Every finding on record at Oak Brook Health Care Center

Based on observation, interview and record review, the facility failed to serve food that was palatable and at an appetizing temperature for 1 of 1 meal (noon meal 06/15/2026) and 9 of 9 residents (Resident #s 2, 23, 30, 37, 56, 59, 67, 81, and 84) reviewed for food palatability. The facility did not provide palatable and appetizing food for the residents for the 06/15/2026 noon meal.Resident #s 2, 23, 30, 37, 56, 59, 67, 81, and 84 complained the food was cool or cold, poorly or not seasoned and was not appealing in appearance. This failure could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.Findings included:During an observation on 06/15/2026 at 12:16 PM the test trays left the kitchen on the last hall cart. On 06/15/2026 at 12:35 PM, the test trays were tasted after the last resident had been served and indicated the following:*Regular tray- Beef Fried Rice, Egg Rolls, Oriental mixed vegetables, fudge cookie. The beef fried rice appeared very dark. The rice and beef mixture was very bland and had no soy sauce or oriental flavor. It was room temperature. The egg roll was tough and slightly doughy and difficult to chew and swallow because it was dry. The Oriental vegetable blend was mushy and had no seasoning or taste and it was lukewarm in temperature. The fudge cookie was a commercially prepared treat in a wrapper and was chewy and fudgy in flavor and tasted good.*Alternate tray- Chicken and dressing and green beans. Carrots were also included by request since it was offered to the mechanical soft textured diets on the main meal. The chicken and dressing was warm and very flavorful and tasted good. The green beans tasted as if they had been poured from the can and heated. There was no seasoning or spices of any kind, they were bland and were barely warm. The carrots tasted bland with no flavor.During an interview on 06/15/2026 at 12:17 PM, Resident #23 said he did not want the regular lunch. Resident #23 said it did not look good and he did not want to eat it. Resident #23 requested a peanut butter and jelly sandwich as an alternative. During an interview on 06/15/2026 at 12:20 PM Resident #67 said her vegetables were way too soft and did not taste very good. She said the egg rolls were tough and difficult to bite through. The resident said she had snacks she was going to eat.During an interview on 06/15/2026 at 12:22 PM Resident #84 said the vegetables were way too soft and mushy and the main dish did not taste like stir fry and did not look appetizing. She ate some but said she would ask for a snack or eat what she already had in her room.During an interview on 06/15/2026 at 12:35 PM Resident #30 said she got her lunch tray, took the lid off, and tried a bite or two, but did not eat it. She said the vegetables were mushy and had no salt or other seasoning. She said the brown stuff did not look good and did not taste good and everything was barely warm. During an interview on 06/15/2026 at 12:40 PM Resident #81 said lunch was not good. She said everything was cold. She said the green beans and carrots tasted like they came straight from the can with no salt or anything else added. She said she did not try any of the rice and meat stuff because it just did not look good. She said she ate the cookie and drank her tea and asked them to bring her a sandwich. During an interview on 06/15/2026 at 12:30 PM Resident #2 refused his lunch tray said he did not like the stir-fried rice with meat or the vegetables with carrots however he said his meal was hot and requested a sandwich. During an interview on 06/15/2026 at12:35 PM Resident #37 said the stir fried looked like leftovers and was not appealing. She ate about 40% of her meal and refused a sandwich.During an observation and interview on 06/15/2026 at 12:40 PM Resident # 59 was observed picking at the food and only ate 1.5 of the 2 eggrolls. She said she did not like the rice and ground meat fried rice entree and said there was not enough meat and it was tasteless and the vegetables were watery with no taste. A sandwich was offered but said she did not want the sandwich. During an observation and interview on 06/15/2026 at 12:45 PM Resident # 56 ate 25-30% of the meal. She said she did not like the lunch meal and said the ground meat and rice were too spicy. She said she did not like the eggrolls and said the eggroll was hard. She said she did not like carrots. During an interview on 06/15/2026 at 1:10 PM the DM said the dietary department does not put any salt or pepper in the foods they prepare. She said the beef fried rice looked pale to her and she added soy sauce to the mixture and it gave it the dark brown color. She said she did not taste it. She said the beef mixture had been prepared with a bag of prepared frozen vegetable rice mixture (rice, peas, corn) and hamburger meat had been cooked and added to the rice mixture. She said she did not think the cook added any spices to the beef rice mixture. She said a lot of residents complain about too much salt or pepper and she said they did not add any salt. She said she buys other spices and flavorings for the cooks to use but they have their way of cooking and do not use the spices or will use one spice blend on everything they cook. She said some use a lot of garlic powder and some of the residents did not care for the garlic. She understood why the residents would say the food was bland because she agreed it was. She said she bought salt free butter and said it could also be added to vegetables for extra flavoring but she had long term staff that just did not listen to her. Review of the undated recipe for Beef Fried [NAME] indicated to serve approximately 90 residents the dietary department was to 1. [NAME] 20 lbs. of hamburger meat and set aside, 2. Heat 18 lbs. of the pre-cooked rice and vegetable medley, 3. Combine ground meat and rice and vegetable medley, 32 ozs. of chicken broth, 2 qts. low-sodium soy sauce, onion powder to taste, garlic powder to taste, and chicken bouillon base, and 1/4 cup of sugar, 4. Heat to temperature and hold.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals (lunch meals 06/15/2026 and 06/16/2026) reviewed for menus and nutritional adequacy. Dietary staff did not serve bread during the noon meals on 06/15/26 and 06/16/2026 to any residents eating mechanical soft diets.This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met. Findings included: Record review of the planned menu dated 06/15/2026, indicated for the noon meal was beef fried rice, egg rolls, Oriental vegetable blend, fudge cookie.During an observation and interview of the kitchen on 06/15/2026 at 9:35 A.M., the DM said the residents receiving mechanical soft diets were not being served the egg rolls because they were the bread item. The DM said nothing was substituted for the bread on mechanical soft diets. She said she would give them an extra vegetable and put some carrots on to heat. She said speech therapy told them last year no residents receiving a mechanical soft diet could have any bread. She said they did not receive slices of bread, rolls, biscuits, bread products or pie crusts. She said there were no substitutions made regarding the bread items. She said they just did not receive it. She was observed looking up the caloric value for the egg rolls on her computer, and the caloric value was 234 calories for the 2 small egg rolls. She said every resident receiving a mechanical soft diet would be losing 234 calories from their meal. She said the RD did not get back to her on what to do about not giving the bread and she never followed up with the RD. She said what was confusing to her was although speech therapy said residents receiving mechanical soft diets could not have any bread, some of the residents were allowed a soft sandwich, which was made of bread.Record review of the planned menu, dated 06/16/2026, indicated the noon meal was Dorito Casserole, mixed vegetables, Mexican rice, slice of bread, and chocolate chip muffin. Residents ordered a mechanical soft diet received fruit for dessert instead of the muffin and no bread. There was nothing extra given in place of the bread.During an interview on 06/17/2026 at 7:50 A.M., the DM said the RD was in contact with her quite often but had the RD not talked with speech therapy about the mechanical diets to her knowledge. She said the speech therapist came last year to the dietary department and informed them the mechanical soft diets were to no longer receive bread products. She said she did not receive an explanation so she could understand the change. She said it was discussed with the RD at that time, but she had not received any guidance as to what to substitute for the bread offered at every meal. She said she remembered the residents getting very upset about not being able to get sandwiches. She said the residents in the facility loved and ate a lot of sandwiches daily. She said the DON spoke with speech therapy and they decided some residents on mechanical soft could have soft sandwiches and some could not. She said it was placed on the dietary slip if they could have a soft sandwich which would consist of either pimiento cheese, egg salad, chicken salad, tuna salad or peanut butter and jelly. She said the speech therapists arrive in the evening so she never got to speak with them so never had her questions answered. She said when they offer an entree that was a pot pie with pie crust, the mechanical soft diets included the inside but not the crust. She said sometimes she compensated with serving mashed white or sweet potatoes. She said she had no guidance from the RD as to what else she could do and she said she thought they probably got very tired of mashed potatoes. She did not know if allowing them to have soft sandwiches also meant they could have the other bread products.During an interview on 06/17/2026 at 9:15 AM the DOR said mechanical soft diets could not have bread or bread products. She said since it could be individualized to every resident she said she had 2 speech therapists and 1 of them was at the facility 4 evenings every week. She said the speech therapist could do a bedside evaluation over a couple of days to see if a resident could tolerate and eat bread safely. She said nursing service was supposed to let the DOR know with a request for a bedside evaluation when they had a resident on a mechanical soft diet. She said for a resident to upgrade from a mechanical soft diet to a regular texture diet a speech therapist had to do the evaluation. She said the same was true for allowing certain food products individualized to each resident. She said some residents receiving a mechanical soft diets may be able to tolerate bread or other foods and the bedside evaluation would indicate that ability. She said speech therapy would communicate with nursing if a resident could tolerate soft sandwiches and nursing would send a communication to the dietary department. During an interview on 06/17/2026 at 9:45 AM the DON said residents receiving mechanical soft diets can have bread or sandwiches if speech therapy had done a bedside evaluation. She said once the resident was approved to be able to eat a sandwich safely a communication form would be sent to the dietary department so it could be added to the meal ticket for that particular resident and they could have soft sandwiches and bread. She said it would be placed in the resident's clinical record as a physician order for a mechanical soft diet with variations. She said speech therapy were the ones who would write the sandwich orders in the clinical record and then it was communicated to nursing service the order had been written so they could tell the dietary department.During an interview on 06/17/2026 at 11:00 AM the DM said the RD had not communicated a substitute for the missed bread items at every meal and acknowledged residents could be losing 300-500 calories a day depending on what foods were being served. She said she needed further clarification from speech if residents receiving soft sandwiches could also have other bread products being offered or did they still have no bread, buns, biscuits, pie crusts and only soft sandwiches. She said she wanted the residents to receive everything they were allowed to have safely.]A review of Mechanical Soft Diet eating plan dated 06/12/2025 provided by the DOR indicated the following: A typical sandwich presents several textural challenges for someone a mechanical soft diet.bread.is a primary obstacle. Fillings like deli meats, raw vegetables, and crunchy condiments pose further difficulties.The goal is to find a bread option that easily falls apart in the mouth with minimal chewing.The fillings of the sandwich are just as important as the bread. Hard, chunky, or stringy ingredients should be avoided. Instead focus on soft, moist, and easily manageable fillings.Avoid tough and chewy meats.raw vegetables are generally not appropriate due to texture, but soft-cooked vegetables are all viable options. Be sure to remove any skins or seeds.avoid chunky or seedy condiments like relish or whole grain mustard. Smooth condiments like mayonnaise, butter, hummus or avocado puree are generally safe choices.

Based on observation, interview, and record review, the facility failed to ensure medications were prepared and administered in a manner that prevented medication errors for 4 of 4 licensed nurse medication carts (Cart #1, Cart #2, Cart #3 and Cart #4) observed for controlled medications storage. The facility failed to Ensure MA (B) did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart #1 and Cart #2, on 6/16/2026The facility failed to Ensure LVN C did not sign the controlled substance count sheets for the end of her shift at the beginning of her shift on Nurses Cart #3 and Cart #4, on 6/16/2026 These failures could place residents at risk of creating the potential for medication diversion, administration of incorrect medication, and compromised resident safety, and not receiving medications as ordered by the physicianFindings include:During an observation and record review on 06/16/2026 at 1:11 PM, 4 of 4 medication carts indicated MA B was signing on and off of hall one and hall two narcotic count checklists at the same time she signed on at shift count for the controlled drugs on hand. During an observation on 6/16/2026 at 1:57 PM, of 4/4 medication carts, LVN C had not signed for receiving at the beginning of her shift on the count sheet, The controlled drugs on hand. During an observation on 6/16/26 at 1:58 PM, of 4/4 med carts, it was discovered that hall one and hall two had missing signatures on: 06/03/2026,06/04/2026, and 06/08/2026 During an observation on 6/16/26 at 2:00 PM, of 4/4 med carts, it was discovered that hall one and hall two had missing signatures on: 06/04/2026, 06/05/2026, and 06/16/2026 outgoing or incoming nurse simply forgot to sign the log after confirming the count, failed to complete the count sheet form.During an interview on 6/16/2026 at 2:10 PM, MA B said she always signed both coming/going slots on the Nurse on and Nurse off at the same time so he would not forget at the end of his shift, she said she thought this was ok to do so she would not forget to sign at the end of her shift, she said she never thought of if something happened to her during her shift what the consequences would be.During an interview on 6/16/2026 at 2:15 PM, LVN C said she almost always signs the controlled count sheet when receiving control off the count, she just forgot to do so today, she said, I simply forgot. LVN C said she knew she should sign because she was now responsible for that medication cart and the narcotics it contained and she was responsible if something happened during her shift.During an interview on 6/16/2026 at 2:30 PM, the DON said all nurses were to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. The DON said she had in serviced all nurses on the procedure and she was ultimately responsible for monitoring and making sure it was done correctly.Record review of a policy and procedure titled, Controlled Substances, dated 2001, indicated, Med-Pass revised December 2012. The facility shall comply with all laws, regulations, and other requirements related to handling, storage disposal and documentation of Schedule II and other controlled substances.8. Nursing staff must count controlled medication at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the director of Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of five residents (Resident # 5, Resident #25) reviewed for quality of life. The facility failed to ensure Resident #5 and Resident #25 received showers and facial hair care. This failure could place residents at risk for poor hygiene, dignity issues, and a decline in quality of life. Findings included: 1. A record review of a face sheet dated 06/17/2026 indicated Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included cerebral palsy (a group of disorders that affect a person's ability to move, maintain balance and posture) speech impediment, muscle wasting, dementia (a decline in mental health severe enough to interfere with daily life), Intellectual Disability (a developmental condition characterized by both intellectual functioning and adaptive behavior), and Hirsutism (in women, the growth of coarse, dark hair in a male-like pattern). A record review of a quarterly MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 12 indicating her cognition was moderately impaired. She was incontinent with bowel and bladder. She was dependent on staff for bathing and grooming care. Her speech was not easily understood. A record review of Resident #25's care plan dated 02/21/2024 indicated Resident #25 required assistance with ADLs and had facial hair. The care plan goals were for Resident #25 to maintain a sense of dignity by being clean, well groomed, and absent of facial hair. A record review of a Nurse Aide Assignment Sheet dated 06/10/2026 indicated Resident #25 was to receive a shower and be shaved on Mondays and Thursdays on the 7AM - 3PM shift. During an observation on 06/15/2026 at 09:07 AM, Resident #25 was observed asleep and lying in bed with the head of the bed slightly elevated. Resident #25 was observed to have approximately a 1-2-day growth of hair on her lower face and neck. During an observation and interview on 06/15/2026 at 03:51 PM, Resident #25 was observed lying in bed. She had not been shaved. When asked if she had received a shower on Monday, 06/15/2026, she said no by moving her head slightly from side to side. During an observation on 06/16/2026 at 10:50 AM, Resident #25 was observed sitting in a wheelchair and was being pushed down the hall. Resident #25 was placed against the wall at the beginning of Hall 2. She had what appeared to be a 2-3-day growth of dark hair on her lower face. She had not been shaved. During an interview on 06/16/2026 at 02:12 PM, CNA-P said she tried to shave Resident #25 that morning, but Resident #25 refused. CNA-P said if a resident refused care she would tell the nurse. During an observation on 06/17/2026 at 10:16 AM, Resident #25 was observed lying in bed. She had not been shaved. During an interview on 06/17/2026 at 10:20 AM, LVN-D said she was not told Resident #25 refused to be shaved on 06/16/2026. 2. A record review of a face sheet dated 06/17/2026 indicated Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included cerebrovascular accident (a stroke) with right-sided hemiparesis and hemiplegia (partial to total paralysis of the right side). A record review of a quarterly MDS dated [DATE] indicated Resident #5 had a BIMS score of 7 (seven) indicating his cognition was severely impaired. He was incontinent with bowel and bladder. The MDS indicated Resident #5 required maximum assistance with bathing and personal hygiene. A record review of Resident #5's care plan dated 04/02/2025 indicated Resident #5 required assistance with ADLs due to right-sided hemiparesis (partial paralysis). The care plan goal was for Resident #5 to maintain a sense of dignity by being clean and groomed. A record review of a Nurse Aide Assignment Sheet dated 06/10/2026 indicated Resident #5 was to receive a shower and be shaved on Mondays and Thursdays. During an observation on 06/15/2026 at 09:48 AM, Resident #5 was observed asleep and lying in bed with the head of the bed slightly elevated. Resident #5 was observed to have approximately a 1 (one) day growth of hair on his face with longer hairs underneath the lower lip extending the full length of the lower lip and a mustache. Long, thick hairs were noted extending out of his nose. During an observation and interview on 06/15/2026 at 03:45 PM, Resident #5 was observed lying in bed. He had not been shaved, nor had the nasal hairs been trimmed. Resident #5 replied no by turning his head from side to side when asked if he was growing a beard and mustache. When asked if he had received a shower on 06/15/2026 (Monday), he said he had not. During an observation on 06/16/2026 at 01:40 PM Resident #5 was observed lying in bed. He had not been shaved, nor had the nasal hairs been trimmed. During an observation and interview on 06/17/2026 at 09:45AM Resident #5 was observed lying in bed and being assisted to dress by CNA-N. He had not been shaved, nor had the nasal hairs been trimmed. CNA-N said she shaved Resident #5 on Sunday, 06/14/2026. She said she did not shave the mustache area. She said she missed shaving the area directly under his lower lip. She said she could not trim Resident #5's nasal hairs because she did not have anything to trim nasal hair with. CNA-N said Resident #5 liked to be shaved and would sometimes ask to be shaved. She said Resident #5 never refused his bath or shave that she knew of. CNA-N said it was important for the residents to get their showers and be shaved if they did not want a beard because it showed respect for them as a person. During an interview with Resident #5 on 06/17/2026 at 11:15 AM with the DON and ADON present, Resident #5 rubbed his right index finger over his upper lip and said, They missed that. When asked if wanted a shave, Resident #5 said he did not want to look like a wolf. During an interview on 06/17/2026 at 11:01 AM, the ADON said the nurses were responsible for monitoring the aides and ensuring the residents' bathing and grooming needs were met. During an interview with the DON on 06/17/2026 at 11:28 AM, she said the aides were supposed to shower and shave the residents according to the instructions on the Nurse Aides Assignment Sheet and turn in a completed shower sheet to the nurses. The DON said she could not find a shower sheet for Resident #25 for 06/15/2026. The DON said the shower sheet dated 06/15/2026 for Resident #5 was marked Bed Bath. The DON said showers and grooming were a basic part of ADLs and were important for promoting dignity and respect. A record review of the facility's policy dated 11/28/2017 and entitled Quality of Life: ADL Care Provided For Dependent Residents indicated the following: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 1 of 8 confidential residents (Confidential Resident #1) reviewed for resident rights. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings included: During a confidential group interview at an undisclosed date and time, Confidential Resident #1 indicated they did not receive their package that was delivered on a Saturday. The confidential resident stated the package arrived on a Saturday and sat by the front door until they retrieved it the following day. During an interview on 06/16/2026 at 2:52 PM, the BOM stated during the week she retrieved the mail, gave it to the AD, and the AD distributed it to the residents. The BOM stated on the weekends the weekend receptionist obtained the mail and delivered it to residents. During an interview on 06/17/2026 at 9:34 AM, the AD stated she had been working as the AD for 2 months and prior to that she worked as a receptionist. The AD stated that when she worked as a receptionist she would obtain the mail on the weekends and distribute it to residents. The AD stated that the facility hired a new weekend receptionist, Receptionist L. The AD stated that Receptionist L was responsible for distributing mail to residents on the weekend. During a telephone interview on 06/17/2026 at 9:37 AM, Receptionist L stated she was the weekend receptionist. Receptionist L stated she obtained the mail on the weekends but did not distribute any mail out to residents. Resident L stated she put resident mail in HR's office box because HR distributed it to residents on the weekends when she was at the facility. Receptionist L stated she did this because she was new to working at the facility and was not familiar with the residents. During an interview on 06/17/2026 at 9:46 AM, HR stated she did not distribute mail to residents on the weekends. HR stated she did come to the facility for personal reasons but stated Receptionist L was to distribute residents' mail. HR stated that Receptionist L was trained to obtain and deliver residents' mail on the weekends. HR stated she had not seen any resident mail in her office box. HR stated she was unaware why Receptionist L would state she put residents' mail in her box, but she might have said if she was unsure about any mail Resident L could slide it under her office door. During a telephone interview on 06/17/2026 at 9:50 AM, Receptionist L stated resident mail did come in on Saturdays. Receptionist L stated she was trained specifically to put resident mail in HR's office box. Receptionist L stated she had been working at the facility for 3 weeks and on the weekend she checked the mail and brought it in so it did not sit in the mailbox over the weekends and when HR came in HR would check the mail and distribute it to the residents. During an interview on 06/17/2026 at 11:29 AM, the DON stated the process for distributing residents' mail on the weekends was HR checked the mail, provided it to Receptionist L, and Receptionist L distributed it to the residents. The DON stated it was her expectation residents got their mail on Saturdays. The DON stated the inconsistency in determining responsibility for distributing mail was a communication error. The DON stated she did not see harm for residents for not receiving mail but acknowledged it was their right as a resident to get mail daily. A record review of the facility policy titled Resident Personal Mail dated 6/2017 indicated the following: Policy:It is the policy of this facility to ensure each resident is able to receive and send mail without interference from facility staff. Procedure: Mail that is received for individual residents at the facility will be delivered unopened to the resident for which it is intended. Resident mail is sorted and delivered to the resident's room.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #6, Resident #47, and Resident #30) reviewed for infection control. The facility failed to ensure RN A wore PPE when providing intravenous care to Resident #6. The facility failed to ensure LVN D wore PPE when providing enteral feeding to Resident #47.CNA-M failed to remove PPE and discard prior to leaving resident 's room after providing perineal care, incontinent care for Resident #30. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements. Finding included: During an observation on 6/15/2026 at 10:30 A.M., RN A was in Resident #6's room providing intravenous medication (abbreviated as IV therapy) is a medical process that administers fluids, medications and nutrients directly into a person's vein. RN A was not wearing a mask or gown. There was signage indicating EBP was to be used, and PPE was present at the room entrance area. During an interview on 6/15/2026 at 12:45 PM, RN A said he didn't notice that he had not put on a gown for Resident #6, but was aware of the EBP and what he should have done when doing care a resident with an IV; The EBP signage read: When providing care for dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use: central line(A central line is a long, flexible tube inserted into a large vein near the heart to deliver medications, fluids, or nutrition and to monitor blood parameters safely over an extended period), urinary catheter(Urinary catheters are medical devices that drain urine from your bladder if you have a condition that makes it difficult or impossible to urinate), feeding tube(A feeding tube is a medical device that delivers nutrition, fluids, and medications directly into the stomach or small intestine when a person cannot eat or swallow safely), tracheostomy(tracheostomy is a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), wound care any skin opening requiring a dressing. During an observation on 6/15/2026 at 1:46 PM, LVN D was observed in Resident #47 's room doing an enteral feeding and not wearing a mask or gown. There was signage indicating EBP was to be used, and PPE was present at the room entrance area. During an interview on 6/15/2026 at 2:15 PM, LVN D said she did not realize that she did not have a gown and mask on but knew she had gloves on. A record review of a face sheet dated 6/16/2026 revealed resident #47 was a [AGE] year-old female admitted to facility on 4/11/2013 with diagnosis of severe dementia, major depression and anxiety and dysphagia (difficulty swallowing) and gastrostomy. Resident #47 was unable to voice any concerns. During an interview on 6/16/2026 at 3:00 PM, the DON/IP (Infection Preventionist Nurse) stated potential negative outcomes for staff's failure to observe EBP for at-risk residents was cross contamination, spread of infection and sepsis, resulting from violation of infection prevention and control requirements. A record review of the facility's policy, dated 04/1/2024 and titled, Enhanced Barrier Precautions, indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., Bed-linen changes, chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). A record review of a face sheet dated 06/16/2026, revealed Resident # 30 was a [AGE] year-old female admitted [DATE]. She had diagnoses which included hypokalemia (lower-than normal blood potassium levels), cellulitis (bacterial skin infection that affects the skin's deeper layer underlying tissues), gastro-esophageal reflux disease, acute myocardial infarction (heart attack), rheumatoid arthritis, cerebral infarction (stroke), candidiasis (a fungal infection), osteomyelitis (infection and inflammation of the bone tissue), hyperlipidemia (having too many lipids (fats), such as cholesterol), depressive disorder, anxiety disorder, hypertension, and type 2 diabetes mellitus. During an observation on 6/16/2026 at 9:50 A.M., CNA-M was observed performing perineal care and changing Resident #30's brief. CNA-M put on appropriate PPE, infection control practices were followed throughout providing perineal care/incontinent care. Upon completion of Perineal Care/Incontinent Care, CNA-M exited the room before removing PPE gown and gloves and discarded the gown and gloves in the hallway trash can. CNA M returned to Resident #30's room and said she forgot to remove the grown and gloves before leaving the room after providing care. CNA-M said she should have removed and discarded the PPE gown and gloves prior to exiting the resident's room. She stated the PPE should have been disposed of in the trash receptacle with the blue liner located in the resident's bathroom. During an interview on 06/16/2026 at 02:30 P.M., with the DON and ADON/IP Nurse, the DON said CNA's received training on the facility's EBP policy. The DON said staff were required to wear appropriate PPE during resident care, such as perineal care and linen changes, and remove and discard PPE before exiting the resident's room to help prevent the spread of pathogens. Both the DON and ADON said proper skill performance of hand hygiene, PPE use, and incontinent care technique were important for preventing the spread of infection. During an interview on 6/16/2026 at 3:00 PM, the ADON/IP (Infection Preventionist Nurse) stated failure of staff to follow EBP for at-risk residents could result in cross contamination, spread of infection and sepsis (a life-threatening response to an infection), due to noncompliance with infection prevention and control practices. During an interview on 6/17/2026 at 10:00 A.M., the DON stated the staff in the building were all trained and retrained on EBP. The DON further said failure of staff to follow EBP for at-risk residents could result in cross contamination, transmission of infection and sepsis (a life-threatening response to an infection), and would be a violation of the facility's infection prevention and control program. A record review of the facility's policy dated 04/1/2024 and titled, Enhanced Barrier Precautions, indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., Bed-linen changes, chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes).

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for four of five rooms (Rooms 201, 203, 205, and 208) reviewed for environment. The facility failed to maintain clean and sanitary conditions in rooms 201, 203, 205, and 208 which had a yellowish liquid substance and brownish-black sticky residue present throughout the rooms along the seams of the vinyl flooring with dirt, debris and food particles adhering to the substance and residue. This failure could place residents at risk of living in an unsafe, unsanitary and uncomfortable environment.Findings included: During an observation on 06/15/2026 at 9:35 A.M. room [ROOM NUMBER] and at 9:58 A.M. room [ROOM NUMBER] had brownish-black raised sticky spots on the floor with dirt and food particles adhered to the substance. The substance appeared to be emerging from the seams of the vinyl flooring. During an observation and interview on 06/16/2026 at 9:10 A.M., Resident #84 stated that maintenance had attempted to clean the brownish-black sticky substance; however, the substance returned. She stated that her feet adhered to the floor and that the substance was transferred to her shoes and other belongings. There was brownish-black sticky residue around the seams of the vinyl flooring, ranging in size from a dime to a quarter. Shoes adhered to the floor while walking across the room. During an interview 06/16/2026 at 9:15 A.M., Resident #67 stated that the brownish-black sticky substance had been present on her floor since she moved into the room in the past month and that dirt adhered to the substance. During an interview on 06/16/2026 at 9:25 A.M., CNA-E stated that rooms on Hall 2 had experienced both the brownish-black sticky substance and a yellowish glue-like liquid emerging from the seams of the vinyl flooring since she began employment in October 2025. She stated the yellow glue-like substance adhered to shoes and dried into a sticky residue. She further stated that approximately three weeks prior she almost fell due to her shoes sticking to the floor and had reported the incident to the SW. During an interview on 06/16/2026 at 9:26 A.M., Resident #55 stated that the brownish-black sticky substance was always present and the housekeeping staff attempted to remove it. She reported that she attempted to wipe up what she could when she noticed the yellowish liquid coming up. During an observation 06/16/2026 at 9:36 A.M., room [ROOM NUMBER] had pieces of plastic bags, food particles, and dirt adhered to the floor by the brownish-black sticky substance. The substance was present throughout the room along the seams of the vinyl flooring. A 3-foot by 5-foot rug on the B side of the room was adhered to the floor and could not be moved. The rug contained dark sticky spots and appeared unmaintained not being washed. Additional dime- to pea-sized areas of brownish-black sticky residue were observed near the room's entrance. During an interview on 06/16/2026 at 9:40 A.M., the SW stated the facility was in the process of cleaning and replacing the flooring but was unable to provide documentation of a corrective action plan and was unaware when the issue was reported to administration. During an interview on 06/16/2026 at 9:50 A.M., the Housekeeping Supervisor stated the flooring was installed approximately one year earlier. She stated she notified the Maintenance Supervisor of the issue. She said although maintenance had cleaned the floors, the substance repeatedly returned. She stated housekeeping swept and mopped daily; however, the sticky substance remained and debris continued to accumulate. During an interview on 06/16/2026 at 10:00 A.M., HSK-F stated that foot traffic caused a yellowish liquid substance to emerge from the flooring seams, which later dried into a brownish-black sticky residue. She reported that the substance could not be removed by sweeping or mopping and that housekeeping scraped it from the floor, only for it to return by the following day. She stated maintenance was aware of the issue in the Hall 2 rooms for approximately two to three months. During an observation and interview on 06/16/2026 at 10:15 A.M., Resident #60 stated that despite cleaning efforts, the sticky brownish-black substance remained. She reported glue was coming up through the flooring seams and stated that when she attempted to clean the substance, her paper towel adhered to the floor. She stated the floor remained sticky and never appeared clean. The floor in room [ROOM NUMBER] had pea-sized areas of yellowish glue-like substances around the seams of the flooring in three separate locations, along with brownish-black sticky residue containing dirt and food particles. During an observation and interview on 06/16/2026 at 12:20 P.M., Resident #20 stated that her family had placed a rug in her room because glue was coming up from beneath the flooring and causing the floor to be sticky. The floor in room [ROOM NUMBER]B had brownish-black sticky substance on both the rug and flooring. During an interview on 06/16/2026 at 12:30 P.M., the MS stated he was aware of the sticky floor issue in room [ROOM NUMBER] but was unaware of similar concerns in other rooms. He stated issues would only come to his attention if entered on the maintenance board. During an interview on 06/16/2026 at 12:35 P.M., the SW stated staff conducted Angel Rounds (department supervisors' daily rounds though facility to check for issues to be addressed) daily Monday through Friday and that maintenance concerns should be identified during those rounds and entered onto the maintenance board for correction. During observations on 06/16/2026 at 2:30 P.M.-2:40 P.M., rooms [ROOM NUMBER] revealed yellowish liquid substance and brownish-black sticky residue throughout the rooms along the seams of the vinyl flooring. Record review of the Maintenance Log, dated 05/07/2026 through 06/01/2026, revealed only one maintenance entry related to sticky flooring in room [ROOM NUMBER]. The entry, dated 05/10/2026, indicated the issue was resolved and was marked completed. During an observation on 06/17/2026 at 9:04 A.M. of room [ROOM NUMBER] the yellowish liquid substance and brownish-black sticky residue remained present despite previous cleaning efforts. During an observation 06/17/2026 at 9:25 A.M., room [ROOM NUMBER] had a yellowish liquid substance emerging from the seams of the vinyl flooring and when pressure was applied by walking across the floor a quarter-sized pool of yellow liquid and multiple pea-sized areas were observed emerging. Brownish-black sticky residue was also present throughout the room along the flooring seams. During an observation and interview on 06/17/2026 at 9:32 AM, the Housekeeping Supervisor observed room [ROOM NUMBER] and stated she believed the substance was glue. She stated the condition had existed since the flooring was installed more than one year earlier and occurred daily in several rooms. She stated housekeeping used a Swiffer to remove wet material and scrapers to remove dried residue. During an interview on 06/17/2026 at 9:33 A.M., the DON stated she believed the substance was glue coming up through the flooring and that the condition had existed since the rooms were retiled more than one year earlier. During an observation and interview on 06/17/2026 at 11:11 A.M., the MS observed rooms [ROOM NUMBERS] and stated a yellowish milky liquid substance was emerging between the vinyl floor tiles. He stated the substance was glue and reported that he rolled the flooring to force the glue upward and cleaned up substance and then waxed the floors. He stated maintenance concerns were communicated through the maintenance board. A record review of facility policy titled, Maintenance Service, revised December 2009, indicated the following: Policy Statement:Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation:2.The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 6 (Resident #65) reviewed for environment. The facility failed to repair or replace Resident #65's bed after the bed remote jammed and the foot of the bed frame creaked and abruptly dropped during operation. This failure could place residents at risk for impaired positioning, discomfort, and a reduced quality of life due to the use of malfunctioning equipment. The findings included: A record review of Resident #65's undated face sheet indicated a [AGE] year-old female admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete weakness on the left side of the body following a blockage in the brain), unspecified lack of coordination, torticollis (involuntary contraction of the neck muscles, causing the head to tilt to one side while the chin points to the opposite side), primary generalized osteoarthritis (a joint disease characterized by the breakdown of cartilage in multiple joints, leading to pain, stiffness, and decreased mobility), cognitive communication deficit (a disruption in mental processes essential for communication), and restless leg syndrome (a neurological disorder characterized by an irresistible urge to move the legs). A record review of Resident #65's most recent Quarterly MDS dated [DATE] indicated a BIMS of 10, which indicated moderate cognitive impairment. The MDS indicated Resident #65 required substantial/maximum assistance for rolling from lying on her back to the left and right side and returning to lying on her back on the bed and was dependent for transferring from the bed to a chair. The MDS indicated Resident #65 was always incontinent of bowel and bladder. During an observation and interview on 06/15/2026 at 11:07 AM, Resident #65 was seen lying in bed with the head of the bed slightly propped. Resident #65 stated her bed was broken. Resident #65 stated when she pushed the button on the remote for the bottom foot area of the bed to lower it would creak and drop all at once. Resident #65 stated she lowered it at 2:00 AM and it startled her but did not harm her. Resident #65 stated a few weeks prior she notified LVN H who notified maintenance of the broken bed. Resident #65 stated the Maintenance Assistant informed her the Maintenance Supervisor was ordering her a new bed. During an interview on 06/16/2026 at 8:45 AM, the Maintenance Supervisor stated he was unaware of anything wrong with Resident #65's bed. The maintenance supervisor provided the current work orders and stated there was no current Maintenance Request for Resident #65's bed. A record review on 06/16/2026 at 8:46 AM of the current maintenance requests dated 06/12/2026 through 06/15/2026 did not reveal any current maintenance requests for Resident #65's bed. During an interview and observation on 06/16/2026 at 8:47 AM, the Maintenance Assistant went to Resident #65's room to look at her bed and stated he did not know it was broken. The Maintenance Assistant was able to operate the buttons on the remote by pushing them with force. The Maintenance Assistant lowered the foot of the bed and a loud creaking sound was heard with a sudden drop occurring as the foot of the bed was lowered. During an interview on 06/16/2026 at 8:49 AM, Resident #65 stated she told LVN H about her issues with the bed weeks prior and CNA G who stated she also notified LVN H. Resident #65 stated LVN H operated the bed and it was working at that time but stated she would place a work order. During an interview on 06/16/2026 at 8:53 AM, LVN H stated Resident #65's bed has always worked fine for her and she was unaware of any issues Resident #65 or staff were having with the bed. During an interview on 06/16/2026 at 8:57 AM, CNA G stated she believed the Maintenance Assistant looked at Resident #65's bed a week or two ago. CNA G stated she noticed issues with the bed and Resident #65 told her. CNA G stated she personally notified the Maintenance Assistant the top buttons of the bed remote were hard to push, but she did not know about any issues with the foot of the bed. During an interview on 06/16/2026 at 9:05 AM, the Maintenance Assistant stated after observing the bed, he thought the metal on the base was grinding against each other. The Maintenance Assistant stated he did not believe the bed was unsafe as the legs are secured, which ensured nothing would fall through or off the bed. The Maintenance Assistant stated he knew Resident #65 wanted the head of the bed to go higher and about the foot of the bed dropping and was notified in the last month, but did not know about the remote being difficult to use or broken. The Maintenance Assistant stated he had never witnessed himself the foot of the bed dropping. The Maintenance Assistant stated he did not complete a maintenance request for this concern. The Maintenance Assistant stated he was unable to order Resident #65 a new bed as that was something the Maintenance Supervisor would have to do. The Maintenance Assistant stated he was sure he had notified the Maintenance Supervisor who stated they could obtain a bed from a different hall. During an interview on 06/16/2026 at 9:14 AM, the Maintenance Supervisor stated he expected staff to complete a maintenance request for any maintenance related concerns. The Maintenance Supervisor stated he did not expect the Maintenance Assistant to complete a maintenance request as they communicate verbally. The Maintenance Supervisor stated nursing staff were his eyes and if they saw any issues they needed to write a maintenance request. The Maintenance Supervisor stated that when a maintenance request was completed he did not have concerns related to it being resolved as he must resolve it before closing it out. The Maintenance Supervisor stated that every staff member was notified of the maintenance request board. A record review of the last month's maintenance request log on 06/16/2026 at 9:33 AM dated 05/07/2026 through 06/01/2026 indicated an undated maintenance request located between two other requests dated 05/21/2026. The undated maintenance request indicated the person making the request was the maintenance assistant, the location of repair was Resident #65's bed, and the type of repair made was maintenance. During an interview on 06/16/2026 at 9:35 AM, Resident #65 stated she was able to operate the buttons on the remote when she beat the remote, jammed the buttons down, and held her mouth right and even then it only occasionally worked. Resident #65 stated she was unsure if CNA G knew about the foot of the bed dropping abruptly. During an interview on 06/16/2026 at 9:44 AM, CNA G stated she personally told the maintenance assistant about Resident #65's bed not lowering completely as Resident #65 was upset about the bed not working. CNA G stated she did not complete a maintenance request. CNA G stated she was not in the room when the maintenance assistant spoke to the resident, but she thought she heard him say that he would get Resident #65's bed changed. During an interview on 06/17/2026 at 9:59 AM, Resident #65 stated she had multiple issues with the remote to the bed in the past day. Resident #65 stated at one time she was unable to push the button on the remote and required a CNA's assistance. Resident #65 stated that at another time she pushed the button to lower the head of the bed and it raised it. During an interview on 06/17/2026 at 11:32 AM, the DON stated if there were issues with a resident's bed or the bed was broken she expected staff to notify maintenance by completing a maintenance request. The DON stated staff could tell maintenance as they see them, but they typically were to write it on the maintenance request board. The DON stated a broken bed would need to be addressed. The DON stated the Maintenance Supervisor and the Maintenance Assistant were responsible for making sure resident beds were in working condition. The DON stated if the resident thought they needed a different bed and was agreeable to changing the bed, it should be changed. The DON stated the Maintenance Assistant told her two days prior that he looked at Resident #65's bed and the bottom was messing up but that he fixed the issue. The DON stated there was a gap in communication in addressing Resident #65's concerns with her bed. The DON stated the risk to residents for a gap in communication depended on what was wrong with the bed. The DON stated staff should have completed a maintenance request to address the issue with Resident #65's bed. A record review of facility policy titled Maintenance Service revised December 2009 indicated the following: Policy StatementMaintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and ImplementationThe Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 2 residents (Residents #59) reviewed for respiratory care. 1.The facility failed to ensure Resident #59's nasal cannula was changed and dated in accordance with facility policy that required weekly replacement. 2. The facility failed to ensure Resident #59's humidifier bottle was changed and dated in accordance with facility policy that required weekly replacement. This deficient practice could place residents at risk for respiratory-related infections Findings included: Record review of a face sheet dated 06/16/2026 revealed Resident # 59 was an [AGE] year-old female, admitted [DATE]. She had diagnoses which included fracture of right femur, cardiac pacemaker, chronic kidney disease, hyperlipidemia (having too many lipids(fats), such as cholesterol), dementia, psychotic disturbance, anxiety disorder, congestive heart failure, presence of cardiac pacemaker, spinal stenosis (narrowing of the spaces within your spine), dyspnea (shortness of breath), hypertension, and type 2 diabetes mellitus. A record review of Resident #59's quarterly MDS assessment, dated 03/19/2026 revealed a BIMS score of 15, which indicated cognitively intact. Section GG-Functional Abilities indicated Resident #59 required substantial/maximal assistance. A record review of Resident #59's physician orders dated 06/1/2026-06/30/2026 revealed an active physician order, initiated on 05/05/2026 for oxygen at 2 liters per minute by nasal cannula as needed for shortness of breath. Nebulizer-Change tubing every week on Wednesday 7:00 A.M. to 3:00 P.M., remember to date and initial tubing/applicator. During an observation on 06/15/2026 at 9:20 A.M., Resident #59's oxygen concentrator humidifier bottle was labeled and dated 6/2/2026. Further observation revealed Resident #59's nasal cannula tubing was labeled and dated 6/2/2026. During an interview on 06/15/2026 at 10:30 A.M., MA-B said the nursing staff were responsible for changing the oxygen concentrator humidifier bottle and the nasal cannula tubing for all residents who used oxygen, which was normally done weekly on Wednesdays. During an observation and interview on 06/16/2026 at 2:20 P.M., the ADON observed Resident #59's oxygen concentrator humidifier bottle, and nasal cannula tubing were labeled and dated 6/2/2026. ADON said the humidifier bottles and oxygen tubing were routinely changed weekly on Wednesdays by the charge nurses. She observed the equipment was not changed as scheduled and could not explain why. The ADON said she would immediately replace the humidifier bottle and oxygen tubing and applied updated labels and dates. She stated this failed practice could increase respiratory infections. During an interview on 06/17/2026 at 1:30 P.M., LVN-D said the charge nurses on each hallway were responsible for changing oxygen concentrator's pre-filled humidifier bottles and nasal cannula tubing weekly, typically on Wednesdays, and documented in the TAR. LVN-D said nursing staff received training and in-service education regarding weekly replacement of oxygen nasal cannula tubing and humified distilled water bottle, and the DON or ADON normally provided training. During an interview on 06/17/2026 at 1:45 P.M., the ADON said she and the DON were responsible for monitoring compliances with changing oxygen concentrator's humidifier bottles and nasal cannula tubing weekly. She further stated staff were informed and trained on the humidifier bottles and oxygen tubing change policy and that she normally completed the in-services. During an interview on 06/17/2026 at 1:45 P.M., the DON said the charge nurses were responsible for changing the oxygen tubing, the humidifier bottles and nasal cannula tubing weekly. The DON further said the ADON and DON were responsible for training and monitoring charge nurses to ensure compliance with facility policies. However, DON was unable to provide the facility's process for monitoring or ensuring staff compliance with the weekly oxygen equipment changes. A record review of the facility's policy titled, Administration of Oxygen, un-dated, indicated: .16. Change distilled water in humidifier weekly. Water in humidifier should be maintained and changed as necessary. Oxygen cannula, tubing and humidifier bottles should be changed weekly and as needed.

Based on observation, interview and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 5 of 26 residents (Residents #23, #35, #37, #46 and #52) reviewed for resident rights. The facility failed to maintain resident-use water to be above 100 degrees Fahrenheit. This deficient practice could place residents at risk of discomfort and unsanitary washing conditions . Findings include: Observation on 04/09/25 at 1:22 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 76.2 degrees Fahrenheit, when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:25 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 76.0 degrees Fahrenheit, when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:28 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 74.4 degrees Fahrenheit when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:31 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 74.1 degrees Fahrenheit, when tested with a state-issued digital thermometer. During a group interview on 04/08/2025, at 10:00AM, Resident #37 and Resident #35 said they did not have hot water in their room. Resident #37 said the water had been out for several weeks. She said she would let it run for a long time , but the water never got warm or hot. During interview on 04/09/25 at 2:21 PM, with the Maintenance Director, he said a water heater went out and a new one was installed . He said he thought the issues had been corrected and his maintenance assistant had been checking the water temperatures daily and recording the temperatures on the water temperature log. The Maintenance Director said it was his responsibility to adjust the water regulator, to provide the proper temperature water for resident-use water . During interview on 04/09/2025 at 2:28 PM, the Maintenance Assistant said the problem with the water heater started 2.5 weeks ago. He said they had a new water heater installed and he had been checking and documenting the water temperatures on the water temperatures log. During observation and interview, on 04/09/2025 at 2:57 PM, the ADM was observed checking water temperatures in resident rooms. Resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 80.0 degrees Fahrenheit, when tested without a state-issued digital thermometer . Resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 80.2 degrees Fahrenheit, when tested without a state issued digital thermometer. The ADM said they had just purchased a new water heater and the problem had been corrected at that time . The ADM said they will have to get the company to come back out . Record review of a water temperature log, dated, April 2nd, 3rd, 4th and 9th, revealed the Maintenance Assistance recorded the water temperatures of 2 rooms on the 200 hall daily. April 2nd, room [ROOM NUMBER]- 73 degrees Fahrenheit / room [ROOM NUMBER]-75 degrees Fahrenheit, April 3rd, room [ROOM NUMBER]- 72 degrees Fahrenheit / room [ROOM NUMBER] -73 degrees Fahrenheit, April 4th, room [ROOM NUMBER] - 74 degrees Fahrenheit / room [ROOM NUMBER] - 73 degrees Fahrenheit April 9th, room [ROOM NUMBER] - 74 degrees Fahrenheit / room [ROOM NUMBER] - 72 degrees Fahrenheit. Record review of the facility policy titled Water Temperatures, Safety of, revision date of December 2009, indicated: 1. Water heaters that serve resident rooms, bathroom, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit (____degrees C), or the maximum allowable temperature per state regulation. The policy did not address water temperatures in resident rooms, bathroom, common areas, and tub/shower areas, that measure below 100 degrees Fahrenheit.

Based on interview and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal, such grievances include those with respect to care and treatment which were furnished as well as that which were not furnished, the behavior or staff and of other residents, and other concerns regarding their LTC facility stay, for 8 of 8 residents reviewed for grievances. The facility failed to ensure residents were informed of their right during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights. Findings include: During record review of resident council meeting minutes, on 04/08/2025 at 10:00 AM, revealed a grievances form had not been explained to the residents or how to use the form, over the past six months of residential council minutes reviewed for, April 2025, March 2025, February 2025, January 2025, December 2024 and November 2024. During interview on 04/08/2025 at 10:00 AM, Residents #14, #22, #30, #35, #37, #54, #62 and #65, said they did not know how to file a grievance. They said they had never had a grievance form reviewed with them. The residents said the Activity Director never reviewed or explained a grievance form with them . During an interview on 04/08/2025 at 11:15 AM, the Activity Director said she did not handle grievances or the grievance forms . She said she was not familiar with the form, had not explained the form to the residents and had never seen a grievance form. She said if the residents had a grievance, they would go to the ADM, all grievances went to the ADM. During interview on 04/09/2025 at 11:30 AM, the Administrator said, residents could express a concern to him, and he would use a complaint/concern form to document the issue. He said he attended the residential council meeting and reviewed resident rights with the residents. The ADM provided minutes from 4 resident council meetings, which which demonstrated, resident rights, had been reviewed. The ADM's signature was not indicated on any of the signature logs, of the 4 months provided and reviewed for; April 2025, March 2025, February 2025 and January 2025. The minutes provided by the ADM, did not indicate a grievance form had been an agenda item, that a grievance form had been shared with the residents, or had been explained to the residents. The ADM said he did not sign in on the signature log. Record review of the facility's, undated, document titled Policy/Procedure, Subject: Resident Right - Grievances: 6. Residents, resident representatives and staff will be information on how to file a grievance.

Based on interview and record review, the facility failed to ensure the residents received mail for 2 of 8 residents reviewed for rights to forms of communication. (Resident #s 38 and 65) The facility did not deliver mail to Resident #s 38 and 65 on Saturdays. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During a group interview on 03/05/2024 at 9:30 a.m., Residents # 38 and 65 said mail was delivered to the facility on Saturday, but the Saturday mail was not delivered to them until Monday. During an interview on 03/05/2024 at 10:55 a.m., the HRD said she collected the facility mail on Saturday, from the mailbox at the front of the facility. She said she took the mail to the office she shared with the BOM and she placed the mail on the desk of the BOM. During an interview on 03/05/2024 at 10:57 a.m., , the BOM said when she comes in on Monday, she sorted the mail on her desk. She said she placed the residents mail in the Activity Director's mail slot, which the Activity Director retrieved and delivered to the residents. The BOM said the door to the business office was locked over the weekend and no one had a key to the office but the BOM and the HRD. During an interview on 03/05/2024 at 11:01 a.m., the Administrator said the AD worked on Saturday, she checked the mail and she passed the residents mail to them. During an interview on 03/06/2024 at 3:30 p.m., the Activity Director said she worked on Saturday, and she got the mail from the mailbox in front on the facility. She said she separated the business office mail and the resident mail. She said she passed the residents' mail to the residents who have mail, and she slid the business office mail under the entrance door to the business office. She said she also slid cards and other things that have come for the resident, under the door as well. Review of a revised policy dated May 2017, titled Mail and Electronic Communication: 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on interview and record review the facility failed to ensue all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure allegations of abuse were reported to the facility administrator. This failure could place residents at risk of continued abuse in the facility. Findings include: Record review of Resident #1's face sheet indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included acute respiratory disease. Record review of Resident #1's Admission MDS, dated [DATE], indicated her cognitive status was moderately impaired. Her bed mobility was listed as extensive assist with two person. Record review of Resident #1's care plan, dated 6/8/23, indicted a problem with memory recall. Evidenced by recalling staff names. The approaches were to engage the resident in meaningful conversation and provide visual reminders. Resident #1 had a problem of she required assistance with ADLs. Some of the approaches were two person assist with bed mobility. During an interview on 6/27/23 at 11:18 a.m., Resident #1 said she had diarrhea and used her call light for assistance and maybe it was quite a bit. Resident #1 said CNA D came in and told her she was using the call light too much, snatched the light out of her hand, and threw it on the floor. Resident #1 said when CNA D came in again, she asked why she had taken her call light. Resident #1 said CNA D flipped her hand in the air like she was insignificant. She said the aide had not been back in her room since that time. During an interview on 6/27/23 at 11:30 a.m., the Investigatior infomed theAdministrator of Resident #1's concern about CNA D taking her call light. He said he would begin an investigation into the incident. The Administrator said no one had informed him about any concerns regarding Resident #1 and someone taking away her call light. He said he was going to report the allegation to the state agency. During an interview on 6/28/29 at 10:10 a.m., TNA A said she heard Resident #1 say to TNA B that CNA D was mean to her. TNA A said Resident #1 said CNA D did not like to help her and took the light because she used it too much. TNA A said Resident #1 was not talking to her, she was assisting TNA B and Resident #1 was telling TNA B. She said TNA B said she was going to report the concern. During an interview on 6/28/29 at 10:20 a.m., TNA B said she worked at the facility about 4 months. She said she was aware of what abuse was and who to report it to. TNA B said Resident #1 told her on Monday, 6/19/23, that CNA D snatched her call light and refused to give it back. She said Resident #1 said when CNA D was cleaning her up she told her not to S*** in her face. The resident had diarrhea. TNA B said she reported her concerns to the ADON and the DON and nothing was done. She said CNA D was not suspended and worked the next weekend. TNA B said she knew they had spoken to CNA D because she was present for some of the conversation. TNA B said she thought reporting Resident #1's concerns to her supervisor was all that was needed. During an interview on 6/28/29 at 10:40 a.m., the ADON said TNA B reported to her that Resident #1 said CNA D took her call light. The ADON said she had gone down and talked to Resident #1 and she told her the same thing. She said Resident #1 said CNA D had disregarded her concerns about the call light. She said she and the DON, who was currently on vacation, called CNA D into the office. The ADON said CNA D denied the allegation. The ADON said she and the DON talked to CNA D, but LVN C had already taken care of the incident. The ADON said LVN C told CNA D not to go back in Resident #1's room. The ADON said she did not know if they told the Administrator or not. She thought she had reported to the Administrator. The ADON said the DON was on vacation. During a telephone interview on 6/28/29 at 10:47 a.m., LVN C said she was not sure exactly who said Resident #1 told her CNA D took her call light. LVN C said someone reported it to her and she immediately went to Resident #1's room. She said she did not ask Resident #1 about the call light and the resident did not mention any incident to her. LVN C said she saw the call light tied to Resident #1's bed and felt nothing had happened. She said she talked to the RN supervisor, and they decided to remove CNA D from caring for Resident #1. She said she had not reported the incident and felt it was handled. She did not know how long it had been since the aide had been in the room, or if anyone gave the light back. She said she saw the resident with the light and felt there was no problem. The LVN said if she had suspected abuse, she would have reported it. During an interview on 6/28/29 at 11:40 a.m., the Administrator said TNA B, the ADON, nor the DON had informed him of the incident with Resident #1. He said they were all aware he was the abuse coordinator, and they should have reported to him immediately. During an interview on 6/28/29 at 11:54 a.m., TNA B said she had not reported her concerns about Resident #1 to the Administrator and knew she should have. She said she thought if she reported the incident to her supervisor that was sufficient. During an interview on 6/28/29 at 12:10 p.m. with the Administrator and Resident #1 in her room, Resident #1 said she did not know who she reported the incident to first. She said she was mad and upset and did not want to be hostile with other staff because of CNA D. She said CNA D had taken her call light and threw it on the floor. Resident #1 said when she asked her why she took her light she flipped her off like she was insignificant, like she was not even a person. Resident #1 said one of the other aides gave her the call light back. She could not be sure who it was, she did not know names that well. During an interview on 6/28/29 at 1:30 p.m., the Administrator said he suspended 5 staff associated with the Resident #1's incident. He suspended LVN C -charge nurse, CNA D, hospitality aide E, ADON, and CNT B. He said they were aware of the abuse and did not report the abuse to him. Record review of employee memorandum indicated LVN C, CNT B, Hospitality aide E, CNA D, and the ADON had suspension violations, dated 6/28/23, the action was the employee had information related to abuse or neglect and did not call the abuse coordinator. The employee's corrective action was an in service on abuse and suspension. Record review of a from titled QA Meeting indicated: on 6/27/23 the facility Administrator was alerted to potential abuse allegations regarding a staff member taking a call light from a resident. During the investigation on 6/28/23 due to the allegation of call light removed from the resident. The facility administrator suspended the ADON who did address the situation but failed to recognize this as a potential abuse and failed to report to the facility administrator. The facility also suspended the charge nurse on the well end as well as the alleged perpetrator pending investigation, in service and retraining. In services on abuse, neglect and reporting to the facility abuse preventionist. The facility Administrator reported to HHSC on 6/27/23 and the facility investigation is ongoing. Record review of the facility Abuse, Neglect Reporting and Investigating policy, last revised 2021, indicated all reports of resident abuse are reported to the local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the administrator and authorities. If abuse is suspected, the suspicion must be reported immediately to the administrator and the other officials according to state law. Any employee who had been accused of resident abuse is placed on leave with no resident contact until the investigation is completed.

Based on observation, interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 4 residents reviewed for antibiotic medications. (Resident #1.) The facility failed to: 1. Ensure Resident #1 was not given medications that caused him to experience a serious allergic reaction. 2. Ensure Resident # 1's physician orders and MAR were reviewed prior to administration of a new medication. 3. Ensure they followed their medication administration policy. Resident #1 experienced an adverse drug interaction to (Bactrim) a medication his clinical records indicated he was allergic to. An Immediate Jeopardy (IJ) situation was identified on 03/07/23 at 5:05 p.m. While the IJ was removed on 03/09/23 at 12;56 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure caused a resident to have serious adverse allergic reaction to a medication and was hospitalized . Findings included: Record review of Resident #1's face sheet indicated he a [AGE] year-old male admitted to the facility on [DATE]. The sheet indicated he had allergies to Bactrim, Nexium, and Sulfate. Record review of Resident #1's Care Plan last revised 12/12/22 indicated he had allergies to of Bactrim, Sulfa, and Nexium. The Care Plan indicated a problem of requiring assistance with ADLs. The resident Required one person assist with bathing, bed mobility dressing, and sit up help with eating. He required one person assist with toileting and transfer as needed. Record review of Resident #1's quarterly MDS indicated he was moderately cognitively impaired. The MDS indicated he required supervision for bed mobility, transfer, locomotion on the unit, eating and toilet use. The MDS indicated he did not walk in the room or the corridor. However, there was no device noted. Observation on 03/07/23 of the outside of Resident #1's chart showed a bright orange sticker that said Allergies listed was Bactrim, Sulfa, and Nexium. Record review of Resident #1's computerized physician orders for 02/01/23 -02/28/23 indicated he had allergies to of Bactrim, Sulfa, and Nexium. His diagnoses were diabetes, anxiety, chronic obstructive pulmonary disease. Record review of Resident #1's nursing notes dated 02/13/23 at 8:55 a.m. indicated the resident complained of lethargy and shortness of breath on exertion with diarrhea and weakness. The resident was unable to hold bowels this AM and had an accident in his bed. New orders were received for labs, a urine analysis, and a chest X-ray with two views. Record review of Resident #1' s Complete Blood Count (CBC lab) dated 02/14/23 indicated platelets 112 low (range 142-424). Urine analysis indicated cloudy positive for catalase bacteria screen (Bacteria.) Record review of a Pathogens (bacteria) Detected report indicated the received date was 02/14/23. There was moderate Acinetobacter Baumannii (bacteria infection) that listed antibiotic treatment options. Record review of a nurse's note dated 2/20/23 at 7:30 p.m. indicated a call was received from the NP and received a new order for Bactrim DS. Give one by mouth every 12 hours for seven days for a diagnosis of urinary tract infection. Written by LVN C. Record review of a handwritten telephone order dated 02/20/23 indicated resident #1 was to receive Bactrim DS 1 by mouth every 12 hours times 7 days for diagnosis of UTI. Signed by LVN C Record review of Resident #3's MAR indicated on 02/21/23 at 10:00 p.m. Bactrim DS was given. Record review of Resident #1's nursing note dated 2/21/23 at 8:45 a.m. indicated blood sugar check was 202, the resident was lethargic with labored respirations of 22. His O2 stat was 72 and he was on 2.5 liters of oxygen via nasal cannula. Resident #1's blood pressure was 120 / 72, pulse was 94 and temperature was 98.9. The resident complained of nausea but refused medications for nausea. Upon assessment the resident had bruising and swelling to the left upper arm, bleeding to the gums was noted. There were red crested secretions noted to the left eye. The resident denied any recent falls. Resident #1 could not recall how he had obtained the bruising or swelling to his left arm. The DON was notified. Written by LVN E. Records review of a nursing note dated 2/21/23 at 9:00 a.m. indicated the pharmacy called to verify new order for Bactrim and said Resident #1 was allergic to Bactrim. A nurse questioned Resident #1 and he said when he took Bactrim his platelets depleted. EMS was called and the resident was transported to the hospital. Written by LVN E. Record review of a medication error report dated 02/21/23 at 8:30 a.m. indicated Resident #1 had a urinalysis with culture and sensitivity ordered on 02/14/23. The culture and sensitivity were received on 02/20/23 an order was given on the second shift from the NP to LVN C for Bactrim DS-1 tablet two times a day for seven days. LVN C wrote the order and RN D gave the initial dose. When the order was taken LVNC failed to verify allergies. Resident #1 was allergic to Bactrim. RN D was passing medications and gave the initial dose of Bactrim at 10:00 p.m. Bactrim was listed on the MAR as an allergy. On 02/21/23 at 10:18 a.m. the NP was contacted. When taking any orders for medication the nurse would check with another nurse to verify that the resident does not have an allergy to that medication. An in service was put out for nurses signed by LVN C and RN D and also the DON on 02/21/23. Record review of Resident #1s hospital records dated 3/7/23 indicated this [AGE] year-old male was admitted for acute chronic hypoxic (absence of enough oxygen) respiratory failures secondary to diffuse alveolar hemorrhage (life threating condition caused by a variety of disorders associated with hemoptysis (coughing up blood), anemia, diffuse lung infiltration, and acute respiratory failure. The patient was coughing up blood which had slowed and believed the underlying cause of his diffused alveolar hemorrhage is pneumonia in the setting of thrombocytopenia (low platelets in the blood can be cause by medication side effects). He underwent treatment with Octogam (used to treat chronic immune thrombocytopenia) 3 days of steroids. Platelets have recovered and he is currently on romiplostim (bone marrow stimulant and can be used to treat thrombocytopenia.) The main concern now is going to be respiratory failure and his hemoglobin was stable believed he is not currently bleeding. Hematology and oncology reported indicated a diagnosis thrombocytopenia, suspected drug induced thrombocytopenia platelets level was found to be 3 on admission. The patient is currently not actively bleeding, had some bruising present notably o his right upper quadrant chest and his left arm. He is not taking any anticoagulants or blood thinners. History significant of severe thrombocytopenia with Bactrim, history significant of patient given Bactrim on 02/20/23. During an interview on 03/07/23 at 9:43 LVN B said he worked as a medication nurse, he administered medications and had worked at the facility for about [AGE] years. He said Resident #1 was sent to the hospital because he had some bruising and bleeding. He said the staff on the evening shift gave Resident #1 Bactrim and he was allergic to the medications. LVN B said Resident #1 was currently in the hospital. During an interview on 03/07/23 at 10:16 a.m. the DON said Resident #1 had been confused and not his normal self. They had completed some labs to determine what was going on 02/14/23. Resident #1 had a UTI they received a culture and sensitivity test on 02/20/23. She said the NP prescribed Bactrim DS. The DON said the NP called with the order, LVN C took the order, and did not check for an allergy. She said LVN C put the order on the MAR. The DON said RN D gave the Bactrim and did not check the MAR for allergies. She said Resident #1 received one dose at 10 p.m. that night. The order was written for 10 p.m. and 10 a.m. Th DON said she saw Resident #1 before he was sent to the hospital on 02/21/23. The DON said she saw a raised bruises on his arm and a blood blister inside his mouth on the top lip, and the eye had a red scab in the corner. She said the blood blister in his mouth busted on the way to the hospital. The DON said Resident #1 was diagnoses at the hospital with Thrombocytopenia (a platelet deficiency.) The DON said the medication administration procedure was the nurse giving the medication was supposed to check for allergies. She said on 02/20/23 the Bactrim was taken from the ER box and the first dose was given. The DON said the Pharmacy called on the morning just about the time they discovered the resident was allergic to Bactrim to report Resident #1 had an allergy to the medication. The DON said she called the NP and they spoke about what happened. She said the NP said when he talked to the nurse, he was not looking at Resident #1's profile, the nurse did not mention the allergy. The DON said she checked to make sure Resident #1 did not get a second dose of the medications. She did a medication error report and an in service on making sure nurses checked for allergies prior to administering medications. During an interview on 03/07/23 at 10:52 a.m. LVN E said she worked at the facility for a year. She said she was not the nurse that took the order for Resident #1. LVN E said when she came in on 02/21/23 she went to assess Resident #1. She said his blood sugar was fine but noticed a large bruise on his left arm. She said the bruise was raised and unusual looking. When she asked Resident #1 if he had fallen, he said no. LVN E said Resident #1 had what looked like a tear in corner of his eye that was blood. She said he was breathing a little fast. LVN E said Resident #1 said something was going on in his mouth, and it looked like a blood blister in his mouth. She said she got the DON to observe Resident #1. LVN E said his arm was huge and swollen. She said they were going to get Xray, his Oxygen stats was 76. She went back to desk, getting ready to send him out and was going to write the order. She said she saw the order right before hers was for Bactrim. LVN E said she knew Resident #1 was allergic to Bactrim. LVN E said she looked on his computer order and the front of the chart at the bright orange sticker and they said allergy to Bactrim. She said she asked someone to ask him what happened when he took Bactrim. LVN E said Resident #1 said his platelets deplete. She said at that time the ambulance was already in route. LVN E said right about that time the pharmacy called and said Resident #1 had an allergy to Bactrim. She said they were aware of how he was doing because the MDS coordinator was able to get updates daily. His platelets were better, but his oxygen was still low. During an interview on 03/07/23 at 11:40 a.m. the NP said he did not talk to Resident #1's physician about Resident #1 incident with receiving the Bactrim. The NP said most of the time he relied on the nurses to tell him what the allergies a resident had. When he talked to the nurse, he was not looking at Resident #1's profile. He said Resident #1 was sent to the hospital; his platelet count had dropped due to the Bactrim. The NP said Resident #1 always had chronic respiratory problems. The NP said in the future he would ask if the residents had allergies. During an interview on 03/07/23 at 11:59 a.m. RN D said she worked at the facility for 4 years and did a little bit of everything. She did staff development, taught aide classes, in services, immunizations, and currently passed medications. She said on 2/20/23 LVN C was the charge nurse and RN D said she was passing medications. She said LVN C told her she received an order to give Resident #1 Bactrim. RN D said she never looked at the order, or the MAR. RN D said she took the order verbally. She got the medication out of the Emergency Kit, gave the medication, and wrote medication administration on the MAR. RN D said she did not look at Resident #1's orders or MAR for allergies but should have. She said she knew he got sick and went to the hospital and she could not help but think it had something to do with the medications she gave. The RN said she had been a nurse for over [AGE] years. She said they did not really monitor a resident after giving a medication. She gave the medication about 10 p.m. and she had saw Resident #1 in the hallway around 11 p.m. RN D said she did not note any adverse reactions to the medications on the MAR or in the nursing notes. During an interview and record review on 03/07/23 at 2:25 the ADON said they monitor residents who received a new medication for 3 days, every shift. They put the monitoring on report or put in nurse notes. The ADON said Resident #1 received his first dose at 10 p.m. and should have been monitored on the next shift. However, review of the 24-hour report with the ADON only showed the medication was given, but no indication it was monitored. Also review of the nursing notes did not show any mention of the medication being monitored. During an interview on 03/07/23 at 2:55 p.m. the DON said they have not had QA meeting regarding Resident #'s Medication Error incident. She said they called the primary physician and the NP. The DON said she did not know if the Medical Director was informed or not. During a telephone interview on 03/07/23 at 2:57 p.m. LVN C said normally the NP would ask her what the allergies were for a Resident. She had faxed the lab to NP, he called to give an order for antibiotic. She said he called about 7:00 p.m. and she wrote the order in the chart and wrote it in on the MAR. LVN C said she never checked the chart for allergies. She said there was an orange sticker, on the front of the chart, it was listed on the computerized physician order, and the MAR. LVN C said RN D was passing medications and told RN D to give the medication. LVN C said the medication was ordered two times daily at 10 a.m. and 10 p.m. LVN C said she checked Resident #1's blood sugar after he received the Bactrim, and he was fine when she did the blood sugar check. LVN C said RN D got off the medication cart about 10 or 10:30 p.m. LVN C said after the incident she received an in services and write up for not checking the allergies. She said she had been a nurse for [AGE] years and had worked at the facility for two years. She said Resident #1would need help sometimes, but for the most part he was independent. During an interview on 03/07/23 at 3:58 p.m. the Regional Nurse, have not taken the incident with Resident #1 receiving medications he was allergic to QA. They had typed up something to address giving resident medications and allergies but was going to wait for the Medical Directors approval before initiating it. She said they did a cart review of other residents taking antibiotics, but had not taken Resident #1's issue to QA. During an interview on 03/07/23 at 4:05 p.m. the Medical Director said the facility staff made her aware Resident #1 received the Bactrim. They had discussed possible plans to ensure it did not happen again. The plans were for all residents to receive the care and serviced needed to make sure they did not get medications they were allergic to. Record review of the facility policy on Medication Utilization and Prescribing- Clinical Protocol last revised July 2016, indicated the physician and staff will identify situation in which a resident is taking medications associated with potentially significant medication related problems such as allergies and adverse drug reactions. This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 5:05 p.m. The facility Administrator, DON, ADON, and MDS coordinator. The Administrator was provided with the IJ template on 03/07/23 at 5:05 p.m. During an observation and interview on 3/9/23 at 8:00 a.m. of Resident #1 in the hospital showed he was sitting up in bed. He was on oxygen and seemed to have some difficulty breathing and talking. He said to come to the right side of the bed because he was hard of hearing. He said he could hear nothing out of his left ear and the right side appeared to be getting worse. He said he trusted the people at the facility to make sure he was taken care of and treated right. Resident #1 said some of the staff knew he was allergic to Bactrim because he had told them what it did to him in the past. He said the nurse came in that night and said she was going to give him some medication for the kidney infection. He did not hear her say Bactrim. His daughter was in the room and said she might have heard the nurse say Bactrim, but it did not register with her at the time. Observation showed he had a pan in the bed with him, he said it was there in case he coughed up blood. Resident said he was still coughing up blood, but it was not bright red like it was. He also said they had not talked to him about discharge at this time. During an interview on 03/09/23 at 9:07 a.m. Regional Nurse said they had a written counseling on LVN C and RN D. They had made some addendums to the facility Policy of Medication Utilization and prescribing. She said on 03/08/23 at 12:30 p.m. a QA meeting was held, and the medical director attended by phone. The Regional nurse said per the POR an audit was conducted and everyone on antibiotics were rechecked for allergies. She said they were ensuring the resident responses to the medications were noted on 24-hour report. They were also making sure resident assessments were completed for adverse reactions and noted in nurse's notes, and to put on the MAR. During a telephone interview on 03/09/23 at 12:09 p.m. RN D said she did tell Resident #1 what medications she was giving him. She said she knew he was hard of hearing and tried to talk loudly when speaking to him. RN D said she thought he heard what she said when he took the medication. The plan of removal was accepted on 03/08/23 at 10:05 a.m. [Residents Who have suffered, or are Likely to suffer, A serious Adverse outcome as a result of the non-compliance. The failure to ensure that residents did not receive medications that were identified as allergies created a finding of immediate jeopardy. Resident #1 received one dose of a medication he had a known allergy to. Negligent practice had the potential to affect all residents. Actions the facility will take. Regional nurse provided in-service to DON and Administrator. Areas covered include the importance of identifying all allergies of residents. The importance of clearly documenting allergies for staff to assess and also shall keep medical record current as new allergies are identified. Facility is expected to have a system in place that ensures nursing receiving orders are verifying the resident is not allergic. Started 03/07/23 5:30 pm completed 03/07/23 6pm. All nurses and medication aides will be in-service prior to their next shift, no nurse or cma will be allowed to work until in-service is complete. In-service will cover the importance of verifying all known allergies prior to receiving an order. All nurses will communicate allergies to physician when obtaining new orders. All nurses will be in serviced on policy change, two nurses to verify medication pulled from emergency kit. This will ensure the correct medication is pulled and that it is not contraindicated due to allergy. All nurses will be in serviced on updated policy that all residents will be assesses every shift during the duration of antibiotic therapy by a licensed nurse to monitor for adverse reaction. Assessment will be documented on MAR, nurses notes and noted on facility 24-hour report. In servicing will be conducted by DON or designee. Started 03/07/23 5:30 pm completed on 03/08/23 11:55 pm. All residents receiving an antibiotic were audited to ensure no other residents were affected. Audit performed by DON. Started 03/07/23 5:40 pm Completed 6:15 pm. Don and admin audited to ensure all residents charts have known allergies clearly identified on chart and MAR. Started 03/07/23 5:40 pm completed 7pm. Administrator verified both nurses that administered the medication have written counseling on file and were provided with education on identified failure. Started 03/07/23 5:40 pm- completed 6pm. Resident #1 remains in the hospital. Administrator notified medical director of immediate jeopardy on 03/07/23 At 5:45 pm. Facility will hold QA on 03/08/23 to address identified failures. Start 03/07/23 completed 03/08/23 12:30 pm Systems, Polices and procedures Facility updated policy and procedure titled medication utilization. Update includes two nurses to verify all medications obtained from pharmacy emergency kit. Two nurses will verify the medication is correct and not contraindicated due to allergies. Residents receiving antibiotic therapy will be assessed every shift during the duration of therapy to monitor for adverse reaction. Assessment will be documented on MAR, nurses notes and noted on facility 24-hour report. In servicing will be conducted by DON or designee. Started 03/07/23 7pm completed 03/08/23 11:55 pm.] The facility noted in their plan of removal some areas would not be completed until 03/08/23 at 11:55 p.m. On 03/09/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 03/09/23 between 9:40 a.m. and 12:48 p.m. facility staff: LVN F/MDS nurse- worked as nurse on the floor sometimes mostly day shift. LVN A- worked 7:00 a.m. to 3:00 p.m. also took on call and worked all 3 shifts. LVN G- worked 7:00 a.m. to 3:00 p.m. LVN E -worked 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. RN H/treatment nurse- worked as a nurse on the floor on occasion. Normally worked 8:00 a.m. to 5:00 p.m. also worked on call and worked had worked all 3 shifts. LVN B/ Medication nurse-worked 7:00 a.m. to 3:00 p.m. RN D/ Medication nurse- worked 3:00 p.m. to 11:00 p.m. ADON/RN - worked 7:00 a.m. to 5:00 p.m.- also worked on call and worked all 3 shifts. LVN I/MDS nurse - worked 7:00 a.m. to 3:00 p.m. LVN J- worked 3:00 p.m. to 11:00 p.m. LVN K/Medication nurse- worked 7a to 3:00 p.m. Record review of in services and staff interviews indicated they were knowledgeable regarding checking documentation to ensure residents did not have allergies to medications prior to administration. The staff indicated they were to check the physician orders, and MAR when receiving the order from the physician for any allergies to medications. They were to check the physician order and MAR prior to administration of medications. They said if the initial dose of medications needed to be given from the ER kit two nurses were to sign and verify there were no allergies. The staff said they would ensue the residents were monitored for adverse side effects to the medications, and the monitoring would be noted in the nurses' notes, on the 24 hour report, and on the MAR. They were able to provide information and refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. Record reviews were completed on two charts to ensure nursing notes contained documentation about adverse reactions to medications. The MARs of those residents were reviewed to ensue documentation about adverse reactions to mediations. The 24-hour report was also reviewed to ensue documentation was noted about adverse reactions to medications. The residents' allergies were also checked to ensure residents were not receiving medications listed that they were allergic to. There were no issues identified. During an interview and observation on 03/9/23 at 11:08 a.m. the DON said she was also in serviced. She was educated on the importance of checking documentation. She said right now she was checking charts to make sure nurses had documented in the nursing notes, MAR and on the 24-hour report. Observation verified the DON checking her records of antibiotics against the 24-hour report and nursing notes. The Administrator, DON, Corporate Nurse, MDS coordinator, and ADON, were informed the Immediate Jeopardy was removed on 03/09/23 at 12:56 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to implement their written policy and procedures for reporting allegations involving abuse, and neglect in accordance with the state laws for 1 of 4 resident reviewed for neglect (Resident #1.) The facility failed to report an incident of neglect to provide adequate a care and services to prevent hospitalization . The facility staff gave Resident #1 Bactrim( antibiotic used to treat or prevent infections) when it was documented he was allergic to Bactrim. This failure could place resident at risk for neglect in care and services. Findings included: Record review of Resident #1's face sheet indicated he a [AGE] year-old male admitted to the facility on [DATE]. The face sheet indicated he had allergies to Bactrim, Nexium, and Sulfate. Record review of Resident #1's computerized physician orders for 02/01/23 -02/28/23 indicated he had allergies to of Bactrim, Sulfa, and Nexium. His diagnoses were diabetes, anxiety, and chronic obstructive pulmonary disease. Record review of a medication error report dated 02/21/23 at 8:30 a.m. indicated Resident #1 had a urinalysis with culture and sensitivity ordered on 02/14/23. The culture and sensitivity were received on 02/20/23. An order was given on the second shift from the NP to LVN C for Bactrim DS-1 tablet two times a day for seven days. LVN C wrote the order and RN D gave the initial dose. When the order was taken LVN C failed to verify allergies. Resident #1 was allergic to Bactrim. RN D was passing medications and gave the initial dose of Bactrim at 10:00 p.m. Bactrim was listed on the MAR as an allergy. On 02/21/23 23 at 10:18 a.m. the NP was contacted. When taking any orders for medication the nurse will check with another nurse to verify that the resident does not have an allergy to that medication. An in service was put out for nurses. signed by LVN C, RN D, and also the DON on 02/21/23. Record review of Resident #1's hospital records dated 3/7/23 indicated this [AGE] year-old male was admitted for acute chronic hypoxic (absence of enough oxygen) respiratory failures secondary to diffuse alveolar hemorrhage (life threating condition caused by a variety of disorders associated with hemoptysis (coughing up blood), anemia, diffuse lung infiltration, and acute respiratory failure. The patient was coughing up blood which had slowed and believed the underlying cause of his diffused alveolar hemorrhage is pneumonia in the setting of thrombocytopenia (low platelets in the blood can be cause by medication side effects). He underwent treatment with Octogam (used to treat chronic immune thrombocytopenia) 3 days of steroids. Platelets have recovered and he is currently on romiplostim (bone marrow stimulant and can be used to treat thrombocytopenia. The main concern now is going to be respiratory failure and his hemoglobin was stable believed he is currently bleeding. Hematology and oncology reported indicated a diagnosis thrombocytopenia, suspected drug induced thrombocytopenia platelets level were found to be 3 on admission. The patient is currently not actively bleeding, had some bruising present notably on his right upper quadrant chest and his left arm. He is not taking any anticoagulants or blood thinners. History significant of severe thrombocytopenia with Bactrim, history significant of patient given Bactrim on 02/20/23. During an interview on 03/07/23 at 9:43 LVN B said he worked as a medication nurse, he administered medications and had worked at the facility for about [AGE] years. He said Resident #1 was sent to the hospital because he had some bruising and bleeding. He said the staff on the evening shift gave Resident #1 Bactrim and he was allergic to the medications. LVN B said Resident #1 was currently in the hospital. During an interview on 03/07/23 at 10:16 a.m. the DON said Resident #1 had been confused and not his normal self. They had completed some labs on 02/14/2023 to determine what was going on. Resident #1 had a UTI and said they received a culture and sensitivity test on 02/20/23. She said the NP prescribed Bactrim DS. The DON said the NP called with the order, LVN C took the order, and did not check for an allergy. She said LVN C put the order on the MAR. The DON said RN D gave the Bactrim did not check the MAR for allergies. She said Resident #1 received one dose at 10 p.m. that night. The order was written for 10 p.m. and 10 a.m. Th DON said she saw Resident #1 before he was sent to the hospital on 02/21/23. The DON said she saw a raised bruises on his arm and a blood blister inside his mouth on the top lip, and the eye had a red scab in the corner. She said the blood blister in his mouth busted on the way to the hospital. The DON said Resident #1 was diagnoses at the hospital with Thrombocytopenia (a platelet deficiency.) The DON said the medication administration procedure was the nurse giving the medication was supposed to check for allergies. She said on 02/20/23 the Bactrim was taken from the ER box and the first dose was given. The DON said the Pharmacy called on the morning just about the time they discovered the resident was allergic to Bactrim to report Resident #1 had an allergy to the medication. The DON said she called the NP and they spoke about what happened. She said the NP said when he talked to the nurse, he was not looking at Resident #1's profile, the nurse did not mention the allergy. The DON said she checked to make sure Resident #1 did not get a second dose of the medications. She did a medication error report and an in service on making sure nurses checked for allergies prior to administering medications. The DON said they did not call the incident into the State because they did not know what was going on at the time. She said she counseled the two nurses involved, it was a medication error and could have led to resident hospitalization , but they did not call it. She said she did not think it was required. During an interview on 03/07/23 at 10:52 a.m. LVN E said she worked at the facility for a year. She said she was not the nurse that took the order for Resident #1. LVN E said when she came in on 02/21/23 she went to assess Resident #1. She said his blood sugar was fine but noticed a large bruise on his left arm. She said the bruise was raised and unusual looking. When she asked Resident #1 if he had fallen, he said no. LVN E said Resident #1 had what looked like a tear in corner of his eye that was blood. She said he was breathing a little fast. LVN E said Resident #1 said something going on in his mouth and it looked like a blood blister in his mouth. She said she got the DON to observe Resident #1. LVN E said his arm was huge and swollen. She said they were going to get Xray, his Oxygen stats was 76. She went back to desk, getting ready to send him out and was going to write the order. She said she saw the order right before hers was for Bactrim. LVN E said she knew Resident #1 was allergic to Bactrim. LVN E said she looked on his computer order and the front of the chart at the bright red sticker, and they said allergy to Bactrim. She said she asked someone to ask him what happened when he took Bactrim. LVN E said Resident #1 said his platelets depleted. She said at that time the ambulance was already in route. LVN E said right about that time the pharmacy called and said Resident #1 had an allergy to Bactrim. She said they were aware of how he was doing because the MDS coordinator was able to get updates daily. His platelets were better, but his oxygen was still low. During an interview on 03/07/23 at 5:15 p.m. the Administrator said they did not report the incident regarding Resident #1. He said when it first happened, they were not sure why he went to the hospital and then said he did not have a good reason for not reporting. They should have reported it. During an observation and interview on 3/9/23 at 8:00 a.m. of Resident #1 in the hospital showed he was sitting up in bed. He was on oxygen and seemed to have some difficulty breathing and talking. He said to come to the right side of the bed because he was hard of hearing. He said he could hear nothing out of his left ear and the right side appeared to be getting worse. He said he trusted the people at the facility to make sure he was taken care of and treated right. Resident #1 said some of the staff knew he was allergic to Bactrim because he had told them what it did to him in the past. He said the nurse came in that night and said she was going to give him some medication for the kidney infection. He did not hear her say Bactrim. His daughter was in the room and said she might have heard the nurse say Bactrim, but it did not register with her at the time. Observation showed he had a pan in the bed with him, he said it was there in case he coughed up blood. Resident said he was still coughing up blood, but it was not bright red like it was. He also said they had not talked to him about discharge at this time. During an interview on 03/09/23 at 9:07 a.m. the Regional Nurse said the DON and Administrator were in serviced on reporting incidents to the state. Record review of the facility policy on Abuse and Neglect last revised May 2017, indicated employees are to immediately report to their supervisor any suspicion of alleged incidents of abuse or neglect to the facility administrator. If the employee knows that Administrator or designee did not report as requires the employee is responsible to report the incident to the appropriate agency. If events that caused the reasonable suspicion resulted in serious bodily injury to a resident the Administrator, DON or designee shall report the suspicion immediately, but not later than 2 hours after forming the suspicion.

Based on observation, interview, and record review, the facility failed to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel. There were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed from [DATE] through [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) On [DATE] at 8:30 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could result in failure to treat cardiac arrest, delayed care during cardiac arrest, or death for residents who wished to be resuscitated in the event of cardiac arrest. Findings included: Record review of a daily census report dated [DATE], provided by the Administrator, indicated there were 42 residents who wished to be resuscitated in the event of cardiac arrest. During an interview on [DATE] at 2:50 p.m., RN C said she had been the Staff Development Nurse for approximately one month. RN C said she taught CNA classes, worked on incident reports, and provided training for the nurses on the Automated External Defibrillator (AED). RN C said nurses were not required to be CPR certified when hired, and when the facility hired a nurse that did not have a CPR certification, the facility tried to get them certified within a month. RN C said she did not know who was responsible for checking CPR certifications. During an interview on [DATE] at 3:23 p.m., the DON said it was the responsibility of the Staff Development Nurse (RN C) to check CPR certifications, but RN C was new in that position and had not had time to get it done. The DON said nurses were not required to have a CPR certification when they were hired. The surveyor asked the DON if the facility had a responsibility to ensure that at least one staff was certified to perform CPR on each shift. The DON said CPR was covered under the nurse's scope of practice, and the facility did not have a policy that required staff to be certified to perform CPR on each shift. During an interview on [DATE] at 3:50 p.m., the Administrator said he had been an Administrator for [AGE] years and had never heard that the facility was required to have staff certified to perform CPR on each shift. The Administrator said the facility knew who CPR was certified but did not say how the facility knew which staff had current certifications to perform CPR. During an interview on [DATE] at 5:07 PM, the DON said the facility was contacting staff in an attempt to get documentation of staff CPR certifications. The DON said the facility did not have copies of staff CPR certifications, and that the night shift staff were not answering their phones. The DON said someone from the facility would have to go to each staff members home to request the certifications. A review of staffing schedules indicated there were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed for the month of [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) Review of records provided by the Administrator on [DATE] included all CPR certifications the facility could provide, and staff sign in sheets from [DATE] thru [DATE]. The records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). Record review of a facility audit of licensed nursing staff CPR certifications, dated [DATE], indicated 13 of 27 licensed nurses did not have current training in performing CPR. Staffing records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). During an interview on [DATE] at 9:00 a.m., the Administrator said the facility audit of CPR certifications was completed on [DATE] and included all licensed staff. The Administrator indicated 13 licensed staff did not have current CPR certifications. Record review of an e-mail from RN F, dated [DATE] at 9:38 p.m., indicated the regional nurse consultant had conducted an in service with the Administrator and DON. The email indicated the in-service was related to requirements for long term care in regard to CPR certification. The in-service indicated the facility must have current CPR certification on nursing staff and ensure availability of certified staff every shift. Systems were discussed for future oversight and maintenance to ensure deficient practice does not reoccur. The in-service was signed by the Administrator and DON. During an interview on [DATE] at 8:50 a.m., RN F said the facility had reviewed the regulations and that she had provided an in-service to the Administrator and the DON regarding the requirement to have someone in the facility who was CPR certified on each shift, and that an online refresher alone was not adequate. RN F said, I can't apologize enough that this has happened. RN F said there would be a CPR class in the facility at 10:00 a.m. During an interview on [DATE] at 9:00 a.m., the Administrator said LVN L worked on the 11p to 7a shift. The Administrator said LVN L told the facility her CPR certification was valid, but the facility did not receive a copy of it when she was hired. The administrator said, we should have. He said when the facility requested a copy of her certification on [DATE] LVN L told them it had expired. The administrator said the HR staff should have obtained a copy of LVN L's CPR certification when she was hired, and that the person who does that now knows to make sure that is done when nurses are hired. The administrator said the facility had been trying to arrange for someone to teach a CPR class, but it hasn't happened yet. The administrator said, It should have already been done. During an interview [DATE] at 9:58 a.m., RN F said at one time there was a system in place to ensure CPR certifications were tracked. She said the facility had experienced turnover in management and that tracking CPR certifications had falling through the cracks, and that has led to this system failure. RN F said usually the HR staff would check CPR certifications when nurses were hired, but in this facility, they intended to assign that task to the RN C, but they didn't, and the system failed. During an interview on [DATE] at 11:02 a.m., LVN H said she worked 8a-5p shift and had worked at the facility for about 3 weeks. She said her CPR certification was current, but the facility never asked to see it when she was hired. During an interview on [DATE] at 11:15 a.m., LVN I said she worked the 3p-11p shift. LVN I said her CPR certification had expired, but she was not sure when. She said the last class she had taken was in 2020. LVN I said when her CPR certification expired the facility did not prompt her to renew it. During an interview on [DATE] at 11:20 a.m., LVN J said she had worked on the 11p-7a shift for about 5 years. She said her CPR certification had expired in [DATE]. LVN J said she did not recall the facility prompting her to renew her CPR certification. During an interview on [DATE] at 11:30 a.m., LVN K said she worked 8a-5p. LVN K said her CPR certification had expired in [DATE]. She said the facility told her once in June or [DATE] to renew her certification, but that was the only time. During an interview on [DATE] at 12:15 p.m., LVN L said she had worked at the facility for about a month on the 11p-7a shift. She said the facility had asked whether she was certified to perform CPR when she was hired and she told them yes. LVN L said the facility did not ask to see documentation of her CPR certification nor ask for a copy of it when she was hired. LVN L said she discovered her CPR certification had expired a couple of days ago when she cleaned out her purse. LVN L said she did not recall the date her certification had expired and that she had thrown the card away. During an interview on [DATE] at 2:49 the administrator said the failure of the facility to ensure there was someone certified to perform CPR on each shift was a system failure related to not understanding who was responsible for keeping records. He said there had been changes in staff and a lack of knowledge on the part of quite a few people who were unnamed. During a telephone interview on [DATE] at 11:00 a.m., the Human Resources manager said she became responsible for ensuring CPR certifications were valid upon hire after the survey ended on [DATE]. The HR manager said that task was previously assigned to the staffing coordinator, who's last day to work at the facility was [DATE]. The HR manager said she did not know who was responsible for the task between [DATE] and [DATE]. During a telephone interview on [DATE] at 1:57 p.m., the DON said the facility did not provide training on how to perform CPR, other than a CPR class. Record review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised [DATE], included a policy statement indicating personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of cardiac arrest. The policy also indicated: The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The CPR team in this facility shall include at least one nurse, one LVN and two CNA's all of whom have received training and certification in CPR Continue with CPR until emergency medical personnel arrive This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:30 p.m. The Administrator was notified on [DATE] at 8:30 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template on [DATE] at 8:30 p.m. The following Plan of Removal was submitted by the facility. The plan of removal was accepted on [DATE] at 3:15 p.m., and included the following: I. RESIDENTS WHO HAVE SUFFERED, OR ARE LIKELY TO SUFFER, A SERIOUS ADVERSE OUTCOME AS A RESULT OF THE NON-COMPLIANCE THE FAILURE TO ENSURE THAT EMPLOYEES HAD THE APPROPRIATE TRAINING AND COMPENTENCAY IN CPR CREATED A FINDING OF IMMEDIATE JEOPARDY. THIS HAD THE POTENTIAL TO IMPACT ALL 42 FULL CODE RESIDENTS WHO DID NOT HAVE AN OOH DNR AND HAD ELECTED TO BE RESUCCIATED IN THE EVENT OF AN CARDIAC ARREST. II. ACTIONS THE FACILITY WILL TAKE ADMINISTRATOR AND DON WERE INSERVICED ON [DATE] AT 9:15 PM BY REGIONAL NURSE ON THE POLICY AND PROCEDURE FACILITIES CPR POLICY AND TRAINING REQUIREMENTS ON THE REGULATION OF F678 WHICH INCLUDES FACILITIES MUST ENSURE THAT PROPERLY TRAINED PERSONNEL (AND CERTIFIED IN CPR FOR HEALTHCARE PROVIDERS) ARE AVAILABLE IMMEDIATELY (24 HOURS PER DAY) TO PROVIDE BASIC LIFE SUPPORT, INCLUDING CARDIOPULMONARY RESUSCITATION (CPR), TO RESIDENTS REQUIRING EMERGENCY CARE PRIOR TO THE ARRIVAL OF EMERGENCY MEDICAL PERSONNEL, AND SUBJECT TO ACCEPTED PROFESSIONAL GUIDELINES, THE RESIDENT'S ADVANCE DIRECTIVES, AND PHYSICIAN ORDERS. INTIATED: [DATE] COMPLETED: [DATE] 10:00 A.M. IN-SERVICES ON THE ON CPR POLICY WERE STARTED ON [DATE] AT 9:20PM BY DON FOR ALL FACILITY STAFF, INCLUDING: DIRECT NURSING STAFF, CHARGE NURSES, DIETARY STAFF, SOCIAL WORKER, MDS NURSES, MAINTENANCE, AND THE RECEPTIONIST.NO EMPLOYEE WILL BE ALLOWED TO WORK UNTIL THEY HAVE BEEN IN-SERVICED ON THE POLICY AND REQUIREMENTS OF ADEQUATELY CPR TRAINED STAFF COVERAGE IN BUILDING AND THE REQUIREMENTS OF CPR TRAINING TO INCLUDE A SKILLS CHECKOFF. ALL IN-SERVICE TRAINING TO BE COMPLETED BY EMPLOYEES NEXT WORKING SHIFT. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR VERIFIED THAT A CERTIFIED CPR TRAINED LVN, PER REGULATORY REQUIREMENTS INCLUDING RETURN DEMONSTRTATION, WILL BE ON SHIFT AT 11:00P.M. ON [DATE] AND WILL STAY ON SHIFT UNTIL 7:00 A.M ON [DATE]. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. AN AUDIT OF ALL EMPLOYEES FOR CPR CERTIFICATION AND TRAINING WAS COMPLETED BY ADMINISTRATOR ON [DATE] FOR CPR COMPLIANCE. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR HAS ARRANGED A BLS CERTIFIED INSTRUCTOR TO APPLY TRAINING AND CERTIFICATION FOR 10 EMPLOYEES ON [DATE] AT 10:00A.M. THIS TRAINING WILL INCLUDE A SKILLS CHECK-OFF. EMPLOYEES INCLUDED IN TRAINING CONSIST OF 1 CHARGE NURSE LVN 11 P.M.- 7:00 A.M SHIFT, 4 CHARGE NURSE LVNS 7:00 A.M. - 3:00 P.M. SHIFT, 1 CHARGE NURSE LVN 3:00 P.M. - 11:00 P.M. SHIFT, 1 R.N - DIRECTOR OF NURSES, 1 RN - ASSISTANT DIRECTOR OF NURSES, 1 RN - WOUND CARE NURSE, AND 1 CHARGE NURSE RN 3:00 P.M. - 11:00 P.M. SHIFT. ALL 11:00 P.M. - 7:00 A.M. ARE NOW CPR CERTIFIED - INITIATED: [DATE] COMPLETED: [DATE] 2:00 P.M. III. SYSTEMS, POLICIES, AND PROCEDURES FACILITIES POLICY AND PROCEDURE TITLED EMERGENCY PROCEDURE- CARDIOPULMONARY RESUCITTATION WAS REVIEWED AND UPDATED BY ADMINISTRATOR AND REGIONAL NURSE ON [DATE] TO ENSURE THAT CURRENT POLICY MEETS THE STANDARDS OF PRACTICE AND REGULATORY REQUIREMENTS ON PROPERLY TRAINED STAFF ARE IN THE BUILDING ,d+[DATE]. INITATED: [DATE] COMPLETED: [DATE] 12:00 P.M. IV. MONITORING, AUDITS, AND QAPI ONGOING SYSTEMATIC CHANGE TO ENSURE CPR TRAINED STAFF ARE ON ALL SHIFTS IS THAT ALL LICENSED PERSONELL WILL NOW BE REQUIRED TO OBTAIN CPR CERTIFICATION. A BINDER WITH ALL CERTIFICATIONS AND CARDS WILL BE KEPT IN THE HUMAN RESOURCE DEPARTMENT AND AUDITED MONTHLY BY HUMARN RESOURCE DIRECTOR TO ENSURE THAT CARDS ARE CURRENT AND NOT EXPIRED. HUMAN RESOURCE DIRECTOR HAS BEEN TRAINED ON HER DUTIES, CPR REQUIREMENTS, AND WHICH CPR CLASSES ARE ACCEPTABLE PER REGULATORY REQUIREMENTS. SHE WILL POST AND NOTIFY SUPERVISORS 60 DAYS BEFORE CPR CERTIFICATION EXPIRES. BINDER WILL BE SEPERATED BY DIVIDERS FOR EACH SHIFT TO ENSURE THAT EACH SHIFT HAS PROPERLY TRAINED PERSONELL. THE ADMINISTRATOR AND OR REGIONAL NURSE WILL MONITOR FOR COMPLIANCE MONTHLY. INITIATED: [DATE] COMPLETED [DATE] 2:30 P.M. THE QAPI TEAM, LED BY THE ADMINISTRATOR, WILL MEET WEEKLY FOR 3 WEEKS TO DISCUSS COORDINATION OF COMPLETION OF ALL IN-SERVICES, ASSESSMENTS, AND INTERVENTIONS ARE UTILIZED AND COMPLETED TO ENSURE THAT APPROPRIATE CPR TRAINED STAFF ARE ON DUTY FOR EACH SHIFT. THE MEDICAL DIRECTOR WAS NOTIFIED ON [DATE] OF THE IMMEDIATE JEOPARDY CALLED ON FACILITY. INITIATED: [DATE] COMPLETED: [DATE] 12:00 P.M. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record review of the staffing schedule for [DATE] indicated LVN G had been scheduled to work the 11p-7a shift to ensure staff certified to perform CPR were available. Documentation for LVN G's CPR certification was reviewed. Record review of an email from RN F, dated [DATE] at 9:38 p.m., indicated the administrator and DON had received an in-service on [DATE] regarding the requirement that the facility must provide staff who are certified to perform CPR on each shift, and that an online only certification was not sufficient to meet the requirement. Observation on [DATE] at 10:00 a.m. indicated the facility had provided an instructor lead CPR class which included return demonstration of skills Record review of an invoice, dated [DATE] and given to the facility by a CPR instructor, indicated 10 staff members had attended a CPR class on that date. Review of the CPR class roster indicated the following nurses by position and shift had completed the CPR certification: of 1 LVN charge nurse on the 11p-7a shift, 4 LVN charge nurses on the 7a-3p shift, 1 LVN charge nurse on the 3p to 11p shift, the DON, 1 RN ADON, 1 RN Wound Care Nurse, and 1 RN charge nurse on the 3p-11p shift. An additional LVN charge nurse on the 11p-7a shift completed a CPR certification outside the facility and provided documentation to the facility. During interviews on [DATE] between 10:00 am and 12:15 p.m., 1 RN and 8 LVNs, representing all shifts, indicated they were CPR certified and could correctly identify the rate of compressions, depth of compressions, and ratio of compressions to rescue breaths (ADON, LVN M, LVN G, LVN H, LVN I, LVN J, LVN N, LVN O, LVN L) All nurses interviewed indicated they were aware the facility was required to ensure staff certified to provide CPR were available on each shift. The administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:00 p.m. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to develop and implement the comprehensive person-centered care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 7 residents reviewed for physician orders. (Resident #s 27 and 50) The facility failed to implement a comprehensive person-centered care plan for Resident #27's IV (intravenous) antibiotics via picc (peripherally inserted central catheter) line as ordered by the physician. The facility failed to implement a comprehensive person-centered care plan for Resident #27's oxygen at 2 liters nasal cannula as needed for shortness of breath. The facility failed to implement a comprehensive person-centered care plan for Resident #27's bi pap (bilevel positive airway pressure ventilator) every hour of sleep. The facility failed to implement a comprehensive person-centered care plan for Resident #50's smoking status. These failures could place residents at risk for not receiving appropriate care and services to meet their needs. Findings included: 1. Record review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's nursing progress notes dated 11/23/2021 indicated he readmitted to the facility with a right [MEDICATION(S)] IV line in place for IV antibiotics. Record review of Resident #27's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27' physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27' physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's treatment administration record dated 12/01/2021-12/31/2021 revealed he received a central line dressing change to right [MEDICATION(S)] every Monday and as needed if it was loose or soiled on 12/06/2021. Record review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's nursing progress notes dated 12/06/2021 at 7:20 a.m. indicated his oxygen saturation was 93% on oxygen at 2 liters per nasal cannula. Record review of the MDS dated [DATE] indicated Resident #27 was cognitively intact and was dependent on one staff for activities of daily living. The MDS did not code him for oxygen, [CONDITION(S)], or intravenous medications. Record review of Resident #27's care plans initiated on 07/23/2021 did not document his picc line, IV antibiotics, oxygen or [CONDITION(S)] as ordered by the physician. During an observation and interview on 12/05/2021 at 9:44 AM, Resident #27 was resting in his bed with the head of his bed elevated, awake and alert, and had oxygen at 2 liters per nasal cannula on and a picc line to his right upper chest wall. He said he was receiving IV antibiotics for the gangrene infection of his toes due to poor circulation. He had a [CONDITION(S)] machine on his nightstand and said he used it every night. He said he sometimes used his oxygen. During an observation and interview on 12/05/2021 at 12:21 PM, Resident #27 was sitting up on the side of his bed in his room. He had oxygen on at 2 liters per nasal cannula. His picc line was clamped and the dressing was intact over the right chest wall site. During an interview on 12/05/2021 at 1:10 PM, CNA D said Resident #27 mostly wore oxygen, but the charge nurse was responsible to monitoring and documenting his nursing stuff. During an interview on 12/05/2021 at 1:25 PM, RN E said she was Resident #27's charge nurse and said care such as oxygen and [CONDITION(S)] administration should be documented on the medication and treatment administration records. During an observation on 12/06/2021 at 8:15 AM, Resident #27 was sitting up in his bed with his head of the bed elevated and was short of breath. RN C evaluated him and initiated his transfer to the emergency room for evaluation. Record review of Resident #27's nursing progress notes dated 12/06/2021 at 8:45 a.m. indicated his oxygen saturation was 96% on oxygen at 2 liters per nasal cannula, he was short of breath and he was transferred to the emergency room for evaluation. During an interview on 12/06/2021 at 2:07 PM, MDS nurse A said she was responsible for creating all care plans except antibiotics, which the DON completed. She said Resident #27's specialized services, such as [CONDITION(S)] and IV ports, should have been care planned. During an interview on 12/06/2021 at 2:12 PM, MDS nurse B said she was the other MDS nurse and assisted to complete care plans and said special services, like lines and oxygen, should have been care planned but some might be missing. During an interview on 12/06/2021 at 2:15 PM, the DON said she was responsible to oversee, and audit physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was unaware Resident #27's care plans were not personalized. 2. Record review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #50's most recent smoking assessment dated [DATE] indicated she was a safe smoker and a plan of care was initiated. Record review of the MDS dated [DATE] indicated Resident #50 was cognitively intact and required supervision for activities of daily living. Record review of Resident #50's care plans initiated on 04/01/2010 did not document or identify she was a smoker. During an observation and interview on 12/05/2021 at 10:36 AM, Resident #50 was sitting up in her wheelchair watching tv in her room. She said she smokes and keeps her smoking material on her person and goes out to smoke as she desired. During an interview on 12/06/2021 at 2:07 PM, MDS nurse A said Resident #50 was assessed as a safe smoker on 10/12/2021 and the care plan should have been updated but she did not find it. During an interview on 12/06/2021 at 2:12 PM, MDS nurse B said she was the other MDS nurse and assisted to complete care plans and said Resident #50 had to have a care plan for smoking but did not find it and thinks some might be missing. During an interview on 12/06/2021 at 2:15 PM, the DON she said she did not know why Resident #50 did not have a smoker care plan but should have had one. During an interview on 12/07/2021 at 10:08 AM, the Administrator said he was not aware of issues of Residents #27 and 50's care plans were not personalized appropriately. He said the MDS nurses were responsible for these and the DON should have overseen that the care plans were completed appropriately and timely. He said they were usually very good about this and attended the daily morning meetings to be informed of changes to be care planned but did not know what happened. Record review of an undated care planning policy indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 14 days of the completion of the resident's comprehensive MDS.

Resident #27 Care Plan 12/06/21 03:31 PM baseline care plan dated 10/8/21, comprehensive care plans 12/5/21-none address iv abt and right cw picc line, [CONDITION(S)] m-w-f, oxygen/[CONDITION(S)] use. Resident #50 Accidents 12/06/21 11:29 AM safe smoking assessment 10/9/20 deemed her safe smoker, she said she keeps her cigarettes and lighter on her person at all times Care Plan 12/06/21 11:34 AM no acute care plan addressing smoking 12/07/21 09:29 AM care plan was created on 12/6/21 at 2:30 p.m. after surveyor intervention

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 7 residents (Resident #49) observed for medication pass and in 2 of 4 medication carts (Hall 3 nurse cart and Hall 4 medication cart) reviewed for pharmacy services. LVN A did not administer all of Resident #49's medications during medication pass. The facility did not dispose of expired medications from the Hall 3 nurse medication cart. The facility did not have open dates on inhalers in the Hall 4 medication cart. Findings included: 1. During an observation on 09/15/20 at 08:15 AM, LVN A administered medications to Resident #49. Resident 49's blood pressure and pulse were checked prior to medication administration. The blood pressure was 191/88 and the pulse was 41. LVN A did not administer [MEDICATION NAME] 25 mg. Physician orders [REDACTED].#49 had an order dated 06/24/16 for [MEDICATION NAME] 25mg give 1 tablet daily at 08:00 AM with parameters to hold for blood pressure less than 110/60. There was no parameter to hold for a pulse rate. During an interview and record review on 09/16/20 at 10:15 AM, LVN A said she held Resident #49's [MEDICATION NAME] on 09/15/20 due to her pulse rate of 41. The MAR for September 2020 indicated a parameter to hold for blood pressure less than 110/60. There was no parameter to hold for pulse rate. LVN A said she should have either given the medication or notified the charge nurse of her holding it to clarify with the physician if they wanted it to be given. During an interview and record review on 09/16/20 at 10:22 AM, LVN B said Resident #49's September 2020 physician orders [REDACTED]. She said there was no parameter to hold the medication for a pulse rate. She said she would have held the medication and contacted the physician immediately to determine if they wanted the medication given with the pulse rate being less than 60. During an interview on 09/16/20 11:03 AM, the DON said medications were to be given unless there was a parameter to hold. She said if a nurse was not comfortable with giving a medication due to vital signs, the physician was to be notified to determine if he wanted the medication held. 2. During an observation of the Hall 4 medication cart on 09/16/20 at 11:35 AM, with LVN C the following was noted: * a card of [MEDICATION NAME] 8mg give 1 tab every 8 hours as needed for nausea/vomiting with 7 tabs remaining-expired on 07/20/20; and * a [MEDICATION NAME] nasal spray-expired on 05/08/20. During an observation of the Hall 3 nurse cart on 09/16/20 at 11:55 AM, with LVN C the following was noted: * a [MEDICATION NAME] inhaler with no open date, * an [MEDICATION NAME] 230/21 inhaler with no open date, * a [MEDICATION NAME] inhaler with no open date, and * an [MEDICATION NAME] 250/50 diskus with no open date. During an interview on 09/16/20 at 11:59 AM, LVN C said the [MEDICATION NAME] inhaler was ordered by the physician on 08/10/20 for 10 days. She said the expired medications were to be pulled for destruction, inhalers were to have open dates on them because they were only good for 30 days after opening, and discontinued medications were to be pulled for destruction. During an interview on 09/16/20 11:03 AM, the DON said expired medications were to be pulled for destruction, inhalers were to have open dates on them because most of them were only good for 30 days after opening, and discontinued medications were to be pulled for destruction. An Administering Oral Medications policy revised October 2010 indicated: Steps in the Procedure: 3. Place the MAR indicated [REDACTED]. 7. Check the expiration date on the medication. Pull from the med cart and return any expired medications to the DON. 8. Check the medication dose. Re-check to confirm the proper dose Reporting: 2. Report other information in accordance with facility policy and professional standards of practice An Administering Oral Medications policy revised October 2010 indicated: Steps in the Procedure: 3. Place the MAR indicated [REDACTED]. 7. Check the expiration date on the inhaler. A Discontinued Medications policy revised April 2007 indicated: Policy Statement: Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy According to the FDA [MEDICATION NAME] information revised April 2008 accessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/ 7s029lbl.pdf .The device should be discarded 1 month after removal from the moisture-protective foil overwrap pouch According to the FDA [MEDICATION NAME] information revised September 2014 accessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/ 6s000lbl.pdf Throw away the [MEDICATION NAME] RESPIMAT inhaler 3 months after insertion of cartridge into inhaler, even if all the medicine has not been used, or when the inhaler is locked, whichever comes first According to the manufacturer [MEDICATION NAME] information revised 08/10/20 accessed at https://ca.gsk.com/media/ 6/[MEDICATION NAME].pdf The inhaler should be discarded 42 days after opening

Based on observation, interview and record review to the facility failed to determine an account of all controlled drugs was maintained and periodically reconciled for 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility did not ensure all narcotics were accounted for. LVN A and LVN B did not notify the DON when there was a discrepancy with the narcotic count and LVN A left the facility without resolving the discrepancy. This failure could place residents at risk of not receiving narcotic medications and a drug diversion in the facility. Findings included: A face sheet dated 07/30/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was ordered [MEDICATION NAME] 0.5 milligram (mg) (treats anxiety) 1 tablet by mouth three times a day. An MDS dated [DATE] indicated the resident had a [DIAGNOSES REDACTED]. A care plan dated 07/03/19 indicated the resident received antianxiety medication related to anxiety disorder. Intervention was to administer and monitor for drug use effectiveness. A pharmacy manifest delivery sheet dated 07/16/19 indicated LVN A received and signed for 12 tablets [MEDICATION NAME] 0.5 milligram (mg) and 30 tablets [MEDICATION NAME] 0.5 milligram (mg) for Resident #1. A narcotic count sheet dated 07/16/19 indicated Resident #1 had 12 tablets [MEDICATION NAME] 0.5 milligram (mg) signed by LVN A as the receiving nurse. A narcotic count sheet dated 07/16/19 indicated Resident #1 had 30 tablets [MEDICATION NAME] 0.5 milligram (mg) signed by LVN A as the receiving nurse. A written witness statement dated 07/15/19 by LVN A stated, I received meds one card for Resident #1 said 30 count, and one was 12 count . When the count came out I felt I had put the card of 12 in the narc box. I went through the carts and looked everywhere . I did receive this and I am very concerned that I do not find them now. During an interview on 07/30/19 at 1:12 p.m., the DON said on 07/16/19 LVN A worked the 3 p.m. to 11 p.m. shift and during her shift signed the pharmacy delivery sheet indicating she received a 12-tablet card of [MEDICATION NAME] 0.5 milligram (mg) and a 30-tablet card [MEDICATION NAME] 0.5 milligram (mg) for Resident #1. The DON said on 07/16/19 LVN A and LVN B could not find Resident #1's 12 tablet card of [MEDICATION NAME] 0.5 milligram (mg) during shift change narcotic count. The DON said on 07/16/19 LVN A and LVN B did not notify her or a nurse manager about Resident #'1's missing [MEDICATION NAME]. The DON said LVN A told LVN B she would look in the medication room for Resident #1's 12 tablet card of [MEDICATION NAME] 0.5 milligram (mg) instead LVN A left the facility without notifying LVN B or finding the missing narcotic. The DON said the facility is responsible to account for all narcotics to prevent a drug diversion. The DON said staff members are to immediately notify her or a nurse manager when a narcotic cannot be found. The DON said staff are not to leave the facility until the narcotic is found or it is determined by a nurse manager the narcotic cannot be found. The DON said LVN A was terminated and LVN B had a disciplinary write up. An attempt was made to contact LVN A on 07/30/19 at 2:20 p.m., but it was unsuccessful. During an interview on 07/30/19 at 2:39 p.m., LVN B said she worked the 11 p.m. to 6:00 a.m. shift on 07/16/19 and did a narcotic count with LVN A. LVN B said during the narcotic count with LVN A Resident #1's 12 tablet card of [MEDICATION NAME] 0.5 milligram (mg) was missing. LVN B said LVN A told her she would look for Resident #1's missing narcotic in the medication room. LVN B said she stayed at the medication cart for LVN A to return but never did. LVN B said LVN A left the facility. LVN B said she did not notify the DON immediately about Resident #1's missing narcotic. LVN B said the DON was notified at the end of her shift. A facility medication storage policy for narcotics and controlled substances undated indicated, Any discrepancies which cannot be resolved must be reported immediately as follows: Notify the DON .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.

Based on observation, interview and record review, the facility failed to assess and provide treatment in accordance with professional standards of practice and based on the comprehensive assessment for 1 of 30 residents reviewed for assessments. (Resident #31) The facility did not assess and treat Resident #31's right elbow wound from 5/10/19 thru 5/20/19 and he [MEDICAL CONDITION]. This could place resident receiving skin treatments at risk for not receiving needed care and services in accordance with individually assessed needs. Findings included: A face sheet dated 01/03/18 indicated Resident #31 was an [AGE] year-old male with [DIAGNOSES REDACTED]. During an observation on 5/21/19 at 3:30 p.m., Resident #31 was alert and confused. He said his right arm hurts, he was noted to be wearing a sling that he would move on and off his arm. An observation on 5/22/19 at 4:36 p.m., Resident #31 was sitting on his bed, the right arm sling was partially on his arm. He said he had no pain in the arm and he raised the right arm up above his head and moved it all around. Resident #31 pulled up the dressing on his right elbow and it was noted to have a small reddened area around the skin tear with light serous drainage. An acute care plan dated 5/20/19 indicated Resident #31 had a skin tear to his right elbow, due to a fall. Interventions included clean with normal saline, apply [MEDICATION NAME] and cover with a dry dressing daily. Assess wound daily. An MDS dated [DATE] indicated Resident #31 was severely cognitively impaired and required assist of one staff for toileting. He had two or more falls with skin tears or abrasions. A 24-hour nurse report for halls 3 and 4 dated 5/10/19 indicated Resident #31 said he fell in the bathroom. He had a skin tear to his right elbow, it was cleaned with normal saline and gauze was placed over the wound. The report indicated to have the skin nurse assess. An incident/accident report dated 5/10/19 indicated LVN F was called to Resident #31's room and blood was noted on his sleeve. Resident #31 was assessed, and a skin tear was noted to the right elbow. LVN F cleaned the site and dressed it with gauze. Resident #31 was sitting on the side of his bed, said he fell in the bathroom. He denied pain at that time. He was able to get around in his wheelchair independently. The clinical record dated 5/10/19 to 5/20/19 for Resident #31 did not have any documentation indicating the physician was notified or physician orders for treatment the skin tear to his right elbow. A nursing note dated 5/20/19 at 8:30 a.m., indicated RN G assessed Resident #31's right arm pain. Further documentation indicated he found a foul smelling wound to his right elbow with purulent drainage, wrapped with gauze and coban. A skin condition report dated 5/20/19 indicated Resident #31 had a 4cm x 3cm skin tear to the right elbow with 50% granulation and 50% slough. The skin tear had purulent drainage with an odor. Pain was noted, and the wound was red and warm. A physician order dated 5/20/19 indicated Resident #31 was to have an x-ray of the right elbow, wound culture and antibiotics with daily wound care. The culture results were not available on 05/22/19. A wound culture, faxed to the surveyor, result dated 5/24/19 indicated light [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). He was given [MEDICATION NAME] (antibiotic for skin infections) 600 mg every 12 hours for 10 days. A physician order dated 5/24/19 indicated he was to receive [MEDICATION NAME] (antibiotic for skin infections) 600 mg every 12 hours for 10 days. A physician order dated 5/20/19 at 06:54 p.m., indicated Resident #31 was to be sent to the ER for evaluation and treatment of [REDACTED]. A hospital after visit summary dated 5/20/19 for Resident #31 indicated a [DIAGNOSES REDACTED]. An arm sling was applied to right arm after 2 view x-ray of the right elbow. Instructions were to follow up with primary physician if symptoms worsen or return to the ER. Consult orthopedics, call in 3 days. Resident #31's blood pressure 142/78, pulse 74, and temperature 97.8 degrees. A radiology report dated 5/20/19 at 12:40 p.m., indicated Resident #31 had a minimally displaced olecranon enthesophyte fracture, which was compared to a previous right elbow x-ray on 2/27/19, the fracture was found to be new. A treatment flowsheet dated 5/1/19-5/31/19 indicated Resident #31 had an order for [REDACTED]. A written statement dated 5/21/19 indicated RN L was the charge nurse for Resident #31 on 5/19/19. The statement indicated the resident did not show any signs of pain and moved around normally. A written statement dated 5/20/19, indicated LVN F received report from the 7-3 p.m. nurse that Resident #31 had an x-ray of the right elbow with results of a fracture. She called the NP and received an order to send him to the ER for evaluation and treatment. Resident #31 denied pain or discomfort. A written statement dated 5/21/19, indicated Resident #31 had not complained of pain within the last 48 hours by LVN M. A written statement dated 5/21/19, indicated Resident #31 had not complained of pain in the last 48 hours by CNA C. The provider report dated 5/20/19 indicated Resident #31 was found sitting on his bed on 5/10/19; he stated he had fallen in the bathroom which resulted in a skin tear to the right elbow. No complaints of pain were noted at any time since that incident. During an interview on 05/22/19 at 2:40 p.m., LVN J said she only does wound care on Saturdays and there was no order for wound care for Resident #31. During an interview on 05/22/19 at 2:43 p.m., RN H said she only does wound care on Sundays and there was no order for wound care for Resident #31. During an interview on 05/22/19 at 4:25 p.m., the administrator said there is nothing documented in Resident #31's chart about his wound, fall or any new physician orders for wound care. He said he spoke with the nurse who cared for Resident #31 and she did not write an order for [REDACTED].>During an interview on 05/22/19 at 4:32 p.m., LVN F said she put the coban on Resident #31's right elbow, she said she did not write an order for [REDACTED]. During an interview on 05/22/19 at 4:40 p.m., the DON said no order was written for the treatment for [REDACTED]. She said the person responsible for wound care when the wound care nurse is on leave is RN H. During an interview on 05/22/19 at 4:45 p.m., LVN K said on Monday's she comes in and goes over the incident reports and they are discussed in the morning meetings. She said if there is a wound she is to check to see if an order has been written, she said she is not the only one that looks at orders.