. The Administrator stated CNA A had not mentioned Resident #2 crying to the nurse on 08/31/24 and stated CNA A provided a statement on 09/03/24 that did not mention abuse or neglect. The Administrator stated CNA A first alleged abuse on 09/04/24 when she told him that she felt the incident with Resident #2's bruising on 08/31/24 was possible abuse. The Administrator stated due to the allegation he then made a self-report at 3:14pm on 09/04/24. The Administrator stated he asked CNA A if she felt Resident #2's family member was trying to cause a mark and CNA A stated yes that it was being done intentionally and she was rubbing hard. The Administrator stated CNA A should have reported any suspicion of abuse to him and stated it was important to report abuse so that they could investigate thoroughly and report to state and keep it from happening. The Administrator stated he and staff monitored and ensured residents were free from abuse and neglect in the facility by doing continuous in-services, completing safe surveys with residents and talking about them during resident council meetings, completing weekly head to toe assessments, and ensuring staff monitored residents for any signs of abuse or neglect with every enteraction. The Administrator stated the facility policy reflected their training to report all suspicions and allegations of abuse to him. The Administrator stated CNA A did not follow the facility policy in regard to reporting The Administrator stated not reporting abuse could negatively impact resident because it would allow abuse to continue. The Administrator stated Resident #2 had no recent falls or other incidents that could have caused bruising and stated after their investigation they determined that the bruising likely came from Resident #2's family member rubbing her forehead. Record review of facility in-services revealed CNA A had been trained over reporting allegations of abuse and neglect on 08/29/24. Record review of a document titled, Record of Disciplinary Measure revealed on 09/04/24 CNA A received counseling over her failure to report an abuse allegation to the abuse prohibition coordinator, the Administrator when she witnessed possible physical abuse on 08/31/24 and did not report until 09/04/24. Record review of facility policy titled Reporting Abuse to Facility Management with a revision date of December 2009 included a section titled, Policy Interpretation and Implementation that included the following verbiage: 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing Services.

Based on observations, interviews, and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 30 staff (LVN A) reviewed for staff qualifications. The facility failed to ensure LVN A renewed her nursing license before the expiration date in order to practice nursing in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed. The findings included: Record review of the Texas Board of Nursing website license verification portal on [DATE] at 5:44 p.m. revealed LVN A's Texas nursing license was listed as delinquent with a license expiration date of [DATE]. Record review of the Texas Board of Nursing website on [DATE] stated, If you do not renew your license before the expiration date, your license will go into delinquent status, and you cannot practice/work as a nurse with a delinquent license. You will not be able to practice nursing until your license is successfully renewed and placed into an active/current status. Record review on [DATE] of LVN A's timecard revealed she worked the following days and hours with a delinquent license. a. Sunday - [DATE] - 11.25 Hours b. Tuesday - [DATE] - 11.50 Hours c. Wednesday - [DATE]- 12 Hours d. Monday - [DATE] - 11.50 Hours e. Tuesday [DATE]- 11.75 Hours f. Friday [DATE]- 11.75 Hours g. Saturday [DATE]- 11.75 Hours h. Sunday [DATE]- 12 Hours i. Monday [DATE]- 12 Hours j. Tuesday [DATE] - 11.75 Hours k. Friday [DATE] - 11.75 Hours l. Saturday - [DATE] - 11 Hours m. Sunday - [DATE] - 11 Hours n. Tuesday - [DATE] - 11 Hours o. Wednesday - [DATE] - 11.75 Hours p. Thursday - [DATE] - 12 Hours q. Monday - [DATE] - 11.5 Hours r. Tuesday - [DATE] - 11.5 Hours s. Friday - [DATE] - 12 Hours t. Saturday - [DATE] - 12.25 Hours u. Sunday - [DATE] - 12 Hours v. Wednesday - [DATE] - 11.75 Hours w. Thursday - [DATE] - 11.25 Hours x. Monday - [DATE] - 11.75 Hours y. Tuesday - [DATE] - 12.5 Hours z. Friday - [DATE] - 11.25 Hours During an observation LVN A was observed in the facility's south wing on [DATE] at 6:18pm and [DATE] at 4:15pm, LVN A was not observed providing direct patient care. During an interview and record review with the DON on [DATE] at 2:35pm she stated before surveyor B identified LVN A had a delinquent license on [DATE] she was not aware of LVN A's delinquent license. The DON stated HR was responsible for verifying staff licenses and certifications and had started checking the nurse aides but had not started checking the nurses. The DON was not sure how often those checks were completed and stated she did know that during their annual survey window they would check and be given a list of expiration dates. The DON stated the last time licenses were checked was in [DATE] and stated she would get a licensure report/update on renewals from HR. The DON stated the nurses themselves were responsible for renewing their licenses. The DON reviewed LVN A licensure information retrieved from the Texas Board of Nursing website license verification portal on [DATE] at 5:44pm and confirmed LVN A's licensure stated delinquent. The DON stated LVN A had since submitted for renewal and was pending confirmation. Shortly after this interview, the DON returned and stated LVN A's renewal had gone through and was active as of [DATE]. The DON stated LVN A had been working the floor and had provided nursing care to residents since her licensure date of expiration on [DATE] and stated the last day she worked was on [DATE]. The DON stated she nor other staff had sent LVN A any reminders for her licensure renewal. The DON stated HR was the only person reviewing staff qualifications. The DON stated she had not identified LVN A's license was delinquent because she thought LVN A would be on top of it. The DON stated LVN's were not allowed to work with a delinquent license because their licenses needed to be active to practice as a nurse. The DON stated when LVN A was identified to be delinquent she was written up, sent home, suspended, and would not be allowed to return to work until LVN A provided proof her license was active. The DON stated although LVN A was not compliant with the regulations of the Texas Board of Nurses she had not had any complaints or seen any effects on resident care due to LVN A not having an active license. During an interview on [DATE] at 2:58pm LVN A stated on Friday [DATE] her nursing license was delinquent and stated she had since renewed it and had confirmed it had become active on [DATE]. LVN A stated she did not have the exact date her nursing license had expired on. LVN A stated she had not known her license had expired and stated she had been working at the facility providing patient care from the time of licensure expiration on [DATE] until Surveyor B identified that her license was delinquent on [DATE]. LVN A stated she didn't know if there was anyone at the facility designated to oversee when staff licensure/certifications were set to expire. LVN A stated no one at the facility notified her of needing to renew her license. LVN A stated the responsibility to renew her license and maintain it active was hers. LVN A stated she had not renewed it because she did not know it was expiring. LVN A stated she was not allowed to work as an LVN and provide nursing care to patients with a delinquent license. LVN A stated when she was identified to have a delinquent license, she was removed from providing patient care. When LVN A was asked about the impact not having an active license could have on residents, LVN A stated that although she did not have an active license she would still have the skills and knowledge. During an interview with HR on [DATE] at 3:11pm she stated before surveyor B identified LVN A had a delinquent license on [DATE] she was not aware of LVN A's delinquent license. She stated she would only track the nurse aides and did not know she needed to check the nurses. HR stated she did not think anyone was responsible for checking the nurse licenses and stated she only checked the nurse's licenses upon hire and had not checked otherwise. HR stated the nurses would now be included in her monthly checks. HR stated because nurses were not being reviewed, she had not provided any licensure report or updates to the DON or Administrator for the nurses. HR stated the nurses themselves were responsible for renewing their licenses. HR stated LVN A had been working the floor and providing nursing care to residents since her licensure date of expiration on [DATE]. HR stated between [DATE] and [DATE] LVN A worked a total of 26 days. HR stated she had not sent LVN A any reminders for her licensure renewal. HR stated she was the only person reviewing staff qualifications and stated she had not identified LVN A's delinquent license because previously she was only checking the aides and not nurses. HR stated LVN s are not allowed to work with a delinquent license because they weren't certified. HR stated when LVN A was identified to have a delinquent license she was written up, suspended, and not able to work until her license was active. HR stated nurses not having an active license could negatively impact residents because they wouldn't be up to date on what's new and updated in their continuing education. During an interview with the Administrator on [DATE] at 4:17pm he stated before surveyor B identified LVN A had a delinquent license he was not aware of LVN A having a delinquent license. The Administrator stated the nurses themselves were responsible for verifying their licenses were renewed, active, and were expected to monitor and check themselves. The Administrator stated HR would check nurse aides' certifications monthly, with the last check completed [DATE]. The Administrator stated no one had been in charge of checking the nurse's licenses and stated they had been checked upon hire, but they had not been checked regularly that he knew of. The Administrator stated there was no licensure report or updates on renewals coming up that was being sent to him for the nurses. The Administrator reviewed LVN A licensure information retrieved from the Texas Board of Nursing website license verification portal on [DATE] at 5:44pm and confirmed LVN A's licensure stated delinquent. The Administrator stated LVN A had been working the floor and providing nursing care to residents since her licensure date of expiration on [DATE] and stated the last day she worked was on [DATE]. The Administrator stated he nor other staff had not sent LVN A any reminders for her licensure renewal. The Administrator stated there was no one who specifically reviewed nurse licenses, and stated they had not identified LVN A's license being delinquent because they did not check them. The Administrator stated LVN's were not allowed to work with a delinquent license because it was part of their job description and expectations. The Administrator stated when LVN A was identified to have a delinquent license she was taken off the floor immediately, counseled, suspended, and stated he completed an audit of other licensed nursing staff with no other issues identified. The Administrator stated nurses not having an active license could negatively impact residents because they may not have the best or most active practices. Record review of a facility document provided by the DON that was titled, Charge Nurse indicated the specific requirements for the position and stated, Must possess a current, unencumbered, active license to practice as an RN or LPN/LVN in this state. Record review of excerpt from the facility handbook provided by the Administrator dated [DATE] revealed section 13.1.7 titled, LICENSE RENEWAL/CONTINUING EDUCATION UNITS stated, All other employees are responsible for maintaining current license including the cost of continuing education. If an employee allows their license to lapse, the employee will be suspended without pay until such a time a license in good standing is produced and verified.

Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation that involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (R #1) of 5 residents reviewed for abuse/neglect. The facility failed to report allegations of resident abuse for R #1 for an incident on 04/24/24 to the State Survey Agency within the allotted time frame of 2 hours. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect. The findings included: Record review of R #1 's file reflected [AGE] year-old female with original admitted [DATE] and last admitted [DATE]. Her diagnosis included: Alzheimer's disease, cognitive communication deficit, muscle weakness, Osteoporosis (weak bones), other specified depressive episodes, and other specified local infections of the skin and subcutaneous tissue. Record review of R #1's MDS assessment dated [DATE] reflected BIMS was not conducted as R #1 was rarely/never understood. R #1 was dependent (helper does all of the effort) for toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Record review of R #1's Care Plan dated 05/03/24 reflected R #1 had an ADL self-care performance deficit related to confusion, dementia, limited mobility, limited range of motion, and musculoskeletal impairment. Interventions included: R #1 required a total assist of 1-2 staff for incontinent care. Date initiated: 12/27/23. R #1 had a deficit in memory, judgement, decision making and thought process related to long term memory loss, short term memory loss, and Alzheimer's disease. Interventions included: explain each activity/care procedure prior to beginning it. Date initiated: 12/27/23. Record review of progress notes for R #1 reflected - On 04/24/24 at 5:16 PM, documented by LVN A. At 4:20 PM, LVN A rendered perineal care to R #1 and applied cream as ordered to the groin and to private area with diaper rash with FM 4 in the room. At around 4:35-4:45 PM, as soon as they finished, after few minutes, the FM 1 came in and went straight to R #1's room then went to LVN A and said she wanted to talk to LVN A. FM 1 directed LVN A to R #1's room and saw R #1's diaper open exposing her private area and FM 1 showed LVN A that R #1 had yeast on her vagina. FM 1 opened R #1's labia with her finger. LVN A explained to FM 1 that they barely changed R #1's diaper and no discharge was noted during that time and a cream was applied which may be the cream she sees as yeast. LVN A and LVN B wiped R #1's private area to verify if it's vaginal discharge but no discharge noted. FM 1 did a body check on R #1 every time she comes to see her. Notified RP and NP. Explained to NP the situation above with order to give Miconazole 1200 mg vaginal suppository x 1 dose and topical cream to outer area daily x 7 days and orders carried out. On 04/25/24 at 9:05 AM, documented by LVN A. Miconazole 7 Vaginal Cream 2 % Insert 1 application vaginally one time a day for yeast for 7 Days vagina outer area. Not in stock yet. On 04/25/24 at 11:11 AM, documented by DON. R #1 resting in bed, no signs of distress noted. As per charge nurse, R #1 had been eating well. R #1 was being repositioned constantly to prevent skin breakdown while she was in bed. Peri care was being provided as needed. R #1 required assist by 1-2 staff for ADLs. Call light within reach. On 04/25/25 at 2:52 PM, documented by LVN A. At 6:30 AM, R #1 was asleep, not in distress and no signs or symptoms pain noted. At 7:00 AM, peri care done and no vaginal discharge noted. Keep resident clean and dry. Keep head elevated with TV on. Breakfast given to resident with the help of the CNA. At 8:00 AM, R #1 showered by CNA and no vaginal discharge noted. Call light within reach. Head of bed to upright position. Touch call light within reach. Continue rounding. At 10:30 AM, again peri care done and no vaginal discharge noted. At 11:03 AM, notified NP of no vaginal discharge noted with order to discontinue Miconazole suppository and cream. Orders carried out. On 04/25/24 at 4:13 PM, documented by DON. attempted to schedule care plan meeting today with family to discuss the care being provided and family's disagreements in regard to FM 1 coming to the facility almost on a daily basis to perform head to toe assessments (skin assessments) on R #1's body including her private areas. FM 1 stated that she could not come in today but will be available tomorrow at 4pm. RP notified. On 04/25/24 at 5:39 PM, documented by DON. Called FM 1 to advise her to ask for a nurse when she wants to assess R #1's body so that she can have a witness when she inspects R #1's body. The nurse will make sure R #1 was okay and not in any kind of distress while FM 1 assesses her body. As per RP, RP was not comfortable with FM 1 completing assessments on R #1. FM 1 stated that she had to do skin assessments on R #1 because she was her advocate and the facility did not have the right to tell her not to do it. DON told FM 1 that the facility needed to protect R #1's privacy and dignity and they had to ensure their residents are safe. DON also suggested to request a skin assessment and be present while the nurse does it so that FM 1 can see if there was any skin breakdown but she was not allowed to touch R #1's private areas without asking R #1 for permission. FM 1 got upset and said that she would be in the care plan meeting tomorrow to continue with this conversation. On 04/26/24 at 3:38 AM, documented by DON. The facility received a visit from APS today in regard to a case on R #1. The APS worker was asking about R #1's care and about any concerns that we had about FM 1. DON notified the APS worker that DON had received a call yesterday from the police department regarding a report that a family member had filed against FM 1 due family not being comfortable about FM 1 being alone in a room with R #1. RP and other siblings fear for R #1's safety when FM 1 visits and does unsupervised head to toe skin assessments. On 04/26/24 at 4:54 PM, documented by DON. Email sent to FM 1 to advise that she must complete all visits in facility with supervision. FM 1 had been given the option of visiting in day room or dining room while there was an active APS case. RP and other siblings aware of the change. Staff have been advised of change and protocol to follow. No further questions or concerns at this moment. In an interview with APS on 05/03/24 at 9:20 AM. APS said she received an intake for R #1 with an allegation of sexual abuse from FM 1. APS said the allegation was that FM 1 had stuck her fingers inside of R #1's vagina. APS said she spoke to the DON and did explain the concerns reported for R #1. APS said that there was also concern that FM 1 took photos and sent them to the DON and staff members. APS said she was not sure exactly what the photos consisted of but the family was not comfortable with this. APS said she told DON there was an allegation of abuse but did not specify sexual abuse. APS said R #1 did not have capacity to make decisions and RP would be responsible to make decisions for R #1. APS said DON informed her that the facility was going to implement supervised visits with FM 1 to keep R #1 safe and no longer allow FM 1 to assess or take such photos of R #1. In an interview with OMB on 05/03/24 at 2:30 PM. OMB said there were family issues for many years and FM 1 used to have a power of attorney for R #1, but it was revoked by the court. OMB said the family voted and made one of the children the RP. OMB said there was a concern that the facility did not report the possible abuse of from FM 1 towards R #1. Observation of R #1 on 05/03/24 at 3:30 PM. R #1 did not respond to questions. R #1 appeared with good personal hygiene. R #1 was not injured or in distress. R #1 was in bed resting. R #1 had the touch call light within reach. R #1 had bed rails on both sides. There was a camera by the overhead light facing R #1's bed. In an interview with FM 1 on 05/06/24 at 11:25 AM. FM 1 said on 4/24/24, she visited R #1 and removed the brief to check for a rash or redness. FM 1 said FM 4 was present. FM 1 said she was only checking for a rash but she saw an abnormal discharge so she rushed to call the nurse. FM 1 said LVN A claimed that she had just changed R #1 5 minutes prior to when FM 1 arrived. FM 1 said LVN A called LVN B to the room and LVN B told her they could discuss things because she was not RP. FM 1 said she insisted on the nurses getting orders for testing and LVN B said they would notify NP/RP. FM 1 said there was an APS case opened against her. FM 1 said that on 4/24/24 she did not do anything wrong. FM 1 said she did not touch R #1's vagina or touch her inappropriately in any way. FM 1 said the nurses explained that they had just changed R #1 and that the discharge was ointment or rash cream, not a yeast infection, but she did not believe so. FM 1 said she was wearing gloves but she did not open R #1's private area or vagina. FM 1 said DON had asked her why she opened R #1's vulva but she did not do that. FM 1 said she did not put her fingers inside of R #1's vagina. FM 1 said that DON informed her she had to ask a nurse to assess R #1 and she also had to be supervised during visits. FM 1 said that before this she would do assessments, but it was only to check R #1's skin, and she never removed R #1's brief until this time on 4/24/24 because she did not believe them that the rash was clear or getting better. FM 1 said she never sent photos of R #1's private areas. FM 1 said she did take photos of R #'1 private areas but it was to show DON or her family that she had a rash, not because she had any malice or sexual intent. FM 1 said hid the private areas and did not expose the genitals in the photos. FM 1 said maybe she should not have done that but she was upset at the time and did not process if it was right or wrong. Observation of R #1 on 05/07/24 at 9:30 AM. R #1 did not respond to questions. R #1 appeared with good personal hygiene. R #1 was sitting in her wheelchair by the nurse's station and wearing the brace boots on both feet. In an interview with FM 4 on 05/07/24 at 12:15 PM. FM 4 said she was present on 4/24/24 when FM 1 visited R #1. FM 4 said the staff had changed R #1 about 5-10 minutes before FM 1 arrived. FM 4 said she informed FM 1 of the brief change. FM 4 said FM 1 still took off R #1's pants and opened her brief. FM 4 said she did not look because she did not want to see R #1 in that way, exposed. FM 4 said FM 1 got upset and went to call the nurse. FM 4 said she did not remember if FM 1 left the brief open, but she probably did. FM 4 said FM 1 told the nurse that R #1 had something, but the nurse told FM 1 that it was the medicine they had put on her. FM 4 said that was all she remembered. FM 4 said she did not see if FM 1 did anything to R #1's private area, but she was not very close because she did not want to see R #1 naked. FM 4 said she did see when the staff changed R #1 before FM 1 arrived and the staff had put 2 different creams on her private areas. FM 4 said she did not see FM 1 open R #1's vagina or do anything inappropriate but she stayed away from the bed and did not see or look at everything that was going because she knew how FM 1 was and she tried to avoid problems with her. FM 4 said she visited R #1 about 3 times a week and assisted in feeding her. FM 4 said she had no concerns with the care provided to R #1 as R #1 was always clean and ate well. In an interview with FM 2 on 05/07/24 at 1:15 PM. FM 2 said RP was notified of an incident that happened on 4/24/24 regarding FM 1 putting her fingers inside of R #1's vagina. FM 2 said she was not present during that time and did not witness this. FM 2 said the family was not comfortable with FM 1 doing this or doing assessments on R #1. FM 2 said the facility did initiate supervised visits and no longer allowed FM 1 to conduct assessments. FM 2 said the situation was better. FM 2 said she had no concerns regarding the care provided to R #1 by the facility staff. In an interview with RP on 05/07/24 at 4:45 PM. RP said he was informed by the facility of an incident on 4/24/24 where FM 1 put her fingers in R #1's vagina because she was assessing her. RP said he did not think FM 1 needed to be doing that and he did not want her checking R #1. RP said R #1 did not comprehend what was going on and he did not think what FM 1 did was justified. RP said he tried to get a restraining order with the police against FM 1, but the police told him that it would be a process, depending on the outcome of the investigations opened with APS and the state. RP said he had no concerns with the care provided to R #1 by the facility staff. In an interview with LVN B on 05/07/24 at 2:55 PM. LVN B said on 04/24/24, FM 1 was upset so she went in to assess R #1 with LVN A. LVN B said FM 1 had R #1's legs open and her brief was open. LVN B said FM 1 opened R #1's labia with her fingers and tried to scoop out what FM 1 thought was yeast from R #1's vagina, but really it was cream that LVN A had just applied during a brief change. LVN B said she explained to FM 1 that she should not be doing that because she could cause trauma or introduce bacteria into R #1's vagina, but FM 1 said it was her right. LVN B said FM 1 insisted that was yeast and that they needed to get orders right away. LVN B said R #1 had not shown signs of a yeast infection, however, LVN A notified the NP of the situation. LVN B said she believed this incident would be sexual abuse because she was putting her fingers inside of R #1's vagina and she did not think it was okay. LVN B said she did not believe it was with sexual intent but R #1 was not able to voice if she gave permission and FM 1 did not explain to R #1 what she was doing. LVN B said she did notify the DON about this incident that same day. LVN B said FM 4 was in the room during the situation but was not sure what she saw. In an interview with LVN A on 05/07/24 at 4:40 PM. LVN A said on 4/24/24, FM 1 visited R #1 and FM 4 was in the room. LVN A said FM 1 called LVN A to the room and when she walked in the room, R #1 had her brief open and her legs were spread apart. LVN A said FM 1 opened R #1's labia with her fingers and said that R #1 had a yeast infection. LVN A said explained to FM 1 that she had just changed R #1's brief and applied the cream/ointment for R #1's rash in that area. LVN A said FM 1 insisted so she called LVN B to assist her. LVN A said she and LVN B returned to the room, and FM 1 again showed them what FM 1 thought was yeast. LVN A said FM 1 opened R #1's labia and showed LVN B. LVN A said LVN B explained to FM 1 that it was not yeast and that R #1 did not have signs or symptoms of a yeast infection. LVN A said she was not able to tell FM 1 to stop but LVN A did not think it was right for FM 1 to do that, to check R #1 in that manner. LVN A said she did not remember FM 1 putting her fingers inside of R #1's vagina or if she did more than open her labia. LVN A said FM 1 did get the substance that she thought was yeast with her fingers, like with a swooping motion, and was trying to show them that it was yeast, but it was the cream and ointment LVN A had applied. LVN A said she and LVN B cleaned R #1 and ensured she was okay before they left the room. LVN A said she notified NP about the situation and obtained orders. LVN A said the NP did discontinue the orders the following day when she followed up regarding R #1 not having signs or symptoms of a yeast infection. LVN A said she continued to monitor R #1 for a yeast infection but she did not show signs or symptoms. LVN A said what she saw what FM 1 was doing to R #1 on 4/24/24, checking her vagina in that manner, LVN A would consider it abuse because it was R #1's private area and R #1 did not know what was going on. LVN A said FM 1 did not explain to R #1 what she was doing and even if R #1 did not understand, FM 1 should have told R #1 that she was going to undress her, open her brief, or check her vagina, but she did not. LVN A said she and LVN B explained to R #1 the care that was being rendered that day. In an interview with the DON on 05/14/24 at 10:55 AM. DON said the facility implemented supervised visits with FM 1 for R #1 when APS informed them about an open investigation. DON said APS informed her that there were concerns regarding FM 1 taking photos of R #1 and that the family was not comfortable with FM 1 assessing R #1 in the manner like it happened on 4/24/24. DON said the staff knew that FM 1 would assess R #1 almost every time she visited, but they were not aware of the extent of the assessments until 4/24/24 when FM 1 showed the nurses what she thought was a yeast infection. DON said they thought FM 1 would only check R #1's skin for bruises or rashes. DON said LVN B notified her on 4/24/24 that FM 1 had removed R #1's pants, opened her brief, and had put her fingers in R #1's vagina because she thought she had a yeast infection. DON said FM 1 should not have been assessing R #1 in that manner by exposing her private areas and putting her hands/fingers on R #1's vagina for any reason. DON said FM 1 was not a nurse or trained professional and did not know how to properly conduct an assessment regarding the vagina or that area. DON said FM 1 was wearing gloves during the incident on 4/24/24 from what the nurse reported, however, FM 1 the gloves are not sterile and she could introduce bacteria into the vaginal canal. DON said she was aware that FM 1 would take photos of R #1 as FM 1 sent the photos to her to show that R #1 had a rash, but at that point the nurse was already aware and the rash or concern had already been addressed with the NP or MD. DON said she did not believe the photos were taken with sexual intent, but it did become a bit much to deal with. DON said on 4/24/24, the staff had performed incontinent care and had applied the cream/ointment for R #1's rash in the groin and vagina area. DON said there were no signs or symptoms of a yeast infection. DON said the staff tried to tell FM 1 that she could not assess R #1 in that manner, but FM 1 said that it was her right. DON said after that, the facility implemented the supervised visits and informed FM 1 that she was not allowed to assess R #1. DON said R #1 was not injured from this incident on 4/24/24. Observation of R #1 on 05/14/24 at 11:55 AM. R #1 did not respond to questions. R #1 appeared with good personal hygiene. R #1 was sitting in her wheelchair by the nurse's station and wearing the brace boots on both feet. Record review of grievances, R #1's electronic medical chart, and the state reporting system completed on 5/14/24 at 12:20 PM reflected the incident on 4/24/24 was not reported to the State Survey Agency. In an interview with the DON on 5/14/24 at 1:10 PM. DON said APS did not tell her that they were investigating abuse but the APS worker did say it was regarding concerns about what had happened on 4/24/24. DON said R #1 was not injured and did not have a negative outcome because of the facility not reporting this incident to the state. DON said she saw the importance of reporting to the state within required timeframes. DON said they should have reported this incident to the state although APS never mentioned abuse or neglect. In an interview with the Administrator on 05/14/24 at 2:00 PM. The Administrator verified this incident regarding FM 1 checking R #1's vagina with her fingers was not reported to the state by the facility. The Administrator said if it had been a staff or another resident that did this to R #1, that would have been reported, but since it was a family member and it was not abuse, in his eyes, he did not report it. The Administrator said his train of thought was that since it was not done with sexual intent, like FM 1 was checking R #1 because she thought she had a yeast infection and she was trying to do an assessment although FM 1 was not a nurse. The Administrator said since there was no sexual intent, it was not sexual abuse or abuse. The Administrator said FM 1 had brought up a lot of issues throughout the time since R #1 had been admitted so he was more focused on keeping R #1 safe and doing what was best on her behalf. The Administrator said FM 1 had sent him photos of R #1's private areas, showing a rash or a concern she had. The Administrator said although it made him uncomfortable, he saw it as FM 1 bringing up concerns, not as sexual abuse or abuse of any kind. The Administrator said APS brought up concerns but did not specify abuse as far as he knew. The Administrator said perhaps maybe there was a miscommunication from what the nurses saw, to what was reported to the family, and what was reported to APS. The Administrator said from what the nurses (witnesses) reported to the facility, they never saw the incident as malice, and what was reported was not considered abuse as FM 1 was not doing it with sexual intent, it was like just like FM 1 was playing nurse. The Administrator said the supervised visits implemented have been sufficient in keeping FM 1 from continuing to do these assessments and to keep R #1 safe. The Administrator said although he did not see it as abuse, and R #1 was not injured or negatively impacted from the incident or by the facility not reporting to the state, he could see both sides of reporting or not. Record review of Abuse Prevention Program Policy (revised December 2016) Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on record review and interview the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 5 residents (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1 medication Ipratropium-Albuterol Solution via nebulizer mask was monitored by staff based on their nursing protocols. This failure could place residents at-risk of not receiving adequate respiratory care. The findings included: Record review of Resident #1's admission record, dated [DATE], reflected he was a [AGE] year-old male with an admitted [DATE] with diagnoses which included dementia (decline in cognitive abilities), chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease and airflow limitation), contracture (shortening of muscles, tendons, skin causing joints to shorten), gastrostomy status (artificial external opening into stomach for nutritional support), and aphasia (damage to the language areas of the brain.) Record review of Resident #1 Physician Order Summary of all orders, dated [DATE], reflected there was an order for oxygen administration at .2 liters per minutes via nasal cannula if O2 below 92% room air, as needed for SOB, start date [DATE]. Including an order for Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (3) mg/3ml vial via mask every 4 hours for cough/congestion, start date [DATE]. Record review of Resident #1's baseline care plan dated [DATE], reflected under pulmonary disease/URI to check lung sounds, clear, O2 per nasal cannula at 2 lpm. Record review of the MARs dated [DATE] for Resident #1 reflected: -Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 2:00 am with O2 at 96, respiratory rate at 20, and pulse at 72 by LVN G. -Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 6:00 am with O2 at 96, respiratory rate at 20, and pulse at 74 by LVN G. -Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 am with O2 at 92, respiratory rate at 17, and pulse at 60 by LVN A. Interview on [DATE] at 2:02 pm with LVN A revealed Resident # 1 had orders for medication nebulizer treatments. LVN said on [DATE] at approximately 10:07 am, he took Resident #1's vitals which included placing a pulse oximeter (to monitor a person's blood oxygen saturation) on resident's finger to check his oxygen saturation. LVN A said he also checked the lung sounds using a stethoscope and respiratory rate.) LVN A said Resident #1's oxygen was 92%, pulse was 60 and respiratory rate was 17. LVN A stated then applied the medication nebulizer treatment by placing the nebulizer mask on Resident# 1's mouth and nose. LVN A said the nebulizer treatment would take about 10 to 15 minutes to complete. LVN A said he stepped out of Resident #1's room and headed to the nurse's station because he could not document in the EMARs, the readings for oxygen, pulse rate and respiratory rate because he was not getting internet in the room or hallway. LVN A said he went and stood by nurse's station at approximately 10:15 am. LVN A said at approximately 10:20 or 10:25 am, Resident #1's FM D came out of Resident #1's room that was halfway down the hall from the nurse's station, appearing distressed voicing the Resident #1 was not responding. LVN A said while he had been standing at the nurse's station, LVN B had walked to the nurse's station and was standing inside the nurse's station and heard FM D voicing Resident #1 was not responding. LVN A said he walked to Resident #1's room, assessed Resident #1 by checking his pulse, and oxygen saturation and got no readings on both vitals. LVN A said Resident #1 code status was DNR in his clinical record. FM C who was the resident's RP, voiced to him to do anything to help Resident #1 who was not breathing. LVN A said FM D came into to the resident's room and told LVN A to do anything to help Resident #1. LVN A said he then asked FM C if she wanted to revoke the code status to Full Code and FM C said she did. Interview on [DATE] at 2:21 pm with LVN B revealed on [DATE] at approximately 10:15 am she walked into the nurse's station and saw LVN A standing by his med cart next to the nurse's station. LVN B said at about 10:20 am she saw Resident #1's FM C and FM D walk by the nurse's station, greeted her and proceeded to walk down Resident #1's hall. LVN B said about a minute or two later, she saw FM D come out of Resident #1's room, appearing distressed and voicing out loud that Resident #1 was not responding to her calling his name. FM D voiced to call 911 or do something to help Resident #1. LVN B said she saw LVN A walk into Resident #1's room and LVN B went to Resident #1's clinical record to verify the code status. LVN B said she saw that Resident #1 was a DNR. LVN B said she walked into Resident #1's room and heard FM C to revoke the code status to full code. LVN B said she assessed the resident and began to provide CPR to Resident #1. LVN B said LVN A went outside the room to call 911 and to nurse's station to begin paperwork for the Emergency staff. LVN B said she continued performing CPR on Resident #1 until EMS arrived and they took over performing CPR on the resident. EMS took Resident #1 on a stretcher to the hospital, and he had not responded as they left the facility. LVN B said Resident #1 was pronounced dead at the ER. Interview on [DATE] at 2:27 pm with the DON revealed Resident #1 was admitted to the facility on [DATE] from another nursing home. On [DATE], Resident #1 was transferred to the hospital with the diagnosis of sepsis. Resident #1 was transferred back to the facility on [DATE]. On [DATE], Resident #1 was transferred to the hospital by doctor orders for diagnosis of hypoxia (low oxygen in the blood). Resident was readmitted to the facility from the hospital on [DATE] with diagnosis of pneumonia and sepsis and orders for antibiotics for pneumonia. The DON said she was notified on [DATE] on the change of condition for Resident #1. Interview on [DATE] at 10:39 am with LVN A revealed he did check Resident #1's oxygen levels, pulse rate and respiratory rate before he applied the nebulizer treatment. LVN A said he wrote the readings on a piece of paper so he could enter the Resident #1's electronic record at the nurse's station. LVN A said he did not enter the vitals in the electronic clinical chart until 5:02 pm in the afternoon because he got very busy after Resident #1 left to the hospital. LVN B said the vitals were taken before and after the nebulizer treatment to assess if the nebulizer treatment was effective and to monitor for the heart rate because the medication administered in the nebulizer treatment might raise the heart rate. LVN A said he did not stay in the resident's room during the nebulizer treatment to monitor or assess the treatment. LVN A said he should have stayed to monitor to see if the resident experienced a rise in the heart rate or to ensure the nebulizer mask did not fall off his face. Interview on [DATE] at 1:38 pm with the DON revealed LVN A should have stayed with Resident #1 through the entire process of administering the medication via nebulizer mask, according to their policy and protocol. The DON said staff were in-serviced after the incident and LVN A was given a disciplinary action warning for not providing respiratory care when he did not follow the facility nursing protocols that indicated staff needed to stay with the resident during the medication nebulizer administration. Interview on [DATE] at 2:45 pm with Resident #1's physician revealed Resident #1 had been in the hospital ICU for a long time while he was intubated (insertion of a tube into the body to keep the airway open.) The physician said Resident #1's prognosis had been very poor when he was transferred back to the facility on [DATE]. The physician said Resident #1 would not have lived very long. Resident #1's physician said in his medical opinion, the staff leaving Resident #1 alone with his medication treatment of the Ipratropium-Albuterol Solution via a nebulizer mask could not have caused any injury, harm, or death to Resident #1. Record review of the facility policy titled Administering Medications through a small volume (handheld) Nebulizer dated [DATE] reflected The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the Procedure; Remain with the resident for the treatment.

Based on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurate, for one Resident (R#1), of five residents reviewed for clinical records, in that. The facility failed to ensure LVN E documented the results of vital sign assessments accurately in Resident #1's clinical records. This failure could place residents at risk for not receiving proper care and treatments. The findings included: Record review of Resident #1's admission record, dated 12/28/23, reflected he was a [AGE] year-old male with an admitted [DATE] with diagnoses which included dementia (decline in cognitive abilities), chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease and airflow limitation), contracture (shortening of muscles, tendons, skin causing joints to shorten), gastrostomy status (artificial external opening into stomach for nutritional support), and aphasia (damage to the language areas of the brain.) Record review of Resident #1 Physician Order Summary of all orders, dated 12/20/23, reflected there was an order for oxygen administration at .2 liters per minutes via nasal cannula if O2 below 92% room air, as needed for SOB, start date 12/16/23. Including an order for Ipratropium-Albuterol Solution 0.05-2.5 (3) mg/3ml vial via mask every 4 hours for cough/congestion, start date 12/16/23. Record review of Resident #1's baseline care plan dated 12/16/2023, reflected under pulmonary disease/URI to check lung sounds, clear, O2 per nasal cannula at 2 lpm. Record review of the MARs dated 12/01/23-12/31/23 for Resident #1 reflected: -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 2:00 am with O2 at 96, respiratory rate at 20, and pulse at 72 by LVN G. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 6:00 am with O2 at 96, respiratory rate at 20, and pulse at 74 by LVN G. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 am with O2 at 92, respiratory rate at 17, and pulse at 60 by LVN A. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 pm with respiratory rate at 18, and pulse at 63 by LVN E. No record of the O2 was recorded. Interview on 12/28/23 at 2:02 pm with LVN A revealed Resident # had orders for medication nebulizer treatments. LVN said on 12/20/23 at approximately 10:07 am he took Resident #1's vitals which included placing a pulse oximeter (to monitor a person's blood oxygen saturation) on resident's finger to check his oxygen saturation. LVN A said he also checked the lung sounds using a stethoscope and respiratory rate.) LVN A said oxygen was 92%, pulse was 60 and respiratory rate was 17. LVN A then applied the medication nebulizer treatment by placing the nebulizer mask on Resident# 1's mouth and nose. LVN A said the nebulizer treatment would take about 10 to 15 minutes to complete. LVN A said he stepped out of Resident #1's room and headed to the nurse's station because he could not document in the EMARs, the readings for oxygen, pulse rate and respiratory rate because he was not getting internet in the room or hallway. Interview on 12/29/23 at 10:39 am with LVN A revealed he did check Resident #1's oxygen levels, pulse rate and respiratory rate before he applied the nebulizer treatment. LVN A said he wrote the readings on a piece of paper so he could enter the Resident #1's electronic record at the nurse's station. LVN A said he did not enter the vitals in the electronic clinical chart until 5:02 pm in the afternoon because he got very busy after Resident #1 left to the hospital. LVN A said he should have entered the readings on Resident #1's clinical record as soon as possible within time necessary to provide the information to staff providing care to the resident. Interview on 12/29/23 at 11:09 with the DON revealed LVN A did not record the vitals for Resident #1 when he took the reading on 12/20/23 at 10:07 am until later in the day at 5:02 pm. Staff are required to document information on clinical records in a timely manner, such as two hours later. If an entry is made after 24 hours, a data entry error must be documented. The vitals taken by LVN A on 12/20/23 at 10:07 am were not recorded until 12/20/23 at 5:02 pm as indicated on the EMAR the time the record was entered. Interview on 12/29/23 at 11:09 am with the DON revealed she had reviewed Resident #1's EMARs on 12/28/23. The DON said she found that LVN E had inaccurately recorded on Resident #1's EMARs on 12/20/23 at 10:00 pm when she entered the vital reading for his pulse and respiratory rate. Resident #1 had been transferred to the hospital on 12/20/23 at about 10:30 am, when he was found unresponsive. The DON said she tried to contact LVN E by telephone to ask her about the error but was unable to contact LVN E. The DON said she entered a note into Resident #1's progress notes to indicate error documentation as a late entry on 12/28/23. The DON said LVN E had gotten confused but should have informed her or someone about the inaccurate documentation on Resident #1 right away. The DON stated it was very important to document accurate information on resident's clinical charts because the misinformation could affect the care the residents should be receiving. The DON every staff member was responsible for ensuring all information recorded was accurate. Interview on 12/30/23 at 9:20 am with LVN E via telephone revealed she had worked on 12/20/23 during the evening shift as she worked PRN. She took a resident's (unnamed) vitals and recorded on a piece of paper to later record in the EMARS for that resident. After entering the vitals, she had taken from another resident and proceeded to enter Resident #1's EMARS on 12/20/23 at around 10:00 am. She immediately realized she was on the wrong resident's EMARs (Resident #1's). She stopped entering the vitals on Resident #1's EMARs and closed his record and started recording on the correct resident's EMAR. LVN E said she did not inform the DON about her mistake on recording on the wrong residents EMARs. LVN E said failure to correctly document on every resident's record could cause misinformation for the resident. Interview on 12/30/23 at 11:40 am with RN F revealed after providing any type of medication or treatment the EMARs should be documented in the resident's clinical record right after the administration. Record review of the facility policy titled Charting and Documentation dated July 2017 reflected All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Accurate medical records should be maintained by this facility.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #49) of three residents reviewed for supervision and ensured the environment remained free of accident hazards for 2 of 2 unlocked resident rooms reviewed for supervision in that. 1) The facility failed to ensure Resident #49 received supervision while in the shower. 2 ) The facility failed to ensure the two resident rooms, 323 and 324 were free of cluttered storage of equipment, furniture, boxes, walkers, wheelchairs in a secured manner. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: 1)Record review of Resident #49's Admission Record dated 10/06/23 revealed a [AGE] year old male with an admitted [DATE] and diagnoses which included: dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time), traumatic subarachnoid hemorrhage without loss of consciousness (presence of blood within the brain most often caused by head trauma, such as from a serious fall or vehicle accident or by a brain aneurysms where the aneurysm can leak or rupture causing life-threatening bleeding), lack of coordination, repeated falls, and history of falling. Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed he required extensive assistance with 1 person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #49 was frequently incontinent of bowel and bladder. Record review of Resident #49's Care Plan dated 09/13/23 revealed he had a history of falls at the facility. Bathing interventions included Resident #49 required 1 staff participation with bathing; need varied. Resident #49 will take a shower by himself without notifying the staff. Combination locks have been applied to all the shower rooms so that resident will not be able to enter the shower room and attempt to shower himself. Record review of Resident #49's Progress Note dated 09/23/23 at 05:25 p.m., Nurse Note written by LVN V revealed, Note Text: Resident noted to be on the floor of the shower room as per CNA resident took a shower and CNA left to bring his clothes and when he come back, he noticed resident on his knees voiding into the trash can with scrapes and redness to the elbows. Resident states he was voiding into trash can of the shower room when he fell forward onto his elbows. Performed a head-to-toe assessment and no abnormalities noted other than 1 small scrap (sic) on each elbow noted with redness and minimal bleeding which were cleaned with NS and pat dry with 4x4 gauze, vital signs are within normal limits, resident able to move all extremities, as per resident complaining of pain to the neck, PRN Tylenol offered, and resident agreed. RP and DON made aware. Called NP and as per NP new orders for x ray of c spine and neck and to give Tylenol for pain. Called mobile x-ray and as per tech is on its way. Record review of Resident #49's Progress Note written on 09/23/23 at 05:35 p.m., Nurse Note written by LVN V revealed, Note Text: Mobile x-ray tech in facility to perform x-ray of c spine and neck. Pending results. Record review of Resident #49's Progress Note written on 09/23/23 at 05:50 p.m., Nurse Note written by LVN V revealed, Note Text: Resident #49 complaining of neck pain and unable to move neck or arms upon request, hand grip strong and equal, PERRLA, and vital signs within normal limits. As per patient requesting to go to hospital. Called NP and as per NP ok to send to hospital. Called hospital and gave report to RN. RP made aware. 911 was called and on its way. Record review of Resident #49's Progress Note written on 09/23/23 06:08 p.m., Nurse Note written by LVN V revealed, Note Text: Resident left to hospital alert and oriented via stretcher accompanied by 2 EMTs, no signs of shortness of breath or any distress noted. Record review of Resident #49's Progress Note written on 09/23/23 11:18 p.m. Nurse Note written by RN Z revealed, Note Text: Called hospital-ER status of the resident S/P fall, per RN resident will be transferred to another hospital d/t mild subdural hematoma (a pool of blood between the brain and its outermost covering). Record review of Resident #49's Progress Note written on 09/24/23 12:50 a.m., Nurse Note written by RN Z revealed, Note Text: Spoke with RN of hospital ER, resident will be transferred to another hospital ER. Record review of Resident #49's Progress Note written on 09/24/23 03:43 a.m., Nurse Note written by RN Z revealed, Note Text: RN of hospital ER called to notify that resident is going to be sent back to facility. Record review of hospital records dated 09/24/23 at 04:30 a.m., Resident #49 was discharged from hospital observation. Record review of Resident #49's Progress Note written on 09/24/23 04:51 a.m., Nurse Note written by RN Z revealed, Note Text: Resident came back from hospital-ER via stretcher. Per RN at hospital ER, CT of the head was performed, and the result presents no danger. Checked V/S and WNL. Resident denies of any pain/discomfort at this time. Will continue with close monitoring and neuro checks. In an interview and observation on 10/06/23 at 03:11 p.m., revealed Resident #49 was standing by the nurse's station saying, I want to go home. Resident #49 stated he had recently fallen and hurt his head. Resident #49 stated it did not hurt anymore. He said he received his medicine and his head did not hurt. Resident #49 stated the nurses are good and take care of him. He said he had no problems with anyone. Resident #49 repeated, I want to go home. In an interview on 10/06/23 at 03:20 p.m., LVN V stated when Resident #49 fell , a CNA in 400 Hall was looking for a chair for a resident. LVN V stated she and another nurse looked in a shower room and Resident #49 was sitting in a shower chair naked. LVN V stated Resident #49 had not taken a shower yet. CNA R came by and they told CNA R Resident #49 was in the shower waiting for his shower. CNA R stated he would be back in a few because he was showering another resident right now. LVN V stated that she and another nurse stayed with Resident #49 until the CNA R came back about twenty minutes later. CNA R came back to shower Resident #49. LVN V stated she saw CNA R a while later and CNA R told her that Resident #49 fell in the shower and had some scrapes on his elbows. CNA R told LVN V he went to get clothes for Resident #49 since Resident #49 did not take any in with him. LVN V stated Resident #49 told her that he had urinated in the trash can in the shower and fell forward on his elbows. LVN V stated she notified the NP and cleaned Resident #49's elbows. The NP gave orders for Tylenol for pain and x-rays. LVN V stated a few minutes later, Resident #49 complained of neck pain and wanted to go to the hospital. LVN V stated she notified the NP and the NP said to send him to the hospital. LVN V stated she followed the orders and sent Resident #49 to the hospital. LVN V stated CNAs should not leave residents in the shower unattended because they could fall. In an interview on 10/06/23 at 04:35 p.m., CNA W stated she had been working at the facility for six months. CNA W stated if she were to see a resident fall or a resident was on the floor, she would call the nurse. CNA W would not move or leave the resident. CNA W stated she would stay with the resident until the nurse told her they were done. CNA W stated she gave showers. CNA W stated she never would leave a resident alone in the shower. If she would forget something, she would call the nurse to stay with the resident while she went to get whatever she forgot. CNA W stated any accident could happen if a resident were left alone in the shower. In an interview on 10/06/23 at 04:51 p.m., CNA X stated she had been working at the facility for 6 months. CNA X stated if she were to see a resident fall or a resident was on the floor, she would call for the nurse. CNA X stated she would not leave or move the resident. CNA X stated she would stay with the nurse to help until they were done. CNA X stated she gave showers to the residents. CNA X she would never leave the resident alone in the shower. She stated she would use the emergency light and ask the nurse to go get whatever she needs or to stay with the resident while she went to get what she needed. CNA X stated if a resident was left alone in the shower while she went to get the items needed, the resident could fall. CNA stated even resident who showers themselves, they watch to make sure the resident does not fall. In an interview on 10/06/23 at 05:11 p.m., ADON E acting DON while DON is on vacation. ADON E stated she had worked at the facility for 4 and a half years. ADON E stated CNAs are checked off on skills at hire and annually. ADON E stated CNAs should never leave residents alone in the shower. ADON E stated the CNA is not supposed to leave the resident in the shower by themselves unless it is care planned that the resident was able to shower alone. In an interview on 10/06/23 at 05:45 p.m., the Administrator stated he started as the Administrator at the facility 03/22/23. The Administrator stated 5 out of the 7 nurses/CNAs surveyor would like to speak with no longer worked at the facility and 1 CNA works nights and may still be asleep. The Administrator stated CNA should not leave the resident in a dangerous position. The Administrator stated the resident, Resident #49, fell . The Administrator stated Resident #49 had gone in the shower waiting for the CNA (CNA R) and did not take any clothes in with him. The Administrator stated CNA R had been in-serviced and educated. Attempted telephone interview on 10/06/23 at 06:30 p.m. with CNA R concerning Resident #49's fall in the shower while not being supervised, but there was no answer. Unable to leave message. Review of facility's Shower/Tub Bath policy dated 2001 MED-PASS, Inc (Revised October 2010) revealed: Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines 1. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 2. Use the emergency call signal to summon assistance, if needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: 3.Robe and slippers; 4.Face cloth and bath towels; 5.Clean gown, pajamas, or street clothing; 9.Comb and/or hairbrush 2) Observation on 10/03/23 at 10:50 am revealed rooms #323 and #324 located at the end of the 300 halls, were filled to the doorway in an unorganized manner, beds, wheelchairs, furniture, desks, walkers, computers, televisions, closed and opened boxes stacked to the ceiling. Both rooms were unlocked and accessible to residents or staff to enter. Observation on 10/06/23 at 11:53 am revealed room [ROOM NUMBER] had been placed with a lock and entry was not available. room [ROOM NUMBER] did not have a lock. Interview on 10/06/23 at 9:32 am with Resident #31 revealed he had been in the same hallway for two years. Resident #31 said he could walk anywhere in the facility. Resident #31 said he had not gone into rooms 323 or 324 and did not know who or what was in the rooms. Interview on 10/06/23 at 10:19 am with LVN O, revealed he was the charge nurse for all three halls, including rooms [ROOM NUMBERS]. LVN O said eight residents in the halls 100, 200 and 300 were able to leave their rooms, were ambulatory, and some were cognitively impaired, and some residents were alert and cognitive. LVN O said both room [ROOM NUMBER] and 324 were vacant, not locked and currently were used for storage. LVN O said the rooms were filled with random furniture, beds, wheelchairs and very many boxes, some that were open and some that were closed. The boxes contained paper goods. LVN O said he had never seen any residents go into the rooms [ROOM NUMBERS]. He said there was a potential that residents might go into the rooms and get harmed with the cluttered manner the items were stored. Interviews on 10/06/23 at 10:29 am with CNA P and CNA Q revealed they had never entered the room [ROOM NUMBER] or 324 and they were not locked. CNA P and CNA Q said they did not know how long the rooms had been used for storage. Both CNAs said if they saw any residents go towards the rooms, they would re-direct them not to go into the rooms because entering those two rooms could be dangerous the way they had all items cluttered in the rooms, items placed on top of each other, etc. Interview on 10/06/23 at 10:34 am with the Maintenance Supervisor revealed the two rooms had been filled with all kinds of furniture, beds, TVs, and boxes for some time. He said the rooms did not have any locks on them because they were still considered residents rooms. Interview on 10/06/23 at 11:00 am with the Administrator revealed the two resident rooms had been used for storage for an undetermined time but the items were stored temporarily. The Administrator said there was a potential that a resident could go into the rooms since they were not locked and could get hurt. The Administrator said his staff would empty the two rooms immediately. 41761

Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for 1 of 1 facility. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella could grow and spread. This deficient practice places the facility residents at risk for airborne infections. The findings included: Interview on 10/05/23 with the Maintenance Director at 10:10 a.m., he stated he did not know what Legionnaire's was. He stated he had been working at the facility for 2 years. Stated the only thing he checks every week is the water temperatures. Stated to his knowledge, there is no system to monitor effectiveness of control measures. Stated he had training upon hire from the previous maintenance director but not on anything regarding checking for bacteria in the facility water. He is also unaware of the facility policy, Legionella Water Management Program. Interview on 10/05/23 with the Administrator at 11:15 a.m., he stated he thinks there is a system in place for preventing and controlling Legionella in the facility. Stated he will look for the map indicating where Legionella and other opportunistic waterborne pathogens can grow and spread. He stated he would speak to the Maintenance Director regarding not being aware of having a Legionella policy. Interview on 10/06/23 at 5:31 p.m. with the Administrator, he stated he was not able to provide me with any system that had been in place to prior to the state agency's visit, to prevent, detect or control water borne contaminates, including Legionella. A map was not provided of where Legionella and other opportunistic waterborne pathogens can grow and spread. A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation revised 09/2022 revealed the water management program included the following elements: 5. b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving 2. Cold water distribution 3. Heating 4. Hot water distribution 5. Waste 5. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment etc. 5. d. The identification of situations that can lead to Legionella growth, such as: 1. Construction 2. Water main breaks 3. Changes in municipal water quality 4. The presence of biofilm, scale, or sediments 5. Water temperature fluctuations 6. Water pressure changes 7. Water stagnation 8. Inadequate disinfection 5. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants) f. The control limits or parameters that are acceptable and that are monitored g. A diagram of where the control measures are in place h. A system to monitor control limits and the effectiveness of control measures i. A plan for when control limits are not met or not effective j. Documentation of the program

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of seven residents (Resident#1) reviewed for accidents and supervision; CNA A and NA B removed Resident #1's floor mat that was placed next to the bed as an intervention for falls. CNA A and NA B left Resident #1's room. Resident #1 suffered a fall that resulted in a right nose fracture, C#2 and C#3 fractures, laceration to her forehead and two-day hospitalization . This failure resulted in an identification of an Immediate Jeopardy at 4:44 p.m. on 12/18/21. While the IJ was removed on 12/19/21, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced. This failure could affect residents and place them at risk of hazards and avoidable incidents. The findings were: Record review of Resident #1s Physician Order Summary Record, dated 12/18/21, revealed Resident #1 was a [AGE] year-old female and was admitted to the facility on [DATE]. Resident #1's diagnoses included: Cerebral Infraction due to [CONDITION(S)] of left middle cerebral Artery (stroke), [CONDITION(S)] and [CONDITION(S)] following Cerebral infraction affecting Right Dominant Side, and [CONDITION(S)]. Resident #1 had orders for may use floor mats while in bed order date 08/24/21. Record Review of Resident #1's physician orders dated 12/18/21 revealed: -[MEDICATION(S)] Tablet 5 mg. Give one 1 tablet by mouth one time a day for Hypertension. Hold medication if blood pressure is -110/60 or HR is -60 bpm. Order dated 07/30/21. -[MEDICATION(S)] tablet 10 mg. Give 1 tablet by mouth one time a day for hypertension. Hold medication if blood pressure is -100/60 or HR is - 60 bpm. Order date 07/30/21. -[MEDICATION(S)] HIC tablet 500 mg. give 1 tablet by mouth one time a day for Diabetes Mellitus. Order date 07/30/21. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident#1: -had severely impaired cognitive status, with a Brief Interview of Mental Status score of 3 out of 15, -required extensive assistance with two-person physical assist for bed mobility, transfer, -required total assistance with two-person physical assist for dressing, eating, and personal hygiene. -activity did not occur for walk in room or corridor, and locomotion. -had limited functional range of motion impairment on one side of her upper and lower extremities. -had no falls since re-admission or last assessment. Record review of Resident #1 Care Plan date initiated 07/24/21 revealed: Risk for falls due to impaired mobility; impaired balance and gait. Interventions: adequate lighting, assess for an provide safety device if needed, assess for possible contribution, assist with transfers, encourage use of call light, evaluation for safety devices, keep call light within reach t all times when in room, keep floors clean and free f spills and/or debris, provide w/c walker , Geri chair as indicated, reinforce call for assistance. Record review of Resident #1 Care Plan date initiated 08/21/21 revealed: -Resident #1 has had an actual fall with bump to left side of head and pain to left arm due to poor communication/comprehension. Interventions: monitor/document/report PRN x 72 hours to MD for sings/symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Record review of Resident #1's care plan date initiated on 08/21/21 for actual fall did not described floor mats as an intervention. Record review of Incident Report completed by LVN E, for Resident #1 dated 12/16/21 revealed: -Incident location: resident's room -Incident Description: Resident from bed B voiced se [NAME] (she fell ), Nurse walked in room and saw resident on the floor. -Immediate action taken admitted to hospital ICU. -Injuries observed at time of incident: no injuries observed at time of incident. Record review of Resident #1's assessments revealed there was no Fall risk assessment completed after Resident #1's fall in 08/21/21. Record review of Resident #1's un-witnessed incident report dated 08/21/21 revealed: -Nursing description: CNA noted resident on the floor, I got called in resident was facing down on the floor. -Resident description: resident sated she doesn't remember how she fell , resident's roommate noted she saw Resident #1 roll out of bed. Description: assessed resident, noted a bump on her left side of head, and she noted pain to the left side of her arm, no skin breakdown or discoloration noted at the time. Took vital sings. Applied ice in a washcloth and applied it to her left side of her head where the bump was noted and administered Tylenol. Instructed CNA to round every 2 hours of the resident. Called NP, she gave orders for STAT X-ray to left side of head and arm and Nuero checks. Record review of Resident #1'a nurses notes dated 08/23/21 revealed: spoke to Hospice RN about x-ray as per RN, DR ordered floor mats, floor mats will be provided by Hospice. Record review of Resident #1's nurses notes dated 08/24/21 revealed: Floor mats were put on the floor, to be in use when resident in bed. Record review of Progress notes for Resident #1 dated 12/16/21 revealed: Note text: 0800 while walking down 500 hallway, SN heard resident's roommate say se [NAME] (she fell ), SN [LVN V] walked into room and saw resident on floor next to be facing up and bed side table next to her. Upon assessment resident was noted with head in pile of blood which she did not have previously. Did not move resident at all and applied pressure with gauze to laceration, called ADON and came in room and went back to station and called 911. Resident was alert at all times. Other staff called hospice and family to notify. 08:13 A.M.: 911 arrived and assessed resident, while I continued to apply pressure, they took over, converted laceration with gauze and wrapped with kerlix around head, all this while giving report. 8:15 A.M. : resident departed on stretcher accompanied by 2 EMT's sated will take her to [hospital] due to it being a trauma hospital. 8:49 A.M.: hospice nurse called back gave report 8:57 A.M.: sister which did not give me name called back and gave report, upset that she fell . Record review of Progress notes for Resident #1 dated 12/16/21 at 05:57 P.M. revealed: -Placed a call to the hospital to get an update on patient's status. Spoke to RN and she informed that patient was admitted diagnosis for C2, C3, and Nasal Bone fracture. DON and floor nurse were made aware. In an interview and observation conducted at the hospital on 12/18/21 at 10:10 a.m., Hospital RN A said Resident #1 was in ICU (intensive care unit) with fractures to right nose, C2, C3 and lacerations to forehead. Surveyor accompanied by Hospital RN A observed Resident #1 in bed with her eyes closed and did not respond to surveyor's greeting. In an interview 12/18/21 10:44 a.m., LVN B said Resident #1 was alert occasionally to name, bed bound and required total care for Activities of Daily Living. LVN B said Resident #1 had limited movement to left arm and hand. LVN B said Resident #1 liked to have her tv remote control in her hand and changed the tv channels. LVN B said Resident #1 did not have the strength sit up in bed without assistance. LVN B said she did not consider Resident #1 a high risk for falls because Resident #1 did not move in bed or was able to reposition. LVN B said on the day of the incident, Resident #1's roommate screamed se [NAME] (she fell ). LVN B said was very surprised about the fall because Resident #1 did not move. LVN B said maybe Resident #1 was looking for her tv remote control. LVN B said when she walked inside the room, she saw Resident #1 on the floor facing up, however she could not recall if the floor mats where next to bed. LVN B said there was a side table next to Resident #1 that had some strands of hair on the bottom part where the wheels were located. She said the CNAs who worked 500 hall were CNA D and NA C. In an interview 12/18/21 at 10:59 a.m., DON said Resident #1 was confused, total care and bed bound. DON said Resident #1 liked to have her tv remote control in her left hands. DON said occasionally Resident #1 was able to feed herself. DON said she saw Resident #1 on the floor and LVN B was applying pressure on Resident #1's forehead because she was bleeding. The DON said the bottom of a side table next to Resident #1 had some strands of hair, which she thought was Resident #1 hair. DON said she did not remember seeing floor mats in place when the incident happened. DON said Resident #1 was a moderate risk for falls and had a previous fall back in August 2021. In an interview on 12/18/21 at 11:33 a.m., NA C said Resident #1 was total care, not able to reposition, and was bed bound. She said on 12/16/21 around 7:50 A.M., her and CNA D provided incontinent care to Resident #1, and after that they lifted the head of the bed so Resident #1 would be in a seating position and able to eat in bed. NA C said they pushed the rolling side table under the bed and left the table ready for the breakfast tray. NA C said the side table was in front of Resident #1. NA C said she and CNA D left the tv remote control on top of the side table so Resident #1 could reach it. NA C said they left the room and started to pass meal trays to other residents. She said Resident #1 had floor mats, however, did not remember seen Resident #1's floor mats. In an interview on 12/18/21 at 11:54 a.m., CNA D said Resident #1 was able to move a little bit on bed, however not able to reposition without assistance. She said on the day of the incident, she and NA C provided incontinent care to Resident #1 and lifted the head of bed to seating position, pushed side table under the bed, so it would be in front of Resident #1. CNA D said removed the floor mat that was on the left side of bed to push in the rolling side table. CNA D said could not place the side table on top of the blue floor mat because the table would be tilted, and Resident #1 could had spilled food on herself. CNA D said she did not place back the floor mat next to the side table of bed. CNA D said she and NA C left the room and started to breakfast trays around 8 A.M. In an interview on 12/18/21 at 1:30 p.m., NA C said on the day of Resident #1's incident she and CNA D removed the floor mat on the left side to push the side table in. NA C said neither her nor CNA D placed the floor mat back on the left side. NA C said they left Resident #1's room to pass meal trays. In an interview on 12/18/21 at 3:01 p.m., the DON said the side table should not be on top of the blue floor mats because the side table could be unbalanced, and food could spill on top of a resident. She said after a resident was done eating the floor mats should be back in place. DON said Resident #1 did not required assistance for eating only for setting the meal tray on top of the side table. She said CNA's left the room and did not place the floor mat back to side of bed. She said CNA's should have done frequent rounds to see how Resident #1 was doing. In an interview on 12/18/21 at 3:56 p.m., the DON said on 12/18/21 she went inside Resident #1's room and did a simulation of what could had happened with Resident #1' fall. The DON said most probably the side table pushed away the floor mats when Resident #1 fell on floor. In an interview on 12/20/21 at 1:10 p.m., Administrator said Resident #1 did not have floor mats that were anti-slipped. He said the fall could had been prevented if Resident #1 was not left unattended and staff would had placed the meal tray in front of Resident #1 so she would have something to do. Administrator said staff found the tv remote control under her bed, so we don't know if Resident #1 attempted to reach for it. In an interview on 12/22/21 at 1:32 p.m., the DON said she did not have an answer to if Resident #1's accident could have been prevented. She said maybe having an anti-slip floor mats in which a side table could be on top of the mat without risk of side table being unbalanced. DON said maybe it could have prevented the impact of the fall for Resident #1 and instead of falling to the floor she could fallen to the floor mat. DON said also the CNAs should have not left Resident #1 unattended. Facility's policy on Fall Risk assessment dated ,d+[DATE] revealed: -The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and other will seek to identify and document resident risk factors for falls. -The staff and attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The Administrator was notified on 12/18/21 at 4:43 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 12/18/21 at 4:44 pm. A Plan of Removal was first submitted by the Administrator on 12/19/21 at 9:00 am and the POR was accepted on 12/19/21 at 2:08 pm. [The facility] submits the following Plan of Removal for the alleged failure to ensure residents remained free from accidents and hazards. By submitting this plan of removal [the facility] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? Resident #1 returned from the hospital on the evening of 12/18/21. Upon her return, resident #1 was assessed and the facility has put an electric lowbed, scoop mattress and fall mats on either side of her bed. The DON has in-serviced nursing staff and housekeeping staff currently in the facility to position her bedside table with legs of table under her bed and the fall mat placed to the outside of the legs of table. Inservice will continue for all 3 shifts and employees will not be allowed to work until this in-service is completed. How were other residents at risk to be affected by this deficient practice identified? Residents with history of falls were at risk of possibly sustaining injuries. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? DON or designee in-serviced nursing staff and housekeeping staff on 12/18 to ensure that they do not remove fall mats completely away from bed to place bedside table for meals, while resident is unattended. Bedside tables are to be placed with legs under bed and fall mats to the outside of table legs if the bedside table is in place for unattended residents. In-services will be completed by 12/19/21. Employees who have not been in-serviced by 12/19/21 will not be allowed to work until they receive this in-service. Facility will compare an employee roster to ensure all personnel are trained. Facility will in-service new personnel as part of their facility orientation. Facility audited current residents who have had falls in the last 3 months, there were 31 residents. Facility audited Fall Risk assessments on 12/18/21 for all residents to ensure a current and accurate fall risk assessment was completed. There were 27 residents who were identified as high risk for falls. Facility completed an audit on 12/19/21 for interventions for residents who have fallen and those that are high risk for falls and will ensure staff are aware of interventions for each resident. The nursing staff and housekeeping staff will have an updated copy of the audit of interventions at each nurse's station. The nursing and housekeeping staff will be in-serviced by 12/19/21. Employees who have not received this in-service will not be allowed to work until they receive it. How will the system be monitored to ensure compliance? Administrator, DON and/or designees will do observation rounds daily on all shifts for the next 3 weeks to ensure that residents have interventions in place as per their care plans. Administrator, DON and/or Designees will do rounds during meals daily for the next 3 weeks to ensure floor mats and bedside tables are placed properly. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 12/18/21 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The survey team monitored the plan of removal on 12/19/21 and 12/20/21 as follows: On 12/18/21 beginning at 2:45 pm nursing staff and housekeeping from different shifts were interviewed on abuse and neglect, fall preventions and floor mats placements. There was a total of 53 nursing staff and housekeeping interviews form all different shifts: 25 Certified Nursing Assistants 4 Medication Aides 10 Housekeeping 12 Nurses On 12/20/2021 at 3:30 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced.