Every finding on record at Paramount Convalescent Hosp.

Based on observation, interview and record review, the facility failed to implement proper infection control practices for all residents in the facility by failing to:1. To ensure Resident 27 was on Enhanced Barrier Precautions (EBP-infection control measure to prevent the spread of germs), for a chronic pressure injury (PI- injury to skin and underlying tissue resulting from prolonged pressure on the skin).2. To ensure hand hygiene was performed prior to checking the residents' lunch meal trays.These failures had the potential to spread germs through cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) to residents, staff and visitors.Findings:1. During an observation on 12/04/2025 at 9:10 a.m. in Resident 27's room. There was no sign or personal protective equipment (PPE) alerting staff Resident 27 should be on EBP. The treatment nurse (TXN) was observed doing a wound care dressing change and was observed not wearing any personal protective equipment.During a review of Resident 27's admission Record (face sheet) dated 12/4/2025, the admission record indicated Resident 27 was admitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sick sinus syndrome (abnormal heart rhythms) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 27's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 27 had fluctuating capacity to understand and make decisions.During a review of Resident 27's Minimum Data Set (MDS)- a standardized assessment and care screening tool), the MDS indicated Resident 27 cognition was intact. The MDS also indicated Resident 27 needed substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 27's Physician Order dated 9/18/2025, the physician order indicated Resident 27 had a sacrococcyx (triangle bone at the bottom of your spine) PI, to clean with normal saline (NS) pat dry apply collagen powder (promotes wound bed healing) and calcium alginate (absorbent wound dressing used for heavy drainage) cover with super absorbent dressing every day, for pressure injury.During an interview on 12/04/2025 at 4:19 p.m. with the TXN, the TXN stated Resident 27 does have a chronic wound on her sacrococcyx and should have been on EBP. The TXN stated there was a risk of transferring bacteria from her clothing to Resident 27's open wound.2. During an observation on 12/02/2025 at 12:09 p.m. in the hallway near the dining room. The IP nurse was observed not washing her hands prior to checking the resident's meal trays.During an interview on 12/04/2025 at 4:24 p.m. with the IP nurse. The IP nurse stated Resident 27 should have been on EBP because Resident 27 had a chronic wound on her sacrococcyx. The IP stated there was a possibility for the staff to spread infection through cross contamination. The IP also stated she should have washed her hands prior to checking the resident's meal trays to ensure there would be no cross contamination from her hands to the resident's meal tray.During an interview on 12/05/2025 at 10:54 a.m. with the Director of Nurses (DON), the DON stated Resident 27 does have a chronic wound on her sacrococcyx and should have been on EBP, to help prevent the spread of infection through cross contamination. The DON stated the IP should have done hand hygiene prior to checking the meal trays to ensure the food the residents are being served is clean.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 12/19/2022 the P&P indicated, it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves during high contact resident care activities. EBP are indicated for residents with wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and even if the resident is not known to be infected or colonized with a MDRO. The P&P indicated to:a. Make gowns and gloves available prior to performing tasks. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.During a review of the facility's policy and procedure titled, Hand Hygiene dated 12/19/2022 the P&P indicated, all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR).1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, between resident contacts and before performing.

Based on interview and record review the facility failed to ensure a safe discharge and transfer for four of four residents (Resident 3, Resident 27, Resident 29 and Resident 51) by failing to:1. Ensure the Long Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified when Resident 3, Resident's 27 and Resident 29 were transferred to the General Acute Care Hospital (GACH).2. Ensure Resident 3, Resident 27 and Resident 51 were offered a bed hold before being transferred to the GACH.These failures violated Resident 3, Resident 27, Resident 29 and Resident 51's rights and had the potential to affect Resident 3, Resident 27 and Resident 51's emotional wellbeing if they could not return to the facility.Findings: A. During a review of Resident's 3 admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 6/12/2025, and was readmitted on [DATE] with diagnoses including encephalopathy (disorder affecting brain function or structure), chronic kidney disease (long-lasting condition where the kidneys slowly stop working), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic pulmonary edema (long-term condition where extra fluid builds up in the lungs). During a review of Resident 3's History and Physical (H&P) dated 11/13/2025, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a concurrent interview and record review on 12/03/2025 at 1:43 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 reviewed Resident 3's medical record and stated Resident 3 was transferred to a hospital on [DATE] due to a low hemoglobin (a protein inside red blood cells that carries oxygen) low blood test of 5.6 grams (gm, unit of measurement) per deciliter (dL, unit of measurement). LVN 3 stated she was unable to locate a bed hold form in the medical record. LVN 3 stated the responsibility for ensuring a bed hold form was completed was the nurse discharging the resident. LVN 3 stated a bed hold was a resident right and the resident or responsible party (RP) may have uncertainty regarding their ability to return to their room and maintain continuity of care. During a concurrent interview and record review on 12/4/2025 at 8:30 a.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 3's medical record and stated there was no bed hold form completed for Resident 3. RN 3 stated the discharge nurse was responsible for completing the required bed hold form on 11/25/2025 at the time of Resident 3's transfer. RN 3 stated providing a written bed-hold notice was important to inform Resident 3 and the RP of their rights and expectations regarding Resident 3's ability to return to their bed following hospitalization. During a record review of the facility's policy and procedure (P&P) titled, Bed Hold Prior to Transfer, dated 3/10/2025, indicated .The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalization. B. During a review of Resident's 3 admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 6/12/2025 and was readmitted on [DATE] with diagnoses including encephalopathy (disorder affecting brain function or structure), chronic kidney disease (long-lasting condition where the kidneys slowly stop working), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic pulmonary edema (long-term condition where extra fluid builds up in the lungs). During a review of Resident 3's History and Physical (H&P) dated 11/13/2025, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a concurrent interview and record review on 12/03/2025 at 1:43 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 reviewed Resident 3's medical chart and stated Resident 3 was transferred to the hospital on [DATE] due to a low hemoglobin (Hgb- a protein inside red blood cells that carries oxygen). LVN 3 stated there was no documentation the Ombudsman was notified of Resident 3's transfer. LVN 3 stated the Social Services Director (SSD) was responsible for notifying the Ombudsman when residents are transferred to hospitals or other facilities. LVN 3 stated notifying the Ombudsman was a required resident-right protection. During a concurrent interview and record review on 12/4/2025 at 8:09 a.m. with the SSD regarding LTC Ombudsman notification, the SSD stated she overlooked notifying the Ombudsman when Resident 3 was discharged from the facility on 11/25/2025. The SSD stated her role included sending discharge notifications to the Ombudsman and stated the Ombudsman's role was to provide advocacy for residents as part of required resident rights. During a concurrent interview and record review on 12/4/2025 at 4:17 p.m. with the Director of Nursing (DON), the DON reviewed Resident 3's discharge on [DATE] in the medical record. The DON stated Resident 3 was transferred due to the hospital due to a low Hgb level. The DON stated the Ombudsman was not notified at the time of Resident 3's transfer and that notifying the Ombudsman was necessary to inform them of the resident's location and to allow the Ombudsman to follow up with the resident, as they serve as advocates for residents. During a record review of the facility's policy and procedure (P&P) titled, Transfer and Discharge (including AMA), dated 12/19/2022, indicated .Exceptions to the 30-day requirement apply when the transfer or discharge is effected because.An immediate transfer or discharge is required by the resident's urgent medical needs;.In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, the LTC ombudsman as soon as practicable before transfer or discharge. C. During a review of Resident 27's admission Record (face sheet) dated 12/4/2025, the admission record indicated Resident 27 was admitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sick sinus syndrome (abnormal heart rhythms) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 27's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 27 had fluctuating capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS- a standardized assessment and care screening tool), the MDS indicated Resident 27's cognition was intact. The MDS also indicated Resident 27 needed substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of the facility's Census List dated 12/5/2025, the census list indicated Resident 27 was transferred to GACH on 9/13/2025 and readmitted back to the facility on 9/15/2025. D. During a review of Resident 29's admission Record dated 12/4/2025, the admission record indicated Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic obstruction pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 29's H&P dated 9/9/2025, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's MDS, the MDS indicated Resident 29's cognition was intact. The MDS also indicated Resident 29 needed substantial/maximal assistance with ADLs such as toileting, showering and putting on and dressing. During a review of the facility's Census List dated 12/5/2025, the census list indicated Resident 29 was transferred to GACH on, 1. 9/30/2025 and readmitted back to the facility on [DATE] 2. 10/06/2025 and readmitted back to the facility on [DATE]. 3. 10/27/2025 and readmitted back to the facility on [DATE]. E. During a review of Resident 51's admission Record dated 12/4/2025, the admission record indicated Resident 51 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) and hyperlipidemia (having too many fats in the blood). During a review of Resident 51's H&P dated 12/2024, the H&P indicated Resident 29 does not have the capacity to understand and make decisions. During a review of Resident 51's MDS, the MDS indicated Resident 51's cognition was severely impaired. The MDS also indicated Resident 51 was totally dependent (helper does all the work) with ADLs such as toileting, showering and dressing. During a review of the facility's Census List dated 12/5/2025, the census list indicated Resident 51 was transferred to GACH on 6/23/2025 and readmitted back to the facility on 6/26/2025. During a concurrent interview and record review on 12/4/2025 at 7:11 a.m. with the Social Services Director (SSD), Resident 27 and Resident 29's GACH transfers were reviewed. The SSD stated she was responsible for letting the Ombudsman know when a resident was transferred to the GACH. The SSD stated Resident 27 was transferred to the hospital on 9/13/2025, and Resident 29 was transferred to the GACH on 10/06/2025 and 10/17/2025. The SSD stated the Ombudsman was not notified of Resident 27 or Resident 29's transfers to the GACH. The SSD stated she should have notified the Ombudsman because the Ombudsman is the residents advocate and can ensure the residents transfer to the GACH was appropriate. During a concurrent interview and record review on 12/4/2025 at 11:16 a.m. with Registered Nurse 3 (RN3), RN3 stated bed holds are done when residents are transferred to the GACH. RN 3 stated Resident 29 was transferred to GACH on 10/6/2025 and 10/17/2025, Resident 51 was transferred to the GACH on 6/23/2025 and no bed hold notice was offered to either Resident 29 or Resident 51. RN 3 stated bed holds are done to inform residents that they have a safe place to return to the facility. RN 3 stated that the residents should not worry about not having a place to come back to and should be focused on getting better. During an interview on 12/05/2025 at 10:54 a.m. with the Director of Nurses (DON), the DON stated she was aware that when Resident 27 and Resident 29 were transferred to GACH, the Ombudsman was not notified. The DON stated the Ombudsman is the advocate for the residents and should have been notified to ensure the transfers were appropriate and safe. The DON stated she was also aware that Resident 29 and Resident 51 were not offered a bed hold notice when transferred to the GACH and that they should have been offered one. The DON stated it could affect the residents' emotional well-being when not knowing if they will have a place to return to. During a review of the facility's Policy and Procedure (P&P) titled, Bed Hold Prior To Transfer dated 03/10/2025, the P&P indicated it is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. During a review of the facility's P&P titled, Transfer and discharge dated 12/19/2022, the P&P indicated, this facility will permit each resident to remain in the facility and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. The P&P indicated that in these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge. The P&P indicated the facility will maintain evidence that the notice was sent to the Ombudsman.

Based on interviews and record review, the facility failed to:1.Complete a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for three of four sampled residents (Resident 2, Resident 7, and Resident 13). 2.Review Resident 2's general acute care hospital (GACH) notes during the admission Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) meeting. These failures resulted in the lack of necessary care and treatment related to antibiotic use for Resident 2, Resident 7, and Resident 13. Findings:1.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease (your kidneys are damaged and slowly lose their ability to clean waste from your blood), urinary tract infections (UTI- an infection of the bladder/urinary tract), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of metronidazole (antibiotic used to treat a variety of infections caused by bacteria) 500 milligrams (mg- unit of measurement), via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours for Helicobacter pylori (H. Pylori- stomach infection) prophylaxis (preventative care to stop disease before it starts) with a stop date to follow.During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of tetracycline (antibiotic-medication to treat infection) 250 mg via gastrostomy tube every 12 hours for H. Pylori prophylaxis with a stop date to follow. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally), hypertension (HTN- high blood pressure), and traumatic brain injury (TBI- serious medical issue that affects how your brain works).During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognition was severely impaired and Resident 7's was dependent (helper does all the effort) with ADLs. During a review of Resident 7's Order Details dated 11/15/2025, the Order Details indicated an order for azithromycin (antibiotic-medication to treat infection) 250 mg, two tablets once followed by one tablet for four days for a respiratory infection for four days.During a review of Resident 7's Nursing Progress Note dated 11/18/2025 at 3:04 p.m., the Nursing Progress Note indicated a note to continue monitoring for cough. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and HTN. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13's cognition was intact, and Resident 13 required maximal assistance with ADLs. During a review of Resident 13's Order Details dated 11/20/2025, the Order Details indicated an order for Ertapenem Sodium (antibiotic-medication to treat infection) 1 gram (g- unit of measurement) for seven days.During a concurrent interview and record review on 12/4/2025 at 7:30 a.m., with the Infection Prevention Nurse (IPN), the IPN stated no COC documentation was completed for Resident 2, Resident 7, or Resident 13 in relation to their antibiotic therapy. The IPN stated COC's should be initiated when an antibiotic was ordered and when a resident was admitted to the facility on antibiotics to ensure staff are monitoring the resident. During an interview on 12/5/2025 at 10:52 a.m. with the Director of Nursing (DON), the DON stated a COC should be documented whenever an antibiotic was initiated for a resident. The DON stated COC documentation was essential to ensure staff were aware of the residents' change in condition and were actively monitoring and addressing their care needs. The DON stated failure to document a COC could result in inadequate follow up and compromised resident care. During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, dated 12/19/2022, the P&P indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician when there is a change requiring notification. Need to alter treatment significantly- commence a new treatment to deal with a problem. Circumstances that require a need to alter treatment includes a new treatment.During a review of the facility's Registered Nurse Job Description dated 2023, the Registered Nurse Job Description indicated, Observes for changes in the residents' status and documentsu accordingly. 2.During an interview on 12/4/2025 at 4:37 p.m., with Registered Nurse Supervisor (RNS) 4, RNS 4 stated the IDT was responsible for reviewing all admission documents during the resident's IDT admission meeting. During an interview on 12/5/2025 at 7:20 a.m., with the IPN, the IPN stated there should have been an IDT meeting regarding Resident 2's antibiotics upon admission. The IPN stated Resident 2 was at high risk for side effects and the development of multidrug resistant infections (MDROs- are microorganisms that have developed resistance to multiple classes of antibiotics).During an interview on 12/5/2025 at 10:52 a.m., with the DON, the DON stated upon a resident's admission, the Interdisciplinary Team (IDT) holds a meeting to review the resident's documentation. The DON indicated the IDT should have reviewed Resident 2's hospital discharge records to ensure the accuracy of medication orders and to prevent potential medication errors. The DON stated reviewing hospital discharge documents was essential for providing appropriate care and ensuring resident safety.During a review of the facility's P&P titled, admission of a Resident, dated 3/10/2025, the P&P indicated, The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. The admission process has several phases including review all available transfer information.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and 27) drug regimen was free from unnecessary medications by failing to: 1. Include a stop date for prescribed antibiotics, and by failing to reassess the continued need for the medications for Resident 2. 2. Ensure Resident 27 was not overprescribed antibiotics. This deficient practice resulted in Resident 2 receiving prolonged antibiotic therapy without appropriate monitoring or clinical justification, increasing the risk of adverse drug effects (unwanted, harmful, or unexpected problem as a result of a medicine) and had the potential for Resident 27 to develop multi-drug-resistant organisms (MDROs- bacteria resistant to multiple antibiotics.)Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease (your kidneys are damaged and slowly lose their ability to clean waste from your blood), urinary tract infections (UTI- an infection of the bladder/urinary tract), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of metronidazole (antibiotic used to treat a variety of infections caused by bacteria) 500 milligrams (mg- unit of measurement), via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours for Helicobacter pylori (H. Pylori- stomach infection) prophylaxis (preventative care to stop disease before it starts) with a stop date to follow. During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of tetracycline (antibiotic used to treat a variety of infections caused by bacteria) 250 mg via gastrostomy tube every 12 hours for H. Pylori prophylaxis with a stop date to follow. During an interview on 12/4/2025 at 2:00 p.m., with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON), the IPN stated there was no stop date for the metronidazole and tetracycline but could not tell me why there should be a stop date. The IPN unable to answer when asked about the potential harm of Resident 2's prolonged antibiotic usage. The DON stated Resident 2's order for antibiotics should have had a stop date because long term usage could lead to kidney problems, the development of multidrug resistant infections (MDROs- are microorganisms that have developed resistance to multiple classes of antibiotics) or clostridium difficile (C-diff- a highly contagious bacteria that causes severe diarrhea). During a phone interview on 12/4/2025 at 4:08 p.m., with the Pharmacy Consultant (PC), the PC stated all antibiotic orders should have a stop date. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program dated 12/19/2022, the P&P indicated, All prescriptions for antibiotics shall specify the dose, duration, and indication for use. 2. During a review of Resident 27's admission Record (face sheet) dated 12/4/2025, the admission record indicated Resident 27 was admitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sick sinus syndrome (abnormal heart rhythms) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 27's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 27 had fluctuating capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set(MDS)- a standardized assessment and care screening tool), the MDS indicated Resident 27 cognition was intact. The MDS also indicated Resident 27 needed substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 27's Order Listing Report dated 12/04/2025, the order listing report indicated Resident 27 was prescribed the following antibiotics: 1. Daptomycin (antibiotic) 500 milligrams (mg- unit of measure) with a start date of 9/08/2025 for 14 days for bacteremia (bacteria in the blood). 2. Ertapenem (antibiotic) one gram (gm-unit of measure) with a start date of 9/16/2025 for 14 days for a Urinary tract infection (UTI- an infection in the bladder/urinary tract). 3. Meropenem (antibiotic) one gram every 12 hours with a start date of10/01/2025 for a UTI. 4. Metronidazole (antibiotic) 500 mg, three times a day (TID) for five days, with a start date of 10/26/25 for foul smelling discharge (abnormal body fluid). 5. Ceftriaxone (antibiotic) one gram, one time a day for seven days, with a start of date10/26/2025 for UTI. 6. Cephalexin (antibiotic) 500 mg TID for five days, with a start date of 10/31/2025 for UTI. 7. Bactrim DS (antibiotic) 888-160 mg's two times a day for five days, with a start date for 11/21/2025 for UTI. During a concurrent interview and record review on 12/03/2025 at 11:35 a.m. with the Infection Preventionist Nurse (IPN), Resident 27's antibiotic use from 9/8/2025 – 12/1/2025 was reviewed. The IPN stated Resident 27 had been on seven different antibiotics and that she had not discussed it with anyone in the facility. The IPN stated she should have discussed it because Resident 27 was at risk for overuse of antibiotics. During an interview on 12/05/2025 at 10:54 a.m. with the Director of Nurses (DON), the DON stated she was made aware that Resident 27 had been on seven different antibiotics since admission to the facility this past September 2025. The DON stated Resident 27 should have had an Interdisciplinary Team Meeting ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care), to discuss Resident 27's multiple use of antibiotics, to ensure Resident 27 was not over prescribed antibiotics. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program dated 12/19/2022 the P&P indicated, it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The P&P indicated the purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The P&P indicated the Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. The P&P indicated the program includes antibiotic use protocols and a system to monitor antibiotic use. The P&P indicated 1. Nursing staff shall assess residents who are suspected of having an infection and complete an SBAR form prior to notifying the physician. 2. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. 3. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. 4. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. 5. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). 6. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. 7. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness

Based on observation, interview and record review, the facility failed to ensure infection control practices in the kitchen were followed by failing to ensure the [NAME] and Dietary Aid washed hands and changed gloves when switching tasks during tray line (process where staff assemble meal trays for residents).These deficient practices had the potential to place residents at risk for acquiring food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria or viruses). Findings: During a kitchen observation on 12/4/2025, at 11:32 a.m., the [NAME] was observed engaging in multiple food service tasks without performing appropriate hand hygiene or changing gloves between activities. Specifically, The [NAME] transitioned from checking food temperatures to scooping beef onto plates without washing hands or changing gloves. The [NAME] walked to the dishwashing area to retrieve a dish and returned to the food preparation area without performing hand hygiene or changing gloves. The [NAME] was also observed opening drawers and then immediately scooping food onto plates, again without washing hands or changing gloves.During an observation on 12/4/2025 at 11:45 a.m., the Dietary Aid (DA) was observed switching tasks from transferring plated meals onto food cart to filling up hot water dispensers. The DA was observed removing used gloves and putting on a new pair of gloves without washing hands. The DA was observed switching tasks from placing food trays on cart to assisting the Dietary Supervisor (DS) with dessert. The DA was observed removing used gloves and putting on a new pair of gloves without washing hands. During an interview on 12/4/2025 at 1:13 p.m. with the Cook, the [NAME] stated, per facility policy staff should wash hands and change gloves every time a new task is performed. The [NAME] stated she should have washed her hands and changed gloves when switching tasks and that failure to do so places residents at risk of acquiring food-borne illnesses.During an interview on 12/4/2025 at 1:20 p.m. with the DA, the DA stated, per facility policy staff should wash hands every time gloves are changed. The DA stated staff should wash hands and change gloves every time a new task is performed. The DA stated she should have washed her hands every time she changed gloves and that failure to do so places residents at risk of acquiring food-borne illnesses. During an interview on 12/4/2025 at 1:30 p.m. with the DS, the DS stated, dietary staff should wash their hands every time gloves are changed and before starting a new task. The DS stated failure to wash hands and change gloves during tray line can result in cross contamination and places residents at risk of acquiring infectionDuring a review of facility policy and procedure (P&P) titled Handwashing Guidelines for Dietary Employees dated 12/19/2022, indicated Dietary employees shall clean their hands and exposed portions of their arms.Before donning gloves for working with food, after engaging in any activity that may contaminate the hands.

Based on observation, interview and record review, the facility failed to follow the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) including the use of McGeer's Criteria (standardized surveillance definitions to identify and track infections for prevention and control) for three of six residents (Resident 2, Resident 25, and Resident 27).This failure placed the Resident 2, Resident 25 and Resident 27 at risk for unnecessary antimicrobial therapy, adverse drug reactions, and the development of antimicrobial resistance. Findings: A. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease (your kidneys are damaged and slowly lose their ability to clean waste from your blood), urinary tract infections (UTI- an infection of the bladder/urinary tract), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of metronidazole (antibiotic used to treat a variety of infections caused by bacteria) 500 milligrams (mg- unit of measurement), via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours for Helicobacter pylori (H. Pylori- stomach infection) prophylaxis (preventative care to stop disease before it starts) with a stop date to follow. During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of tetracycline (antibiotic-medication to treat infection) 250 mg via gastrostomy tube every 12 hours for H. Pylori prophylaxis with a stop date to follow. During a review of Resident 2's general acute care hospital (GACH) Discharge Note dated 10/6/2025, the GACH Discharge Note indicated for the treatment of Helicobacter pylori (H. Pylori- stomach infection) continue metronidazole (antibiotic used to treat a variety of infections caused by bacteria) and tetracycline (antibiotic used to treat a variety of infections caused by bacteria) for a duration of 14 days. Confirmation of eradication should be conducted at least four weeks after completing the antibiotic regimen. During a concurrent interview and record review on 12/4/2025 at 2:00 p.m., with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON), the IPN stated that because the antibiotics were prescribed prophylactically, she did not believe they needed to be included in the facility's antibiotic stewardship program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). The Director of Nursing (DON) stated that the IPN should have assessed the appropriateness of Resident 2's antibiotic regimen upon admission, as prolonged use could lead to kidney complications, the development of multidrug-resistant organisms (MDROs—microorganisms resistant to multiple classes of antibiotics), or Clostridium difficile (C. diff—a highly contagious bacterium that causes severe diarrhea). B. During a review of Resident 25's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/12/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage), hypertension (HTN-high blood pressure), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 25's History and Physical (H&P) dated 11/13/2025, the H&P indicated Resident 25 has fluctuating capacity to understand and make decisions. During a record review on 12/4/2025 at 7:35 a.m. of Resident 25's medication administration records [(MAR) a daily documentation of record used by a licensed nurse to document medication treatments given to a resident], the MAR indicated a physician's order dated on 11/13/2025 at 9:00 a.m., to administer Levofloxacin 500 milligram (mg, unit of measurement), give one tablet by mouth in the morning for UTI for 7 days. During a concurrent interview and record review on 12/4/2025 at 7:55 a.m. with the Infection Preventionist (IP), the IP reviewed the Antibiotic Stewardship Surveillance form and McGeer's criteria for Resident 25. The IP stated she did not review Resident 25's progress notes to assess whether Resident 25 met McGeer's criteria for a UTI prior to completing the surveillance form. The IP stated Resident 25's symptoms from the progress notes were not documented, and corresponding progress notes did not match the required clinical indicators for McGeer's criteria. The IP stated not reviewing Resident's chart and symptoms before completing the Antibiotic Stewardship Surveillance form may place residents at risk of receiving antibiotics without clinical justification. The IP stated accurate symptom documentation was necessary to determine whether a resident meets clinical criteria to reduce unnecessary antibiotic exposure. During a concurrent interview and record review on 12/4/2025 at 4:45 p.m. with the Director of Nursing (DON), the DON reviewed Resident 25's Antibiotic Stewardship Surveillance form and progress notes. The DON stated the IP did not review Resident 25's documented symptoms prior to completing the surveillance form. The DON stated the progress notes did not match the required clinical indicators for McGeer's criteria. The DON stated by not accurately documenting symptoms would be treated with antibiotics not meeting McGeer's criteria and exposing residents to potential medication side effects and antibiotic overuse. During a record review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 12/19/2022, indicated Infection Preventionist – coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff.The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria) to define infections.Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: .Data collection forms for antibiotic use, process, and outcomes measures. C. During a review of Resident 27's admission Record (face sheet) dated 12/4/2025, the admission record indicated Resident 27 was admitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sick sinus syndrome (abnormal heart rhythms) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 27's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 27 had fluctuating capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS)- a standardized assessment and care screening tool), the MDS indicated Resident 27 cognition was intact. The MDS also indicated Resident 27 needed substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 27's Order Listing Report dated 12/04/2025, the order listing report indicated Resident 27 was prescribed metronidazole (antibiotic) 500 mg three times a day (TID) for five days for foul smelling discharge (abnormal body fluid) on 10/25/2025 and Cephalexin (antibiotic) 500 mg TID for five days for urinary tract infection ((UTI- an infection in the bladder/urinary tract). During a concurrent interview and record review on 12/03/2025 at 11:35 a.m. with the Infection Preventionist (IP) Resident 27's antibiotic use from 9/8/2025 – 12/1/2025 was reviewed. The IP stated the facility used the McGeer's Criteria (assessment tool used to help define a true infection) to ensure that residents are not over prescribed antibiotics. The IP stated Resident 27 was prescribed metronidazole 500 mg three times a day (TID) for five days, on 10/25/2025 and Cephalexin 500 mg TID for five days on10/31/2025 and that no McGeer's criteria assessment was found. The IP stated there should have been an assessment done to ensure that Resident 27 met the criteria to be started on antibiotics. The IP stated that Resident 27 was at risk for multi-drug resident organisms (MDRO – germs that have become resistant to multiple antibiotics) when being over prescribed antibiotics. During an interview on 12/05/2025 at 10:54 a.m. with the Director of Nurses (DON), the DON stated the McGeer's Criteria should have been completed by the IP nurse when Resident 27 was started on the metronidazole and the Cephalexin to ensure Resident 27 meet the criteria of a true infection to be placed on antibiotics. The DON stated Resident 27 was at risk of becoming resistant to antibiotics if over prescribed. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 12/19/2022, the P&P indicated, It is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Infection Preventionist coordinates all antibiotic stewardship activities, maintains documentation, and serves as a source for all clinical staff. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.

Based on interview and record review, the facility failed to ensure the Infection Prevention Nurse (IPN) demonstrated competency in implementing infection control practices related to antibiotic usage for one of one sampled residents (Resident 2). The facility failed to:1.Monitor Resident 2 who was administered two antibiotics (medications used to treat an infection) since admission on [DATE] with no end date to stop treatment. This failure resulted in Resident 2 receiving two antibiotics for an extended period without appropriate monitoring or reassessment, placing the resident at risk for adverse effects, including potential worsening of chronic kidney disease ( condition in which the kidneys are damaged and gradually lose their ability to filter waste and excess fluids from the blood effectively), which could lead to fluid retention (condition where excess fluid accumulates in the body's tissues, leading to swelling), swelling, and cognitive (ability to think, understand, learn, and remember) impairment.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease (your kidneys are damaged and slowly lose their ability to clean waste from your blood), urinary tract infections (UTI- an infection of the bladder/urinary tract), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 2's general acute care hospital (GACH) Discharge Note dated 10/6/2025, the GACH Discharge Note indicated for the treatment of Helicobacter pylori (H. Pylori- stomach infection) continue metronidazole (antibiotic used to treat a variety of infections caused by bacteria) and tetracycline (antibiotic used to treat a variety of infections caused by bacteria) for a duration of 14 days. Confirmation of eradication should be conducted at least four weeks after completing the antibiotic regimen.During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of metronidazole 500 milligrams (mg- unit of measurement), via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours for H. Pylori prophylaxis (preventative care to stop disease before it starts) with a stop date to follow.During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of tetracycline 250 mg via gastrostomy tube every 12 hours for H. Pylori prophylaxis with a stop date to follow. During an interview with the IPN on 12/4/2025 at 2:00 p.m., the IPN was unable to locate Resident 2's antibiotic orders and stated she was unaware that Resident 2 had been receiving antibiotics since 10/22/2025. The IPN stated that because the antibiotics were prescribed prophylactically, she did not believe they needed to be included in the facility's antibiotic stewardship program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). When asked about the potential impact of long-term antibiotic use on residents, the IPN was unable to provide an explanation. She also acknowledged that she did not follow the physician's order indicating stop date to follow and admitted that she does not consistently review hospital discharge records upon a resident's admission but stated she should have done so in Resident 2's case.During a review of the facility's Infection Preventionist (IP) Job Description dated 2022, the IP Job Description indicated, Major Duties and Responsibilities include: develops and implements an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment; oversees the facility's antibiotic stewardship program; maintains documentation of infection prevention and control program activities. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 12/19/2022, the P&P indicated, Infection Preventionist coordinates all antibiotic stewardship activities, maintains documentation, and serves as a source for all clinical staff.

Based on observation, interview, and record review the facility failed to ensure consent to treatment documentation was completed with all required elements for one of 14 sampled residents (Resident 44).This deficient practice has the potential to result in residents receiving treatments or interventions without understanding the risks, benefits, or alternatives. Findings:During a review of Resident 44's admission Record (Face sheet), the admission Record indicated the facility admitted the patient on 10/26/2001 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN- high blood pressure), and major depressive disorder (feel very sad, empty or hopeless most days and interferes with daily life).A review of Resident 4's History and Physical (H&P) dated 8/16/2025, the H&P indicated Resident 4 has the capacity to understand and make decisions.During a record review on 12/03/2025 at 9:15 a.m. of Resident 44's medical record (chart), the documentation of consent to treatment was missing Resident 44's date, facility representative's name, signature, and date. During an interview on 12/03/2025 at 9:25 a.m. with Resident 44 about his recollection in signing consent to treatment form, Resident 44 stated he signed the consent to treatment, and he was informed about the risk and benefits for treatments.During a concurrent interview and record review on 12/3/2025 at 9:33 a.m. with the Infection Preventionist (IP), the IP stated the consent to treatment for Resident 44 was incomplete and missing was Resident 44's date, facility representative name, signature and date. The IP stated completed consent to treatment was necessary to inform Resident 44 of the risks and benefits of the recommended treatment. The IP stated an incomplete consent to treatment fails to provide this information and may place Resident 44 at risk if treatment was given without Resident 44's knowledge and understanding. During a concurrent interview and record review on 12/04/2025 at 4:25 p.m. with the Director of Nursing (DON), the DON stated the consent to treatment for Resident 44 was incomplete and was missing Resident 44's date, facility representative's name, signature and date. The DON stated a completed consent to treatment allows the facility to treat residents based on their consent. The DON stated an incomplete informed consent fails to provide this information and may place Resident 44 at risk if treatment was given without his knowledge and understanding. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 12/19/2022, indicated, It is the policy of the facility to uphold the rights of residents to participate in the planning and decision-making process concerning their care and treatment. When situations arise that involve complex decisions, the facility will verify that.consent has been obtained prior to any medical intervention or treatment is initiated .If a form is used to document that informed consent was verified, the licensed nursing staff will complete the Verification of Informed Consent Form and place it under the consent section in the clinical record.

Based on interview and record review, the facility failed to perform consistent monitor Resident 53's nutritional status by failing to:a. Initiate a weight variance (monitoring process triggered when a resident experiences significant weight fluctuations) andb. Discuss nutritional recommendations during the Interdisciplinary Care Conference {(ICC), a collaborative meeting involving various healthcare professionals to review and update the resident's care plan} after Resident 53 had a significant weight loss (a weight loss greater than 5% in one month, or 10% change in weight in 6 months) of 40 pounds (unit for measuring weight) following admission from the General Acute Care Hospital (GACH) for one of four sampled residents (Resident 53).This deficient practice had the potential to place resident at risk for continued weight loss. Findings:During a review of Resident 53's admission Record, the admission Record indicated the facility admitted Resident 53 on 9/23/2025 and was readmitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often rapid heartbeat caused by abnormal electrical signals in the hearts upper chambers), gastroesophageal reflux disease (GERD- a chronic condition where stomach acid frequently flows back up into the esophagus), and dysphagia (difficulty swallowing).During a review of Resident 53's History and Physical (H&P) dated 11/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 53's Minimum Data Set (MDS-a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 53 had severely impaired cognition (ability to think and understand). The MDS indicated Resident 53 was dependent on staff for toileting, dressing and required substantial assistance from staff for eating. The MDS indicated Resident 53 had a weight loss of 5% or more in the last month and not on physician prescribed weight loss regimen. During a review of Resident 53's weights and vitals summary for October 2025, indicated Resident 53's weight on 10/1/2025 (monthly weight) was 224 pounds and on 10/14/2025 (readmission date from the GACH) Resident 53's weight was 184 pounds. During a concurrent interview and record review on 12/3/2025 at 1:44 p.m. with the Dietary Supervisor (DS), The Nutritional assessment dated [DATE] was reviewed. The Nutritional Assessment indicated RD to implement nutritional interventions for Resident 53 including provide liberalized diet and Boost very high calorie (calorically dense nutritional drink) every day for 30 days. ICC dated 10/22/2025 was reviewed, the ICC indicated Resident 53 was not placed on weight variance. The DS stated residents with significant weight loss should be placed on weight variance and Resident 53 should be on it. The DS stated the nutritional interventions from the Nutritional assessment dated [DATE] were not included in the ICC dated 10/22/2025. The DS stated failure to place Resident 53 on weight variance or discuss nutritional interventions during ICC meeting places resident at risk for continued weight loss. During a concurrent interview and record review on 12/5/2025 at 8:38 a.m. with the Director of Nursing (DON), Resident 53's weight and vitals summary for October 2025 was reviewed, the DON stated Resident 53 had a weight loss of 40 pounds following GACH admission [DATE]. The Nutritional assessment dated [DATE] was reviewed, the DON stated Resident 53 was not placed on weight variance. The DON stated Resident 53 had a significant weight loss and per facility policy, should have been placed on weight variance. The DON stated the RD's recommendations for Resident 53's significant weight loss to provide a liberalized diet and Boost very high calorie every day for 30 days. The DON stated the RD's nutritional interventions were not included in the ICC dated 10/22/2025. The DON stated failure to place Resident 53 on weight variance or discuss nutritional interventions during ICC meeting places resident at risk for continued weight loss.During a review of facility policy and procedure (P&P) titled Weight Management Policy dated 1/20/2023, the P&P indicated, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight. The P&P indicated, A significant change in weight is defined as 5% change in weight in 1 month (30 days). Documentation of significant weight changes shall be completed in accordance with the facility's documentation policies and procedures and acceptable standards of practice.

Based on interview and record review the facility failed to implement goals and interventions on the care plan for two of two residents (Resident 2 and Resident 27) by failing to: 1. Ensure the Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care), developed a care plan for Resident 27 who had multiple Urinary tract infections (UTI- an infection in the bladder/urinary tract) and was prescribed multiple antibiotics (medication that kills bacteria). 2. Ensure Resident 27 who should have been on Enhanced Barrier Precautions (EBP-infection control measure to prevent the spread of germs) for a chronic pressure injury pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) had goals and interventions for the care plan.3. Review Resident 2's hospital discharge notes upon admission. These failures resulted in delayed care and necessary treatment for Resident 2, as well as a lack of appropriate care for Resident 27, increasing the potential for the spread of infection to other residents, staff, and visitors. Findings: 1. During a review of Resident 27's admission Record (face sheet) dated 12/4/2025, the admission record indicated Resident 27 was admitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sick sinus syndrome (abnormal heart rhythms) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 27's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 27 had fluctuating capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS)- a standardized assessment and care screening tool), the MDS indicated Resident 27 cognition was intact. The MDS also indicated Resident 27 needed substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 27's Order Listing Report dated 12/04/2025, the order listing report indicated Resident 27 was prescribed: 1.Daptomycin (antibiotic) 500 milligrams (mg- unit of measure) give once a day for 14 days, starting date 9/08/2025 for bacteremia (bacteria in the blood). 2. Ertapenem (antibiotic) one gram (unit of measure) give once a day for 14 days, starting date 9/16/2025 for UTI. 3. Meropenem (antibiotic) one gram every 12 hours for seven days, start date10/01/2025 for UTI. 4. Metronidazole (antibiotic) 500 mg give three times a day (TID) for five days, start date 10/26/25 for foul smelling discharge. 5. Ceftriaxone (antibiotic) one gram give one time a day for seven days, start date10/26/2025 for UTI. 6. Cephalexin (antibiotic) 500 mg give TID for five days, start date 10/31/2025 for UTI. 7. Bactrim DS (antibiotic) 888-160 mg give two times a day (BID) for five days, start date 11/21/2025 for UTI. 2. During a review of Resident 27's Physician Order dated 9/18/2025, the physician order indicated Resident 27 had a sacrococcyx pressure injury to clean with normal saline (NS) pat dry apply collagen powder (promotes wound bed healing) and calcium alginate (absorbent wound dressing used for heavy drainage) cover with super absorbent dressing every day, for pressure injury. During a review of Resident 27's care plan dated 9/24/2025 titled Resident is on Enhanced Barrier Precautions related to (r/t) chronic wound the care plan indicated there were no goals or interventions in place for Resident 27. During a concurrent interview and record review on 12/03/2025 at 11:35 a.m. with the Infection Preventionist (IP), Resident 27's antibiotic use from 9/8/2025 – 12/1/2025 was reviewed. The IP stated Resident 27 had been on six different antibiotics for UTI's and one for bacteremia. The IP stated the facility should have had an IDT meeting for Resident 27, so the team could have discussed possible interventions to help with prevention for Resident 27 and come up with a plan of care. During a concurrent interview and record review on 12/04/2025 at 4:24 p.m. with the IP, Resident 27's EBP care plan was reviewed. The IP stated Resident 27 care plan for EBP did not have any goals or interventions in place and did not know why. The IP stated the care plan was important to ensure the staff would know how to provide the appropriate care for Resident 27. During an interview on 12/05/2025 at 10:54 a.m. with the Director of Nurses (DON), the DON stated all care plans need to have a goal and interventions for the staff to properly coordinate care for the residents. The DON stated the facility should have had an IDT meeting to develop a plan of care for Resident 27's who had multiple UTI's and had been on multiple antibiotics, to ensure Resident 27's received the appropriate care. During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plan dated 12/19/2022, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be prepared by an interdisciplinary team. 3. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease (your kidneys are damaged and slowly lose their ability to clean waste from your blood), urinary tract infections (UTI- an infection of the bladder/urinary tract), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 2's general acute care hospital (GACH) Discharge Note dated 10/6/2025, the GACH Discharge Note indicated For Helicobacter pylori (H. Pylori- stomach infection) treatment, continue metronidazole (antibiotic used to treat a variety of infections caused by bacteria) and tetracycline (antibiotic-medication to treat infection) for 14 days, eradication (elimination) may be confirmed four weeks or more after completion of antibiotic therapy. During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of metronidazole 500 milligrams (mg- unit of measurement), via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours for H. Pylori prophylaxis (preventative care to stop disease before it starts) with a stop date to follow. During a review of Resident 2's Order Details dated 10/11/2025, the Order Details indicated an order of tetracycline 250 mg via gastrostomy tube every 12 hours for H. Pylori prophylaxis with a stop date to follow. During a concurrent interview and record review on 12/4/2025 at 4:37 p.m., with Registered Nurse Supervisor (RNS) 4, RNS 4 stated the Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) reviews all admission documents during the IDT admission meeting. RNS 4 stated she did not review Resident 2's hospital discharge notes and stated she should have. During an interview on 12/5/2025 at 7:20 a.m., with the Infection Prevention Nurse (IPN), IPN stated that an IDT meeting should have occurred regarding Resident 2's antibiotics upon admission due to the resident's high risk for side effects and development of multidrug-resistant organisms (MDROs- are microorganisms that have developed resistance to multiple classes of antibiotics). During an interview on 12/5/2025 at 10:52 a.m., with the Director of Nursing (DON), the DON stated that the IDT was responsible for reviewing admission documents to ensure proper medication orders and prevent potential medication errors. The DON stated the hospital discharge documents should have been reviewed upon admission for Resident 2's safety and care. During a review of the facility's policy and procedure (P&P) titled, admission of a Resident, dated 3/10/2025, the P&P indicated, The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. The admission process has several phases including review all available transfer information. During a review of the facility's P&P titled, Antibiotic Stewardship, dated 12/19/2022, the P&P indicated, Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.

Based on observation, interview and record review, the facility failed to monitor target behaviors for one of 14 residents (Resident 25) while on a psychotropic medication (substance that affects how the brain works, used to treat mental illnesses).This failure resulted in Resident 25 not receiving individualized behavior monitoring necessary to identify the presence, absence, or change in behaviors targeted by the psychotropic medication. Findings:During a review of Resident 25's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/12/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage), hypertension (HTN-high blood pressure), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 25's History and Physical (H&P) dated 11/13/2025, the H&P indicated Resident 25 has fluctuating capacity to understand and make decisions.During a record review on 12/4/2025 at 7:35 a.m. of Resident 25's medication administration records (MAR- a daily documentation of record used by a licensed nurse to document medication treatments given to a resident), the MAR indicated a physician's order dated on 11/13/2025 at 9:00 a.m., aripiprazole 5 milligram (mg, unit of measurement), give one tablet by mouth in the morning psychosis for angry outburst with a stop date of 11/18/2025.During a record review on 12/4/2025 at 7:35 a.m. of Resident 25's monitor behavior form, used to document targeted behavior for monitoring when an antipsychotic medication is ordered, the form indicated Resident 25's behavior was not monitored or documented during every shift on 11/13/2025, and there was no documentation for the morning and afternoon shifts on 11/14/2025.During a concurrent interview and record review on 12/4/2025 at 8:51 a.m. with a Registered Nurse (RN) 4, Resident 25's MAR for aripiprazole 5 mg, ordered for psychosis and angry outburst was reviewed. RN 4 stated the behavior monitoring form and identified monitoring was not performed on 11/13/25 for the morning, afternoon, and evening shifts, and not performed on 11/14/25 for the morning and afternoon shifts. RN 4 stated the lack of monitoring and documentation meant the facility was unable to assess Resident 25's response to aripiprazole, determine medication effectiveness, or identify potential adverse reactions. During a concurrent interview and record review on 12/4/2025 at 4:31 p.m. with the Director of Nursing (DON), Resident 25's MAR for aripiprazole 5 mg, ordered for psychosis and angry outburst and the behavior monitoring form and identified monitoring was not performed on 11/13/25 for the morning, afternoon, and evening shifts, and not performed on 11/14/25 for the morning and afternoon shifts were reviewed. The DON stated behavior monitoring should occur every shift when an antipsychotic medication was prescribed. The DON stated when behavior monitoring was not completed, staff are unable to track changes in Resident 25's target behaviors, which may prevent the facility from determining the effectiveness of aripiprazole. The DON stated staff may fail to recognize or report critical side effects or adverse reactions when Resident 25's behavior was not monitored as required.During a record review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 12/19/2022, indicated .The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as:.In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan.The resident's response to the medication(s), including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on interview and record review, the facility failed to notify the physician of a significant weight loss (a weight loss greater than 5% in one month, or 10% change in weight in six months) following readmission from General Acute Care Hospital (GACH) stay for one of four sampled residents (Resident 53).This deficient practice had the potential to delay the Physician's assessment and intervention, placing Resident 53 at risk for continued weight loss and malnutrition. Findings:During a review of Resident 53's admission Record (face sheet), the admission Record indicated the facility admitted Resident 53 on 9/23/2025 and was readmitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often rapid heartbeat caused by abnormal electrical signals in the hearts upper chambers), gastroesophageal reflux disease (GERD- a chronic condition where stomach acid frequently flows back up into the esophagus), and dysphagia (difficulty swallowing). During a review of Resident 53's History and Physical (H&P) dated 11/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 53's Minimum Data Set (MDS-a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 53 had severely impaired cognition (ability to think and understand). The MDS indicated Resident 53 was dependent on staff for toileting, dressing and required substantial assistance from staff for eating. The MDS indicated Resident 53 had a weight loss of 5% or more in the last month and not on physician prescribed weight loss regimen. During a review of Resident 53's weights and vitals summary for October 2025, indicated Resident 53's weight on 10/1/2025 (monthly weight) was 224 pounds and on 10/14/2025 (admission date from the hospital) Resident 53's weight was 184 pounds. Resident 53's weight and vitals summary indicated Resident 53 had a 17.9% weight loss between 10/1/2025 and 10/14/2025. During a concurrent interview and record review on 12/3/2025 at 3:15 p.m. with Registered nurse (RN) 3, Resident 53's admission inquiry dated 10/14/2025 was reviewed. RN 3 stated Resident 53 was admitted to General Acute Care Hospital (GACH) from 10/6/2025 to 10/13/2025. Resident 53's weight and vitals summary for October 2025 was reviewed, RN 3 stated Resident 53 had a weight loss of 40 pounds from GACH on 10/1/2025 to 10/14/2025. RN 3 stated per facility policy, this weight loss of 17.9% would be considered a significant weight loss upon readmission. RN 3 stated Licensed Nurses are expected to notify physician for significant changes in resident condition including significant weight loss upon readmission. RN 3 stated failure to notify physician of significant weight loss can result in continued weight loss and malnutrition.During a concurrent interview and record review on 12/5/2025 at 8:38 a.m. with the Director of Nursing (DON), Resident 53's weight and vitals summary for October 2025 was reviewed. The DON stated Resident 53 had a weight loss of 40 pounds from GACH on 10/1/2025 to 10/14/2025 and is considered a significant weight loss. The DON stated nurses are expected to notify physician for significant weight loss. During a subsequent interview with the DON on 12/5/2025 at 8:38 a.m. and record review of Resident 53's nursing progress note dated 10/13/2025 was reviewed, the DON stated that the nurse did not notify the physician of significant weight loss following discharge from the GACH. The DON stated there was no documentation indicating the physician notification of Resident 53's significant weight loss. The DON stated failure to notify physician of significant weight loss could result in continued weight loss and malnutrition. During a review of facility policy and procedure titled, Notification of Changes dated 12/19/2022, the P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition.

Based on observations, interviews, and record review, the facility failed to ensure that expired enteral nutrition products (specialized liquid formulas used in tube feeding to provide essential nutrients to residents unable to eat by mouth) were removed from the medication storage room after their expiration date. This failure had the potential to result in adverse side effects, including gastrointestinal distress, infection, and loss of potency (strength of a drug or its effectiveness in achieving a desired result), compromising the health and safety of residents receiving enteral nutrition.Findings:During an observation on 12/3/2025 at 2:17 p.m. in Medication Storage room [ROOM NUMBER], one expired 1500 milliliter (mL-unit of measurement) container of Diabetes source ( enteral nutrition formula) was found in a red basket. The product had an expiration date of 11/24/2025.During a concurrent observation and interview on 12/3/2025 at 2:45p.m. with Registered Nurse (RN) 3 in the central supply room (where nurses obtain medications and necessary items for resident care), observed seven Glucerna feeding source with expiration date of 12/1/2025. During an interview on 12/3/25 at 2:47 p.m. with RN 3, RN 3 stated she had checked Medication Storage room [ROOM NUMBER] on 12/1/2025 and did not observe any expired enteral feeding products at that time. RN 3 stated that if residents were to receive expired feeding formulas, it could result in adverse reactions. RN 3 stated expired feeding formula should be discarded promptly and should not be stored in medication storage areas.During an interview on 12/4/2025 at 8:33 a.m. with the Director of Nursing (DON), the DON statedregular monitoring of the supply room was necessary to ensure expired items were identified and removed. The DON stated both the Registered Nurse and central supply staff were responsible for checking the medication storage room, with central supply personnel expected to conduct weekly inspections and additional checks as needed. The DON stated administering expired medications or enteral feeding products to residents could result in harmful effects or reduced potency, potentially compromising the effectiveness of treatment. The DON stated all expired supplies should be promptly removed from the medication storage room to maintain resident safety.During an interview on 12/4/25 at 9:04 a.m. with Maintenance Supervisor (MS) 1, MS 1 stated he was responsible for overseeing maintenance and central supply operations. MS 1 stated part of his job duties include checking supplies for expiration dates. He reported conducting weekly checks, particularly on Tuesdays when new supplies were restocked, and performing a full inventory review at the end of each month. MS 1 stated that expired items should not be kept in stock and recognized the importance of removing them promptly. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility dated 4/2008, the P&P indicated Outdated , contaminated , or deteriorated medications and those containers that are cracked, soiled, expired, or with out secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on observation, interview, and record review, the facility failed to assess one of five residents (Resident 1) during a change of condition and notify the physician in a timely manner during multiple episodes of elevated blood pressure. This failure resulted in Resident 1 having a headache and had the potential to result in dizziness, cerebral infarction (part of the brain dies because it's not getting enough blood and oxygen) and re-hospitalization for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/4/2022, and readmitted on [DATE] with diagnoses including hemiplegia (a condition where one side of your body is paralyzed or experiences weakness), cerebral infarction, atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) and hypertension (HTN-high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 2/28/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/3/2025, the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 1 required supervision assistance (helper provides verbal cues and/ or touching/ steading and/or contact guard assistance as resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, maximal assistance (helper does more than half the effort to complete task) with oral hygiene, toileting, showering, upper body dressings, was dependent (helper does all of the effort) with lower body dressing. During a review of Resident 1's Order Summary Report dated 6/25/2025, the Order Summary Report indicated the following physician orders: a. On 5/16/2025- Monitor blood pressure and pulse rate every eight hours for Hydralazine (a medication used to treat high blood pressure) use. b. On 5/17/2025- Administer one Atenolol (used to treat high blood pressure) tablet 25 milligram (mg-unit dose) by mouth in the morning for hypertension, hold if Systolic Blood Pressure (SBP- top number in a blood pressure reading) is lower than 110 mmHg or heart rate less than 60 beats per minute. c. On 5/17/2025- Administer one Hydralazine (used to lower high blood pressure) tablet 10mg by mouth every 12 hours as needed for hypertension if SBP above 140. d. On 5/17/2025- Administer one Losartan Potassium (used to treat high blood pressure) tablet 50mg by mouth two times a day for hypertension, hold if SBP is lower than 110. During a review of Resident 1's care plan for Cerebral Vascular Accident (CVA-Stroke), revised on 3/1/2025, the care plan indicated Resident 1 had cerebral infarction and sustained right hemiplegia, and dysphagia (difficulty swallowing). The care plan interventions included monitoring vital signs and notifying the physician of significant abnormalities. During a review of Resident 1's care plan for re-hospitalization, revised 3/1/2025 The care plan indicated Resident 1 was at risk for re-hospitalization due to high blood pressure and CVA. The care plan's goal indicated the facility would prevent unplanned re-hospitalization. The care plan interventions included monitoring vital signs every shift and to notify the physician for results out of baseline range and notify the physician for non-compliance with plan of care. During a review of Resident 1's Weights and Vitals Summary, for the months of March, April and May 2025, the Vitals Summary indicated that Resident had following episodes of blood pressure above 150 systolic before the resident was transferred to the GACH on 5/16/2025: 1. 3/30/2025 at 07:48 a.m., 162/88 2. 3/30/2025 at 11:02 a.m., 162/88 3. 4/24/25 at 1:03 a.m., 153/77 4. 4/24/25 at 7:09 a.m., 150/76 5. 5/1/25 at 11:34 a.m., 151/71 6. 5/2/25 at 7:00 a.m., 150/72 7. 5/6/25 at 00:02 a.m., 150/79 8. 5/8/25 at 11:38 a.m., 150/75 9. 5/12/25 at 12:43 p.m., 152/74 10. 5/14/25 at 3:43 p.m., 162/75 10. /15/25 at 7:44 a.m., 171/81 During a review of Resident 1's Change in Condition Evaluation, dated 5/16/2025, the Change in Condition Evaluation indicated that Resident 1 had elevated blood pressure with headache and was transferred to the GACH on 5/16/2025. The following blood pressures were documented on 5/16/2025: 1. 5/16/25 at 09:14 a.m., 162/92mmHg 2. 5/16/25 at 10:24 a.m., 163/90mmHg 3. 5/16/25 at 10:36 a.m., 165/81mmgh During a review of Resident 1's GACH records on the Clinical Decision Unit (CDU) dated 5/16/2025, the CDU indicated Resident 1's CDU diagnosis was hypertensive urgency with a blood pressure result of 181/95 mmHg at 4:32 p.m. at the GACH upon arrival. During an interview on 6/26/2025 at 10:28 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated staff consider a resident hypertensive when the systolic blood pressure is above 140mmHg and when it is 160 or higher, they are required to call the physician and document the incident. During a concurrent interview and record review on 6/26/2025 at 10:50 a.m. with Registered Nurse (RN) 1, Resident 1's Order Summary Report and Weights and Vitals Summary for month of March, April and May were reviewed. RN 1 stated when Resident 1's SBP was above 150, it is considered high based on Resident1's baseline and regarded as a change of condition. RN 1 stated Resident 1's average BP had increased over a period of three months prior to being transferred to the GACH, and the high blood pressure episodes could have led to another stroke. RN 1 stated licensed staff did not follow Resident 1's care plan regarding blood pressure monitoring for Resident 1. RN 1 stated staff failed to assess Resident 1's change in condition or notify the physician in a timely manner for early intervention prior to the transfer to the GACH on 5/16/2025.RN 1 stated staff failed to assess Resident 1's change in condition or notify the physician in a timely manner for early intervention prior to the transfer to the GACH on 5/16/2025. During an interview on 6/26/2025 at 3:30 p.m. with the Director of Nursing, the DON stated, when there is a change in a resident's condition, the staff need to notify the physician to allow for early treatment. The DON stated staff must carry out the interventions listed in the care plan to ensure residents' safety and to manage any existing conditions. The DON stated the staff should notify the physician when there is a change in condition and following the outlined interventions in the plan of care are essential components of providing quality care. During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, dated 12/19/2022, the P&P indicated that the facility must consult with the resident's physician when there is a change requiring such notification, circumstances requiring notification include: significant change in the resident's physical, mental or psychosocial condition, this may include: clinical complications, circumstances that require a need to alter treatment, including new treatment. During a review of the facility's policy and procedure (P&P) titled, Licensed Vocational Nurse's job description, dated 2023, the P&P indicated that LVN observes for changes in resident's status, notifying the physician and resident's family or representative and documenting accordingly. During a review of the facility's policy and procedure (P&P) titled, Registered Nurse's job description, dated 2023, the P&P indicated the RN observes for changes in resident's status, notifying the physician and resident's family or representative and documenting accordingly.

Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by failing to ensure Resident 1 ' s indwelling urinary catheter (medical device which helps drain urine from the bladder) drainage bag was covered with a privacy bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This deficient practice had the potential for Resident 1 to feel embarrassed and have low self-esteem by not having his catheter drainage bag not covered. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and urinary retention (a condition which makes it difficult or impossible to empty the bladder). During a review of Resident 1 ' s History and Physical (H&P), dated 1/3/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/25/2023, The MDS indicated Resident 1 had moderate cognitive impairment and required substantial/maximal assistance (helper does more than half the effort) for toileting and showering. The MDS indicated Resident 1 had an indwelling catheter during the assessment period. During an observation on 1/6/2025 at 9:45 a.m., in Resident 1 ' s room, Resident 1 ' s indwelling catheter drainage bag was observed without a privacy bag. During an interview on 1/6/2025 at 10:00 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated the responsibility for caring for residents with catheters is the responsibility of all nursing staff. CNA 1 stated she is responsible for emptying the drainage bags and report any abnormalities to the charge nurse immediately. CNA 1 stated she should have notified the charge nurse immediately to have him/her apply a privacy bag when she noticed Resident 1 ' s drainage bag was not covered. CNA 1 stated residents with exposed drainage bags could feel embarrassed and ashamed if the drainage bag is not covered. During a concurrent observation and interview on 1/6/2025 at 11:03 a.m., with License Vocational Nurse (LVN) 1 in Resident 1 ' s room, LVN 1 stated all staff are responsible for maintaining residents ' drainage bag. LVN 1 stated Resident 1 ' s drainage bag should have had a privacy bag covering the draining bag. LVN 1 stated residents should have a privacy bag, so they don ' t feel embarrassed and/or ashamed by having the drainage bag exposed to others. LVN 1 stated Resident 1 ' s dignity was compromised by him not having a privacy bag. During an interview on 1/6/2025 at 11:45 a.m., with License Vocational Nurse (LVN) 2, LVN 2 stated all residents that have an indwelling catheter should have a privacy bag cover to ensure the residents dignity is maintained. LVN 2 stated Resident 1 could feel embarrassed and humiliated by his drainage bag being exposed to the public. During a concurrent observation and interview on 1/6/2025 at 12:00 p.m., with Registered Nurse Supervisor (RNS) 1, in Resident 1 ' s room, RNS 1 validated Resident 1 did not have a privacy bag to cover his drainage bag. RNS 1 stated all staff are responsible for ensuring the residents drainage bags are covered with a privacy bag. RNS 1 stated Resident 1 could feel embarrassed, and his privacy was violated because his drainage bag was exposed. During a review of the facility ' s policy and procedure (P&P) titled, Catheter Care, dated 12/19/2022, the P&P indicated, privacy bags will be available and catheter drainage bags will be covered at all times while in use. During a review of the facility ' s P&P titled, Promoting/Maintaining Resident Dignity, revised 12/19/2022, the P&P indicated to maintain resident privacy.

Based on observation, interview, and record review, the facility failed to provide services to three of seven sampled residents (Resident 43, 5, and 18) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to: 1. Obtain baseline (initial measurement taken at an early point and used for comparison over time to monitor changes) ROM measurements of Resident 43's both arms and legs upon admission on 8/12/2023 using the Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy titled, Joint Mobility and Screening and Assessment revised on 1/25/2024. 2. Obtain a baseline ROM measurement of Resident 43's left arm during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation on 8/14/2023. 3. Assess Resident 43's left wrist hand orthosis ([WHO] material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures [condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness]) for fit and wear tolerance (amount of time a person can wear an orthosis before experience discomfort or any other side effects) of up to eight (8) hours upon discharge from OT services on 9/10/2023 in accordance with professional standards (guidelines that outline the practices, skills, and qualifications that professionals in a given field should follow), including assessment of the orthosis (external medical device used for supporting, immobilizing and treating joints) for fit and wear tolerance. 4. Provide Resident 43 with Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services from 9/11/2023 to 9/20/2023 (10 days) and from 10/20/2023 to 11/30/2023 (over one month) for passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to the left arm and the application of Resident 43's left WHO in accordance with the OT Discharge Summary recommendations on 9/10/2023. 5. Monitor ROM changes in both of Resident 43's arms and legs from 9/11/2023 to 4/1/2024 (over 6 months). 6. Apply Resident 43's left WHO on 9/30/2024. 7. Perform ROM exercises to Resident 43's left elbow on 10/1/2024. 8. Obtain baseline ROM measurements of Resident 5's arms and legs upon admission on 7/19/2023 in accordance with the facility's policy and procedure titled Joint Mobility Screening and Assessment, revised on 1/25/2024. 9. Obtain baseline ROM measurements of Resident 5's legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation on 10/26/2023. 10. Obtain baseline ROM measurements of Resident 5's arms during the OT Evaluation on 10/27/2023. 11. Monitor ROM changes in both of Resident 5's arms and legs from 10/26/2023 to 8/19/2024 (10 months). 12. Position Resident 18's hips at midline (line through the body that divides it into halves that are mirror images of each other) while lying in bed. These failures resulted in: 1. Resident 43 developing ROM limitations in the left shoulder, elbow, and hand, including the development of a left-hand contracture. 2. Placing Resident 5 and 18 at risk to develop further ROM limitations which would affect the residents' ability to participate in activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). Findings: a. During a review of Resident 43's Admission Record, the Admission Record indicated Resident 43 was initially admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure), dependence on renal (kidney) dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side (less often used during completion of daily living tasks). During a review of Resident 43's PT Evaluation and Plan of Treatment, dated 8/13/2023, the PT Evaluation indicated Resident 43 fell from the bed and had a right-side brain hemorrhage (bleeding), which caused weakness on the left side of Resident 43's body. The PT Evaluation indicated the ROM in both of Resident 43's legs were within functional limits ([WFL] sufficient movement without significant limitation). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 8/14/2023, the OT Evaluation indicated Resident 43's ROM in the right arm, left wrist, and left hand were WFL. The OT Evaluation indicated Resident 43's ROM in the left shoulder and elbow was impaired (unspecified). During a review of Resident 43's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/16/2023, the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg. During a review of Resident 43's PT Discharge Summary, dated 9/10/2023, the PT Discharge Summary indicated Resident 43 was dependent (required more than 75 percent [%] physical assistance to perform the task) with bed mobility and transfers, requiring a mechanical lift (a device that helps residents who have difficulty moving on their own to be transferred or moved from one place to another) for transfers. The PT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to both legs. During a review of Resident 43's OT Discharge Summary, dated 9/10/2023, the OT Discharge Summary indicated Resident 43 required moderate assistance (required between 26 to 50% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to the left arm and application of a left WHO. The OT Discharge Summary did not include an OT goal related to monitoring Resident 43's wear tolerance of the left WHO. During a review of Resident 43's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated 9/2023, the Documentation Survey Report indicated Resident 43 started receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 9/21/2023 (10 days after OT Discharge Resident 43). During a review of Resident 43's Nurses Progress Notes, dated 10/19/2023, the Nurses Progress Notes indicated Resident 43 was transferred to a general acute care hospital (GACH) to replace Resident 43's permanent catheter ([PermaCath]- flexible tube interested into a blood vessel in the neck or upper chest and threaded to the right side of the heart) for dialysis. During a review of Resident 43's Documentation Survey Report for RNA, dated 10/2023, the Documentation Survey Report indicated Resident 43 stopped receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 10/20/2023. During a review of Resident 43's Physician Orders, dated 10/20/2023, the Physician Orders indicated to readmit Resident 43 to the facility and resume all medications. The Physician's Orders did not include an RNA task for Resident 43 upon their admission to the facility on [DATE]. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's Documentation Survey Report, dated 12/2023, the Documentation Survey Report indicated Resident 43 started receiving RNA program for PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 12/1/2023 (over one month from the last treatment and application of WHO). During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/1/2024, the OT Evaluation indicated Resident 43 had WFL ROM in the left arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. During a review of Resident 43's OT Discharge Summary, dated 4/5/2024 and signed on 4/16/2024, the OT Discharge Summary indicated Resident 43 went to GACH. During a review of Resident 43's Change in Condition ([CIC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) Evaluation, dated 4/8/2024, the CIC Evaluation indicated Resident 43 refused dialysis in the morning, vomited multiple times, and refused meals. The CIC Evaluation indicated the physician ordered Resident 43's transfer to GACH. During a review of Resident 43's Nurses Progress Notes, dated 4/11/2024, the Nurses Progress Notes indicated Resident 43 was readmitted to the facility on [DATE]. During a review of Resident 43's Joint Mobility Assessment (JMA), dated 4/12/2024, the JMA indicated Resident 43's ROM was within normal limits ([WNL] normal ROM for that joint) at all joints of the right arm and both legs. The JMA indicated Resident 43's ROM was minimally impaired (51 to 75% available range for that joint) for left wrist flexion (bending the wrist downward) and left wrist extension (bending the wrist upward), moderately impaired (26 to 50% available range for that joint) for the left elbow flexion (bending the elbow) and extension (straightening the elbow), and severely impaired (less than 25% available range for that joint) for left shoulder flexion (lifting the arm upward), left shoulder abduction (lifting the arm up and away from the body), left hand/fingers flexion (bending the fingers toward the palm), and left hand/fingers extension (straightening out the fingers). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/12/2024, the OT Evaluation indicated Resident 46 had WFL ROM in the right arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. During a review of Resident 43's PT Evaluation and Plan of Treatment, dated 4/14/2024, the PT Evaluation indicated Resident 43 had WFL ROM in both legs. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's OT Discharge Summary, dated 7/25/2024, the OT Discharge Summary indicated Resident 43 required maximum assistance (required 41 to 75% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary indicated Resident 43 achieved an OT goal of safely wearing a left WHO for 8 hours without any redness, swelling, discomfort and pain. The OT Discharge Summary recommendations included RNA program to provide Resident 43 with PROM to both arms and legs and to apply the left WHO. During a review of Resident 43's PT Discharge Summary, dated 7/25/2024, the PT Discharge Summary indicated Resident 43 required maximum assistance for bed mobility and dependent for transfers. The PT Discharge Summary recommendations included RNA to provide Resident 43 with PROM to both legs. During a review of Resident 43's Documentation Survey Report, dated 8/2024, the Documentation Survey Report indicated Resident 43 received RNA for PROM to the left arm and both legs and application of the left WHO on 8/7/2024 (14 days after PT and OT recommendations). During a review of Resident 43's care plan titled, Restorative Nursing Program, initiated 9/19/2023 and revised on 8/7/2024, the care plan interventions included for RNA to provide PROM to the left arm, PROM of both legs, and application of the left WHO for up to six hours, five times per week. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had clear speech, understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 43 required substantial/maximal assistance (helper does more than half the effort) for eating and rolling to either side while lying in bed and dependent for hygiene, dressing, bathing, and chair/bed-to-chair transfers. The MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a concurrent observation and interview on 9/30/2024 at 11:04 a.m. in Resident 43's bedroom, Resident 43 was observed lying awake in bed and unable to move the left arm. Resident 43 stated she required physical assistance from someone to move her left arm. During an interview on 9/30/2024 at 11:23 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapists (PT and OT) complete a JMA on each resident upon admission and annually. The DOR stated the purpose of the RNA program was to maintain the residents' function to prevent decline in mobility. The DOR stated the RNA program included providing mobility, including walking and transfers, ROM exercises, and application of orthoses (also known as splints; material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). The DOR stated the purpose of ROM exercises (in general) included to maintain a resident's joint flexibility to prevent stiffness. The DOR stated the purpose of orthoses (in general) included to maintain ROM and prevent the development of contractures, which can cause pain and lead to skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). During a concurrent observation and interview on 9/30/2024 at 12:05 p.m. in Resident 43's bedroom, Resident 43 was observed lying awake in bed and stated she fell from the bed at home, which caused bleeding in the brain. Resident 43 was observed moving the right arm normally at each joint but was unable to move the left arm. Resident 43 stated the nurse (unknown) did exercises (unspecified) on 9/30/2024 morning. Resident 43's left elbow was bent at 90 degrees with the left hand resting on Resident 43's abdomen. Resident 43's left hand was positioned in a closed fist and did not have an orthosis (WHO) applied. Resident 43 stated she received exercises once per week. During a concurrent observation and interview on 10/1/2024 at 10:27 a.m. in Resident 43's bedroom, Resident 43 was observed sleepy but agreeable to receive RNA services. RNA 1 was observed standing on the right side of Resident 43's bed while RNA 2 was standing on the left side of Resident 43's bed. RNA 1 performed exercises on Resident 43's right leg, including hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straight), hip flexion with knee flexion (bending), hip abduction (moving the leg away from the body), hip rotation (circular motion) in clockwise (in the direction in which the hands of a clock turn) and counterclockwise (opposite direction in which the hands of a clock turn) directions, ankle rotation in clockwise and counterclockwise directions, and rotation of each toe of the right foot. RNA 1 left the room to assist another staff member. RNA 2 performed exercises on Resident 43's left leg, including hip flexion with the knee extended, hip flexion with knee flexion, hip rotation in clockwise and counterclockwise directions, ankle rotation in clockwise and counterclockwise directions, and ankle dorsiflexion (bending the ankle toward the body). Resident 43's left elbow was observed being bent to 90 degrees and the left hand was observed positioned in a closed fist. RNA 2 was observed performing PROM to Resident 43's left arm, including shoulder abduction (lifting the arm up and away from the body), shoulder rotation in clockwise and counterclockwise directions, wrist rotation in clockwise and counterclockwise directions, thumb rotation, and attempted to extend Resident 43's left-hand fingers. RNA 2 was observed being unable to fully extend Resident 43's fingers, which remained in a bent position. RNA 2 did not perform any PROM to Resident 43's left elbow. RNA 2 attempted to apply Resident 43's left WHO. The portion of the left WHO for Resident 43's fingers was bent completely downward to accommodate Resident 43's fingers. RNA 2 had difficulty extending Resident 43's fingers to apply the left WHO and stated he needed another person's assistance. The Physical Therapy Assistant (PTA 1) came into the room and assisted with extending Resident 43's left-hand fingers while RNA 2 applied the left WHO. Resident 43 complained of pain while RNA 2 and PTA 1 applied the left WHO. Resident 43 stated the WHO has not been applied to her left hand in two months. During an interview on 10/1/2024 at 10:59 a.m., RNA 1 and RNA 2, RNA 1 stated Resident 43 received PROM exercises to the left arm and both legs. RNA 2 stated he could not extend Resident 43's left-hand fingers and required two people to apply the left WHO. RNA 2 stated he forgot to perform the left elbow PROM exercises on 10/1/2024 at 10:27 a.m. During an observation on 10/1/2024 at 11:09 a.m. in Resident 43's bedroom, RNA 2 performed PROM exercises to Resident 43's left elbow into flexion and extension. RNA 2 was unable to fully extend Resident 43's left elbow, which continued to have a bent position. During a concurrent interview and record review on 10/2/2024 at 1:50 p.m. with the DOR, Resident 43's OT Discharge Summary, dated 9/10/2023, was reviewed. The DOR stated the professional standard for therapists prior to providing a resident with an orthosis (in general) included the therapist determining the orthosis' fit, monitoring the skin, and determining the wear time. The DOR stated a resident (in general) could develop skin breakdown if a therapist (PT or OT) did not monitor and determine the orthosis wear time. The DOR stated Resident 43 was provided a left WHO without establishing an OT goal to determine Resident 43's wear tolerance. During an interview on 10/2/2024 at 4:03 p.m. the Regional Director of Rehabilitation (RDR) stated the therapists (PT and OT) should perform JMA on each resident upon admission, change of condition, and annually. During a concurrent interview and record review on 10/2/2024 at 4:40 p.m. with the DOR, Resident 43's clinical record (medical records -collection of documents that contain a resident's medical history and care) was reviewed for the JMA. The DOR was unable to locate Resident 43's JMA upon admission to the facility on [DATE]. During a concurrent interview and record review on 10/3/2024 at 12:19 p.m., with the Director of Medical Records (DMR), the DMR reviewed Resident 43's RNA tasks, dated 8/2024. The DMR stated Resident 43 did not receive RNA for PROM on the left arm and both legs and application of the left WHO until 8/7/2024 when the care plan, titled Restorative Nursing Program, was revised on 8/7/2024. During a concurrent observation and interview on 10/3/2024 at 2:00 p.m. with RNA 2 and Resident 43, in Resident 43's room, Resident 43 was observed lying in bed while RNA 2 removed the left WHO. RNA 2 stated the WHO was applied to Resident 43's left hand at 9:20 a.m. and tolerated wearing the left WHO for more than four hours. Resident 43 stated the facility did not provide exercises and apply the left WHO that often (unspecified amount of time) prior to this week. During a concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDS Coordinator (MDSC), Resident 43's clinical record was reviewed, including Resident 43 MDS, PT Evaluation dated 8/13/2023, and OT Evaluation dated 8/14/2023. The DOR and MDSC were unable to locate Resident 43's JMA upon admission to the facility on [DATE] in the electronic and physical clinical records. The DOR and MDSC reviewed Resident 43's PT Evaluation, dated 8/13/2023, which indicated Resident 43 had WFL ROM in both legs. The DOR and MDSC reviewed Resident 43's OT Evaluation, dated 8/14/2023, which indicated Resident 43 had WFL ROM in the right arm, left wrist, and left hand and impaired ROM in the left shoulder and elbow. The MDSC stated the OT Evaluation did not indicate any measurement of Resident 43's ROM impairments in the left shoulder and elbow. The MDSC reviewed Resident 43's MDS, dated [DATE], which indicated Resident 43 had ROM impairments in one arm and one leg. The MDSC stated the MDS did not indicate which arm and leg were impaired, did not indicate which joints in the arm and leg were impaired, and did not indicate ROM measurements of the impairments. The DOR stated the facility did not have a baseline ROM assessment for Resident 43's left arm impairments. During the same concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's OT Treatment Notes from 8/14/2023 to 9/10/2023, OT Discharge Summary, dated 9/10/2023, PT Discharge Summary, dated 9/10/2023, and RNA tasks for 9/2023 were reviewed. The DOR and MDSC reviewed Resident 43's OT Discharge Summary, dated 9/10/2023, which indicated recommendations for the RNA to perform PROM exercises to both arms and to apply the left WHO. The DOR stated Resident 43's PT Discharge recommendation included for the RNA to perform PROM exercises to both legs. The MDSC reviewed Resident 43's RNA tasks and stated the DOR inputted the RNA tasks to provide PROM to both arms and legs and to apply the left WHO for up to 8 hours in Resident 43's clinical record on 9/20/2023 (10 days after discharge). The DOR reviewed all OT treatment notes and stated the OT documentation did not include any assessment of Resident 43's left WHO for fit and 8-hour wear tolerance prior to discharge on 9/10/2023. The MDSC stated Resident 43 did not receive RNA program from 9/11/2023 to 9/20/2023. During a concurrent interview on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's RNA tasks note from 10/2023 to 12/2023 were reviewed. The MDSC stated Resident 43's RNA tasks were cancelled on 10/19/2023 due to Resident 43's hospitalization on [DATE] for a PermaCath replacement. The MDSC stated Resident 43 returned to the facility on [DATE]. The MDSC stated Resident 43's RNA tasks for PROM exercises to both arms and legs and application of the left WHO were not inputted into Resident 43's electronic clinical records until 11/30/2023 (more than one month after readmission to the facility). The MDSC stated Resident 43 did not receive RNA for PROM to both arms and legs and the application of the left WHO from 10/20/2023 to 11/30/2023. During a concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's Nurses Progress Notes and JMA, dated 4/12/2024, were reviewed. The MDSC reviewed the Nurses Progress Notes, dated 4/8/2024, which indicated Resident 43 was transferred to the hospital for vomiting related to missing dialysis. The MDSC stated the facility readmitted Resident 43 on 4/12/2024. The MDSC and DOR reviewed the JMA, dated 4/12/2024, which indicated Resident 43's had minimal ROM limitations in the left wrist, moderate ROM limitations in the left elbow, and severe ROM limitations in the left shoulder and hand. The DOR stated Resident 43's hand experienced a three step (WFL, minimal, moderate, severe) ROM decline from WFL on 8/14/2023 to severe ROM impairment on 4/12/2024. During the same concurrent interview with the DOR and the MDSC on 10/3/2024 at 4:20 p.m., Resident 43's quarterly MDS assessments since 8/16/2023 (admission) and RNA meetings notes were reviewed. The DOR stated the facility relied on RNA report and the MDS to monitor Resident 43's ROM since it was the facility's policy to perform the JMA upon admission and annually. The MDSC and DOR were unable to locate any RNA meetings notes for any resident with RNA services, including Resident 43, from 9/2023 to 4/2024. The MDSC stated Resident 43's MDS assessments were performed quarterly but the MDS did not indicate which arm and leg had ROM impairments, the joint location of the ROM impairment, and the severity of the ROM impairment. The MDSC stated Resident 43's quarterly MDS assessments did not reflect any changes in ROM. During an interview on 10/3/2024 at 6:08 p.m. with the Director of Nursing (DON), DOR, and MDSC, the DON stated the facility's process for monitoring each resident's ROM included RNA meetings and the MDS assessments. The DON stated there was a potential for a resident (in general) to experience a decline in ROM without the application of an orthosis and provision of ROM exercises. The DON stated the measuring and monitoring ROM was not in the RNA's scope of practice. The DON stated quarterly assessments completed for each resident included smoking, risk for developing skin breakdown, and falls. The DON stated the facility did not perform any quarterly assessments to monitor residents (in general) for ROM. The DOR stated Resident 43's medical condition caused Resident 43 to develop hypertonicity (increased muscle stiffness or tightness) in the left arm. The DOR stated Resident 43's hypertonicity in the left arm should be monitored since the hypertonicity increased Resident 43's risk for ROM decline. The DOR was unable to provide any documentation Resident 43's left arm ROM was monitored due to hypertonicity from 9/2023 to 4/2024. During a concurrent interview and record review on 10/4/2024 at 7:54 a.m. with the DOR, the DOR reviewed Resident 43's OT Evaluation, dated 8/13/2023, Treatment Notes from 8/13/2023 to 9/10/2023, and OT Discharge Summary, dated 9/10/2023. The DOR stated Resident 43's baseline ROM of the left hand was WFL. The DOR stated the typical position of the WHO included the fingers positioned in extension. The DOR reviewed Resident 43's OT Treatment Notes and Discharge Summary and stated the OT documentation did not indicate Resident 43's left WHO was adjusted from the typical position upon discharge on 9/10/2023. During a review of a textbook titled, Occupational Therapy for Physical Dysfunction, (Fifth edition, 2002, page 316), the textbook indicated the OT's Role is to evaluate the need for a splint clinically and functionally; to select the most appropriate splint; to provide or fabricate (make) the splint; to assess the fit of the splint; to teach the patient and caregivers the purpose, care, and use of the splint. The Occupational Therapy for Physical Dysfunction textbook, page 316, indicated the OT must consider, carefully monitor, and teach the patient and caregiver to report any of these problems related to orthotic use, including impaired skin integrity (skin health), pain, and swelling. b. During a review of Resident 5's Admission Record, the Admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right side and facial weakness following a cerebral infarction. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 expressed ideas and wants, clearly understood verbal content, and had intact cognition. The MDS indicated Resident 5 had functional ROM limitations in one arm and one leg. During a review of Resident 5's care plan titled, Restorative Nursing Program, initiated on 10/5/2023, the care plan interventions included for the RNA to perform PROM to both resident's arms and legs and apply a right-hand palm guard (material used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture). During a review of Resident 5's PT Evaluation, dated 10/26/2023, the PT Evaluation indicated Resident 5's ROM in both hips and knees were within functional limits ([WFL] sufficient movement without significant limitation). The PT Evaluation indicated Resident 5's ROM in both ankles were impaired (unspecified). During a review of Resident 5's PT Discharge Summary, dated 10/26/2023, the PT Discharge Summary recommendations indicated for the RNA to provide PROM to both legs. During a review of Resident 5's OT Evaluation, dated 10/27/2023, the OT Evaluation indicated Resident 5's ROM in the left arm and right elbow were WFL. The OT Evaluation indicated Resident 5's ROM in the right shoulder, right wrist, and right hand were impaired (unspecified). The OT Evaluation indicated Resident 5 had a contracture in the right hand, limiting Resident 5's ability to grasp and release. During a review of Resident 5's OT Discharge Summary, dated 10/27/2023, the OT Discharge Summary indicated recommendations for the RNA to provide PROM to both arms and apply a right-hand palm guard. During a review of Resident 5's MDS, dated [DATE], 1/24/2024, 4/19/2024, and 7/23/2024, the MDS indicated Resident 5 expressed ideas and wants, clearly understood verbal content, and had intact cognition. Each MDS indicated Resident 5 had ROM limitations in one arm and one leg (unspecified side). During a review of Resident 5's JMA, dated 7/23/2024, the JMA indicated Resident 5's ROM was WNL in the left shoulder, both elbows, left wrist, left hand, both hips, and both knees. The JMA indicated Resident 5's ROM was severely impaired (less than 25 percent [%] available range for that joint) in the right shoulder, right wrist, right hand, and both ankles. During an interview on 9/30/2024 at 11:23 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapists (PT and OT) complete a JMA on each resident upon admission and annually. During an observation on 9/30/2024 at 12:43 p.m. in the dining room, Resident 5 was observed sitting in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) eating lunch while watching a movie. Resident 5 moved the left arm actively at all joints to scoop food from the plate and hold a cup to drink liquids. Resident 5's moved the right arm at the elbow and shoulder joints, but Resident 5's right hand was observed positioned in a closed fist without a palm guard. During a concurrent observation and interview on 9/30/2024 at 2:00 p.m. with Resident 5, in the facility lobby, Resident 5 was observed awake, alert, and sitting upright in a Geri chair. Resident 5 used gestures and the left hand to write responses to questions. Resident 5 wrote and gestured that the RNAs does not apply the palm guard to the right hand every day. During an observation on 10/1/2024 at 9:15 a.m., in Resident 5's bedroom, Resident 5 was observed awake and lying flat in bed. Resident 5 was already wearing a right-hand palm guard, which was lined with sheepskin, and both ankles were positioned in plantar flexion (ankle bent with toes pointing away from the body). RNA 1 was observed standing on the right side of Resident 5's bed and RNA 2 was standing on the left side. RNA 1 was observed performing PROM on Resident 5's right leg into hip flexion (bending the leg at the hip joint toward the body) and hip abduction (moving the leg away from the body). RNA 1 attempted to perform right knee flexion (bending the knee) but Re [TRUNCATED]

Based on observation, interview and record review, the facility failed to observe infection control measures. The facility failed to : a.Ensure Resident 1 and 48's tube feeding ( medical device used to provide nutrition to resident who cannot obtain nutrition by mouth ) and water bags were changed every 24 hours. These failures had the potential to result in cross contamination and place the residents at risk for the spread of infection. b. To practice handwashing during wound care treatment on Resident 18 who had a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacro coccyx (tail bone) area. c. To ensure dirty linens were handled and disposed in a sanitary way after providing personal care for Resident 33 who was treated with antibiotic because of Extended spectrum beta lactamase ([ESBL]-an enzyme that makes bacteria resistant to many antibiotics {medication to treat infection} which makes the infection difficult to treat). d. To ensure Resident 33's intravenous heplock (IV catheter placed in a vein to administer medication or fluids into the bloodstream) site was assessed and dressing was changed. e. Ensure the door separating the soiled linen and clean linen was closed while placing soiled linen in the washing machine f. Ensure soiled disposable gowns (worn to provide a barrier of protection) were not hung on a hook near the clean linen area. g. Ensure three of four sampled residents (Residents 28,37,38,) shared care equipment was disinfected before and after each use. Resident 28's, blood pressure cuff, stethoscope (instrument that listens to the heart) and pulse oximeter (measures oxygen in the blood and heart rate), Resident 37's blood pressure cuff, stethoscope, and Resident 38's stethoscope. These failures had the potential to result in cross contamination and place the residents at risk for the spread of infection. h. Ensure facility have Legionella (bacteria found in natural occurring water) water management program. This failure had the potential for Legionella to grow and multiply and cause disease for resident who inhale the contaminated aerosol water. Findings: a.During a review of Resident 48's Admission Record, the Admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (loss of blood flow to a part of the brain) and dysphagia (swallowing difficulties). During a review of Resident 48's care plan titled Impaired immunity initiated on 8/22/2024, the care plan goal indicated for Resident 48 to remain free of infection. The care plan interventions included monitoring, documenting, and reporting any signs and symptoms of infection and keeping the environment clean because Resident 48 was at risk for contracting infections due to impaired immune system (helps the body fight infections and other diseases). During a concurrent observation and interview on 9/30/2024, at 9:40 a.m., in Resident 48's room, Licensed Vocational Nurse (LVN) 4 verbally confirmed Resident 48's tube feeding water bag was dated 9/28/2024 and should have been changed. LVN 4 stated the tube feeding water bags were supposed to be changed every 24 hours. During an interview on 10/2/2024, at 3:37 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated tube feeding water bags were supposed to be changed every 24 hours to prevent infection. During an interview on 10/3/2024, at 11:30 a.m., with Infection Prevention Nurse (IPN), the IPN stated tube feeding water bags were changed every 24 hours and should not go more than 24 hours because it can place the residents at high risk for infection. During an interview on 10/4/2024, at 3:05 p.m., with the Director of Nursing (DON), the DON stated it was the responsibility of the licensed nurses to change the tube feeding water bags every 24 hours to prevent infection and to ensure the resident does not receive spoiled tube feeding nutrition. b. To practice handwashing during wound care treatment on Resident 18 who had a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacro coccyx (tail bone) area. c. To ensure dirty linens were handled and disposed in a sanitary way after providing personal care for Resident 33 who was treated with antibiotic because of Extended spectrum beta lactamase ([ESBL]-an enzyme that makes bacteria resistant to many antibiotics {medication to treat infection} which makes the infection difficult to treat). d. To ensure Resident 33's intravenous heplock (IV catheter placed in a vein to administer medication or fluids into the bloodstream) site was assessed and dressing was changed. Findings: During a review of Resident 18's Admission Record, the Admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Stage 4 pressure ulcer of sacral region, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and autistic disorder( developmental disability that affects how people communicate, interact, learn, and behave). During a review of Resident 18's History and Physical (H&P) dated 4/15/2024, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS- federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated the Resident 18 had moderately impaired cognitive skills for daily decision making, and required substantial assistance with eating, oral hygiene, dressing, toileting, personal hygiene, and bed mobility. The MDS indicated the resident had one unhealed Stage 4 pressure injury. During a review of Resident 18's Physician Order Summary Report dated 8/20/2024, the Physician Order Summary Report indicated an physician order for sacro coccyx : cleanse with normal saline (cleaning solution) , pat dry, apply collagen ( medicine used for wound healing), pack with saline moistened hydrofera blue ( sterile, absorbent, and moist foam dressing) dressing that provide and cover with foam dressing as needed for pressure ulcer if soiled or dislodged. During a review of Resident 18's Physician Order Summary Report dated 9/24/2024, the Physician Order Summary Report indicated ammonium lactate (skin cream used to dry skin and other skin conditions) cream to apply on both arms topically (used on the outside of the body) every day for xerosis (rough, dry skin that may have scales or small cracks) for four weeks. During a wound care dressing observation on 10/3/2024, at 9:36 a.m., in Resident 18's room with Treatment Nurse (TN 1) and Certified Nursing Assistant (CNA 7), TN 1 removed the soiled (dirty) dressings on the sacro coccyx area and changed gloves without performing hand hygiene. TN 1 applied medication and special dressing on the sacrococcyx wound and used the same gloves when TN 1 applied ammonium lactate cream on both arms of the resident. During an interview on 10/3/2024 at 10:24 a.m., with TN 1, TN 1 stated she should have done hand hygiene and not used the same gloves before applying the cream on Resident 18's arms. TN 1 stated hand hygiene should be practiced before entering the resident's room, in between the dressing change, each wound to prevent spread of infection. During an interview on 10/4/2024, at 11:18 a.m., with Infection Preventionist Nurse (IPN), IPN stated TN 1 should performed handwashing after removal of soiled dressing of the Stage 4 pressure injury and before applying the new wound dressing and not just changed gloves because this practice could cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread of infection. During an interview on 10/4/2024, at 3:11 p.m., with the Director of Nursing (DON), the DON stated hand hygiene should be practiced every time gloves were changed, after removal of old and soiled dressings to prevent spread of infection. During a review of facility's policies and procedures (P&P) titled Hand Hygiene revised 1/25/2024, the P&P indicated hand hygiene was indicated after handling contaminated objects, before and after handling clean or soiled dressings, when during resident care, moving from a contaminated body site to a clean site. The P& P indicated the use of gloves does not replace hand hygiene. c. During a review of Resident 33's Admission Record, the Admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (long term condition where the kidneys gradually lose their ability to filter blood properly), ESBL, and bipolar disorder. During a review of Resident 33's H &P dated 5/10/2024, the H&P indicated Resident 33 had a capacity to understand and make decisions. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 required substantial assistance (helper does more than half the effort) with bathing, toileting hygiene, dressing, and personal hygiene. During an observation on 10/3/2024, at 9:47 a.m., in Resident 33's room, observed CNA 2 carrying dirty linens on her arms and gloved hands after providing personal care to Resident 33. Observed the soiled linens were not placed on a plastic bag. CNA 2 called an unnamed staff to bring the hamper near Resident 33's room. During an interview on 10/3/2024, at 10:56 a.m., with CNA 2, CNA 2 stated dirty linens should be placed in a plastic bag before bringing them in the hamper. CNA 2 stated she wanted her job to be easy and quick because of other residents she needs to attend. CNA 2 stated she did not use a plastic bag to put the dirty linens from Resident 33's room. During an interview on 10/3/2024, at 11:06 a.m., with IPN, IPN stated dirty linens should be placed in a plastic bag and placed them in a hamper outside the door of the resident's room. IPN stated placing the soiled linens in a plastic bag will prevent cross contamination and spread of infection among the residents. During a review of facility's P&P titled Laundry reviewed and revised 1/25/2024, the P&P indicated linens should be bagged separately from resident's clothing at the point of use. The P&P indicated soiled linens shall be handled as little as possible with minimum agitation to avoid contamination of air, surfaces, and persons. d. During a review of Resident 33's Physician Order dated 9/17/2024, the Physician Order indicated an order of ertapenem sodium (antibiotic) injection one gram (gm- unit of measurement) intravenously one time a day for ESBL of urine for seven days. During a review of Resident 33's Physician Order dated 9/17/2024, the Physician Order indicated to change/restart IV as needed, change dressing with site change and as needed. The Physician Order indicated to check IV site for signs and symptoms of complications or adverse reactions from IV therapies every shift for 7 days. During an observation on 9/30/2024, at 10:12 a.m., in Resident 33's room, Resident 33 had an IV heplock on his right arm, site looked dirty, with transparent dressing dated 9/13/2024. Resident 33 stated he had told the staff to remove the heplock due to pain. During an interview and record review of Resident 33's picture of heplock on 10/2/2024, at 2:12 p.m., with LVN 2, LVN 2 stated the heplock dressing was dirty and had to be changed. LVN 2 stated she should have told Registered NS 1 Resident 33's heplock required assessment and change of dressing because the resident could have an infection on the IV heplock site. LVN 2 stated she forgot to report to RN Supervisor (RNS1). During an interview on 10/4/2024, at 11:25 a.m., with RNS 1, RNS 1 stated registered nurses (RN) were responsible in assessing IV heplock site. RNS 1 stated Resident 33 was on IV antibiotic when he came back from the hospital. RNS 1 stated she forgot to remove the heplock. RNS 1 stated not assessing and changing the dressing could lead to infection. During an interview on 10/4/ 2024, at 3:32 p.m. with the DON, the DON stated the IV heplock dressing should be changed and assessed. The DON stated RNs were responsible in monitoring and assessing IV sites and the practice in the facility was as soon as the resident was finished with the IV therapy, the heplock is discontinued to prevent infection in the iv site. During a review of facility P&P titled Peripheral Needleless Access Device Change dated 3/2023, the P&P indicated peripheral catheter are changed at the time of site rotation or at least every seven days and anytime the integrity of the needless device is questioned. During a review of facility's P&P titled Peripheral Catheter Dressing Change dated 3/2023, the P&P indicated to assess site for complications included redness, drainage, leakage, tenderness in the site. The P&P indicated transparent dressings are changed at least every seven days or if the integrity of the dressing is compromised (wet, soiled, and loose). e. During a concurrent observation and interview on 9/30/2024 at 8:29 a.m., in the clean linen room, Laundry Staff 1 (Laundry 1) was observed wearing a disposable gown and gloves to place soiled linen in the washing machine. A disposable gown was hanging on a hook, which was in the soiled linen area and directly next to the clean linen area. Laundry 1 closed the door dividing the clean linen room and soiled linen room. Laundry 1 stated the disposable gown hanging in the soiled linen area should be thrown away since it was dirty and was located close to the clean linen area. f.During a concurrent observation and interview on 10/2/2024 at 9:04 a.m., with the Infection Prevention Nurse (IPN) and Laundry Staff 2 (Laundry 2), the door between the clean linen and soiled linen room was locked. IPN stated the door between the soiled linen and clean linen rooms should be closed while placing soiled linen in the washing machine to prevent contamination of the clean linen. The IPN stated the disposable gowns used to handle soiled linen should not be hung in the soiled linen area because the gown was contaminated and can potentially contaminate the clean linens. During a review of the facility's policy and procedure (P&P) titled, Handling Soiled Linen, revised 1/25/2024, the P&P indicated transmission of pathogens (bacteria, viruses, and any microorganism causing disease) can occur through direct contact with linens or aerosols (tiny particles or droplets suspended in the air) generated from sorting and handling contaminated linen. The P&P indicated soiled linen shall be kept separate from clean linen. g.During an observation on 10/1/24 at 10:10 a.m., in Resident 37's room, Licensed Vocational Nurse (LVN 4), observed LVN 4 took Resident 37's blood pressure and did not disinfect the blood pressure cuff or stethoscope before or after using the shared care equipment. During an observation on 10/1/24 at 11:10 a.m., in Resident 28's room, observed LVN 4 took Resident 28's blood pressure and did not disinfect the blood pressure cuff, or stethoscope before or after using the shared care equipment. LVN 4 also checked Resident 28's heart rate with a pulse oximeter and did not disinfect equipment before or after using it on Resident 28. During an observation on 10/1/24 at 12:15 p.m., in Resident 38's room observed LVN 4 checked for placement of Resident 38 gastrostomy tube ([g-tube] tube inserted through the abdomen into the stomach) and did not disinfect the stethoscope before or after using the shared care equipment on Resident 38. During a review of Resident 37' s Admission Record, the Admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including hypertensive heart disease without heart failure, cerebral infarction (disrupted blood flow to the brain), and depression (a low mood or loss of pleasure or interest in activities for long periods of time). During a review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/25/2024, the MDS indicated Resident 37 had intact cognitive (ability to think, understand, learn, and remember) skills in daily decision making. During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE] and readmitted [DATE] with the diagnoses including acute and chronic respiratory failure ( a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide [gas]), pulmonary hypertension (the heart work harder than normal to pump blood into the lungs) , hypertensive heart disease (heart problems that occur because of high blood pressure), epilepsy (disorder in which nerve cell activity in the brain is disturbed causing, seizures ), diabetes mellitus type 2, (the body has trouble controlling blood sugar), diabetic neuropathy ( nerve damage caused from diabetes), dementia ( loss of cognitive functioning, thinking, and remembering). During a review of Resident 28's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/17/2024, the MDS indicated Resident 28's cognitive (ability to think, understand, learn, and remember) skills are moderately impaired with fluctuating (comes and goes) capacity. During a review of Resident 28's History and Physical (H&P) dated 5/14/2024 indicated Resident 28 has fluctuating capacity to understand and make decisions. During a review of Resident 38's Admission Record dated 10/3/ 2024, the Admission Record indicated Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including gastrostomy (tube inserted in the stomach to assist with feeding), hypertensive heart disease (heart problems that occur because of high blood pressure), depression (a low mood or loss of pleasure or interest in activities for long periods of time) type 2 diabetes mellitus (the body has trouble controlling blood sugar), and dementia ( loss of cognitive functioning, thinking, and remembering). During a review of Resident 38's MDS dated [DATE] indicated Resident 28 had severe impairment in cognitive skills. During a review of Resident 38's History and Physical (H&P) dated 8/15/2024 indicated Resident 38 was alert and orientated to self and unable to make decisions for self. During an interview on 10/1/24 at 3:15 p.m., with LVN 4, LVN 4 stated, he did not disinfect the blood pressure cuff, stethoscope, or pulse oximetry, before or after using the shared resident's care equipment for Resident's 28, 37, and 38. LVN 4 stated he should have disinfected Resident 28,37, and 38's shared care equipment before and after using it. LVN 4 stated Residents 28,37, and 38 were at risk for infection due to cross contamination. During an interview on 10/2/24 at 2:38 p.m. with Infection Preventionist Nurse (IPN), IPN stated all shared resident care equipment (blood pressure cuff, stethoscope, and pulse oximetry] needs to be disinfected before and after using them on residents. IPN stated without properly disinfecting shared care equipment residents (in general) were at risk for infection due to cross contamination. During an interview 10/2/24 at 10:09 a.m. the Director of Nursing (DON), the DON, stated all shared care equipment blood pressure cuff, stethoscope and pulse oximetry are to be disinfected before and after using them on the residents. The DON stated residents were at risk for infection when shared care equipment was not disinfected properly. During a review of the facility's policy and procedure titled Cleaning and Disinfection of Residents-Care Equipment dated 1/25/2024, indicated Resident -care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non- critical equipment. Each user is responsible for routine cleaning and disinfection of multi- use items after each use, particularly before use for another resident. Use only Environment Protection Agency ([EPA]) registered disinfectants with kill claims for the common organisms found in the facility. If the equipment is exposed to residents on transmission-based precautions, verify the disinfectants are registered for use with the relevant organism. h.During a concurrent interview and record review on 10/02/24 at 3:47 p.m., with Maintenance Supervisor (MS), reviewed facility's Legionella Water Management Program dated 1/5/2024, the Legionella Water Management Program indicated, that water samples are collected to be tested by a certified, CDC- approved laboratory. MS stated the facility was not testing the water for legionella. The MS stated we do not have a Legionella water management program in place. The MS stated residents can get sick and die from Legionella. During an interview on 10/3/24 at 11:30 a.m. with Administrator (ADM), ADM stated, the facility has no plan in place to check for legionella. During a concurrent phone interview and record review on 10/3/24 at 4:22 p.m. with Facility Consultant (FC), reviewed the facility's Legionella Water Management Program dated 1/5/ 2024, the FC stated the Legionella water management program prepared for the facility was a sample and that no assessment or testing of the facilities water system was completed. FC stated residents who inhale aerosol water infected with Legionella could get Legionnaires disease (type of pneumonia) which was associated with high mortality (death) rates for residents with co- morbidities (two or more diseases or medical conditions). During a review of the facility's policy and procedure (P&P) titled, Legionella Surveillance dated 12/19/2022, indicated the facility is to establish primary and secondary strategies for the prevention and control of Legionella infections. Primary prevention strategies: a. Diagnostic testing 1.Investigation for a facility source of Legionella, which may include culturing of facility water for Legionella: Physical Controls: Cooling towers and potable water systems shall be routinely maintained. 11. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. iii. non-potable water systems shall be routinely cleaned and disinfected. Iv. Nebulization devices shall be filled only with sterile fluid (e.g., sterile water or aerosol medication). Temperature controls: Cold water shall be stored and distributed below 68 F. Hot water shall be stored above 140 F and circulated at a minimum return temperature of 124 F. 36943 45269 49889

Based on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 39 and Resident 18) received the necessary treatment and services that will prevent development and promote healing of pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by: a.Failing to monitor and assess Resident 39's skin areas where the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was applied. b. Failing to ensure Resident 18 who had Stage 4 pressure injury on the Sacro coccyx area (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone on the tail bone) was repositioned to offload (method of reducing or removing pressure on the area to help prevent and heal pressure injury) was implemented. These failures resulted in the development of a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) on Resident 39's nose and had the potential to put Resident 18 at risk for delayed healing of Stage 4 pressure injury located in the sacral (triangle shaped bone between the hip bones) and coccyx area (tailbone). Findings: a.During a review of Resident 39's Admission record, the Admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included aphasia ( a disorder that makes it difficult to speak), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), unspecified dementia ( progressive state of decline in mental abilities) and respiratory ( relating to lungs) disorder. During a review of Resident 39's History and Physical (H & P) dated 8/10/2024, the H & P indicated the resident had a fluctuating capacity to understand and make decisions due to seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 39's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/9/2024, the MDS indicated the resident was unable express ideas and wants or unable to understand others. The MDS indicated the resident was dependent on the staff with bathing, toileting hygiene, dressing, personal hygiene, oral hygiene, and transfer to and from the bed to a chair. The MDS indicated the resident had no pressure injury. During a review of Resident 39's Quarterly Braden Scale (standardized, assessment tool used to assess and document resident's risk for developing pressure injuries. The score of 15-18 resident is at risk, 13-14 means moderate risk, 10-12 means high risk and score of 9 and below means very high risk)) dated 4/9/2024, Braden Scale indicated the resident's score is 11. During an observation on 9/30/2024, at 3:35 p.m. in Resident 39's room, Resident 39 was lying in bed, removed the nasal cannula and kept pinching his nostril. Observed a reddened area on the nostril of Resident 39 and an unnamed staff applied the nasal cannula that was laying on the bed of Resident 39. During a concurrent observation and interview with Treatment Nurse (TN1) on 9/30/2024, at 4:00 p.m., TN1 stated Resident 39 had redness on the nasal septum (wall of bone, cartilage, and tissue that separates the left and right sides of the nose). TN 1 stated it was a Stage 1 pressure injury on the nasal area because the skin was intact. TN 1 stated the pressure injury was caused by the nasal cannula and the resident had no prior history of pressure injury on the nose. TN 1 stated the Certified Nurse Assistant's (CNA's) supposed to report to her if there was any change in a resident's skin like redness or scratches. TN 1 stated she was not aware of Resident 39's redness on the nasal septum. During a telephone interview on 10/2/2024, at 12:15 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated he was assigned to the Resident 39 last 9/30/2024 and noticed a redness on the center of the nostril and he applied an ointment because the affected skin looked irritated. CNA1 stated he filled out a skin check form and submitted it to Licensed Vocational Nurse (LVN 2). CNA 1 stated any skin changes should be reported to the licensed nurse because the skin problem could get worse. During an interview on 10/2/2024, at 1:44 p.m. with LVN 2, LVN 2 stated she could not remember if Resident 39's skin check form was submitted to her and did not receive any notification from CNA1 that Resident 39 developed redness on the nose. LVN 2 stated everyone is responsible in checking the skin of each resident and if there was any presence of skin issue, the CNA's report them to the licensed nurse and treatment nurse is notified. LVN 2 stated she did not check the skin of Resident 39's skin behind the ears and nose last 9/30/2024. LVN 2 stated she was supposed to check residents' skin every shift. During an interview on 10/2/2024, at 2:55 p.m. with TN 1, TN 1 stated the CNA's supposed to check the skin of all residents while they are doing their care and notify licensed nurses for any skin changes.TN 1 stated the staff should perform skin check every day and should have assessed residents' skin who had medical device like nasal cannula for any skin breakdown while in use because pressure injury could develop within a couple of hours on the nose. During an interview on 10/2/2024, at 3:56 p.m. with RN Supervisor (RNS1), RNS 1 stated all licensed nurses should assess the skin of residents. RNS 1 stated the licensed nurses should have checked the skin of residents with nasal cannula frequently and pressure injury related to the use of nasal cannula is preventable. RNS 1 stated if the resident's skin is not monitored and assessed for skin breakdown related to the use of nasal cannula, redness could develop to deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue due to pressure or shear) or the wound could get worse. b.During a review of Resident 18's Admission Record, the Admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included Stage 4 pressure ulcer of sacral region (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone on the tail bone), and contracture of right and left knee ( stiffening /shortening at ant joint that reduces the joint's range of motion of right and left knees). During a review of Resident 18's History and Physical (H & P) dated 4/15/2024, the H and P indicated the resident did not have the capacity to understand and make decisions. During a review of MDS dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making (decisions are poor and supervision or cues is required), and required substantial assistance with eating, oral hygiene, dressing, toileting, personal hygiene, and bed mobility. The MDS indicated the resident had one unhealed Stage 4 pressure injury. During a review of Resident 18's Braden Scale dated 9/13/2024, the Braden scale indicated a score of 15. During a review of Resident 18's Physician Order date 8/20/2024, the Physician Order indicated for Sacro coccyx: cleanse with normal saline, pat dry, apply collagen ( medicine used for wound healing), pack with saline moistened hydrofera blue ( sterile, absorbent, and moist foam dressing) dressing that provide and cover with foam dressing as needed for pressure ulcer if soiled or dislodged. During a review of Resident 18's Wound Progress Report dated 9/9/2024, the progress Report indicated the resident had a chronic, non-healing pressure ulceration in the Sacro coccyx area and had been present for approximately 7 months. During a review of Resident 18's Care Plan about resident's actual/ potential impairment to skin integrity related to sacrococyx (related to sacral and coccyx area) pressure ulcer/injury revised on 6/25/2024. The Care Plan 's goal indicated the resident will not develop further skin breakdown and complications. The Care Plan interventions included avoiding friction or shearing to prevent further skin impairment, offloading affected area as much as possible and reminding, reeducating resident to reduce constant sliding self-up and down to avoid friction and shear. During an observation on 9/30/2024, at 10:54 a.m., Resident 18 was lying on his back both legs are bent towards the left side of the bed. During a subsequent observation on 10/2/2024, at 8:10 a.m. and on 10/2/2024, at 4:12 p.m. in Resident 18's room, Resident 18 was lying on his back with pillows. During an interview on 10/4/2024, at 10:41 a.m. with Certified Nursing Assistant (CNA7), CNA 7 stated Resident 18 had a pressure injury in his lower back and redness on the scrotal area. CNA7 sated the resident is difficult to turn and reposition because his legs turned to the left side and threw the pillows on his back. CNA7 stated the pillows would only remain on his right side for or left side for ten minutes. CNA7 stated the pillows are placed on the left side of his legs because he liked the position. During an interview on 10/4/2024, at 11:43 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated they were using pillows since April 2024 to reposition and offload the pressure injury on the sacral and coccyx area. LVN 2 stated the resident liked to be positioned to the left and when pillows are used to position him on the right, the resident removed the pillow and always moved a lot. LVN 2 stated if the resident's pressure injury site is not offloaded properly it could get worse. During an interview on 10/3/2024, at 1:19 p.m. with Treatment Nurse (TN 1),TN 1 stated the condition of resident's pressure injury on his Sacro coccyx area is up and down because the resident tends to slide down on the bed, TN1 stated they tried to reposition him to reduce the pressure on the wounds by using pillows but the resident removed the pillows and unable to stay in one position because of the contractures on both of his legs. TN 1 stated she could not encourage him to follow instructions in repositioning because the resident would not understand due to poor cognitive skills (a person had trouble with thinking, learning, remembering, and making decisions).TN 1 stated when the resident repositioned himself when he is agitated causing him to slide up and down in the bed. TN 1 stated she should have contacted the physician for effective interventions that could help heal the resident's pressure injury other than what was in place to help offload the sacral area. During an interview on 10/4/2024, at 11:06 a.m. with RN Supervisor (RNS1), RNS 1 stated because of Resident 18's behavior manifested by frequent movements they could not keep him on one position or reposition him on one side. RNS 1 stated the facility is planning to use a wedge pillow to help the resident with repositioning. RNS 1 stated resident's pressure injury was not improving. During a subsequent interview on 10/4/2024, at 3:11 p.m. and at 3:05 p.m. with Director of Nursing (DON), DON stated residents with pressure injury who are not properly repositioned, and interventions implemented for offloading pressure injury were not working, the pressure injury could deteriorate and worsen. DON stated CNAs should identify any skin breakdown during care or shower and report it to the charge nurse. DON stated the CNA's can verbally report the skin concern to the charge nurse and the licensed nurse will do a skin assessment, change of condition, notify the physician, and obtain treatment order. DON stated not monitoring and assessing any skin breakdown could result to a higher degree of pressure injury. During a review of facility's policy and procedure(P/P) titled Pressure Injury Prevention and Management revised 1/25/2024, the P/P indicated the facility is committed to the prevention of avoidable pressure injury, prevent infection and the development of additional pressure injuries. The P/P indicated nursing assistants will inspect skin during bath and will report any concerns to the nurse immediately, licensed nurses will conduct a full body skin assessment at least weekly, and assessment of pressure injuries will be performed by a licensed nurse. The P/P indicated interventions will be modified for any changes in resident's degree of risk for developing a pressure injury, residents' noncompliance, and lack of progression in wound healing.

49145 Based on observation, interview, and record review, the facility failed to ensure two of three residents had clean and trimmed nails (Resident 17 and 45). This failure had the potential to negatively impact the resident's quality of care and self-esteem. Findings: 1.During a review of Resident 17's Admission Record, the Admission Record indicated Resident 10 was admitted on [DATE] with diagnoses that included Psoriatic Arthritis Mutilans (rare and painful condition that severely damages the hands, feet, and sometimes the spine) and atrial fibrillation (irregular and fast heartbeat). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/26/2024, the MDS indicated Resident 17 required partial/moderate assistance (helper does less than half the effort) with personal hygiene. During a review of Resident 17's care plan initiated 9/6/2024, the care plan focus was, Resident 17 was at risk for skin integrity with goals that included Resident 17 was to maintain and develop clean and intact skin and was to minimize skin injuries such as skin tears. Interventions for Resident 17 included to avoid scratching and keep hands and body parts from excess moisture; keep fingernails short and to identify/document potential causative factors and eliminate/resolve where possible. During a review of Resident 17's care plan initiated 9/6/2024, the care plan focus was, Resident 17 had potential for bleeding, bruising, and/or skin tears secondary to aspirin therapy (a drug that reduces pain, fever, inflammation, and blood clots) with goals that included Resident 17 will have no bleeding episodes. Interventions for Resident 17 included to check skin per protocol and monitor for bruising or bleeding. During an observation on 10/1/2024, at 2:05 p.m., in Resident 17's room, Resident 17 was observed unclean and long fingernails. Resident 17 stated he is unable to cut his own nails because of his arthritis (swelling and tenderness of one of more joints). During a concurrent observation and interview on 10/1/2024, at 2:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 verbally confirmed Resident 17's nails were unclean and long. LVN 3 stated besides the certified nurse assistants (CNA), she is also responsible for cutting the resident's fingernails. LVN 3 stated it is important to keep the residents' nails cut and clean to prevent bacteria from building up under their nails and to prevent residents from scratching or hurting themselves. During an interview on 10/2/2024, at 10:05 a.m., with Certified Nurse Assistant (CNA) 5, CNA 5 stated the CNAs are responsible to cut and clean the residents' fingernails and it is her practice to assess their fingernails when she bathes/showers them. CNA 5 stated it is important to cut the resident's nails and keep them clean for infection control and, so they do not scratch themselves. During a concurrent interview and record review on 10/4/2024, at 11:30 a.m., with the Registered Nurse Supervisor (RNS) 1, RNS 1 was reviewing the Shower Day Skin Inspection form, dated 10/1/2024. RNS 1 stated the form is filled out by the CNA's. RNS 1 verbally confirmed CNA 4 documented Resident 17's fingernails were clean but there was no documentation under need clipping. RNS 1 stated CNA 4 should have documented that Resident 17's nails need trimming because he could potentially scratch himself and for infection control because there could be bacteria under his nails. During a concurrent interview and record review on 10/4/2024, at 3:05 p.m., with the Director of Nursing, the DON states fingernail care for the resident's is the responsibility of the CNA's and is part of their daily tasks. The DON stated long, and dirty fingernails can lead to skin breakdown from scratching which could then lead to infection. The DON reviewed Resident 17's Shower Day Skin Infection form, dated 10/1/2024, and stated CNA 4 documented Resident 17's nails were clean but did not document under need clipping. 2. During a review of Resident 45's Admission Record, the Admission Record indicated the resident was initially admitted on [DATE] to the facility with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia( a progressive state of decline in mental abilities) and osteoporosis( a weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 45's History and Physical (H &P) dated 11/25/2023, the H & P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 45's MDS dated [DATE], the MDS indicated the resident required partial/ moderate assistance with personal hygiene. During a review of Resident 45's Care Plan revised 1/19/2024, the Care Plan indicated the resident had an activity of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) deficit related to disease process, fatigue, and impaired balance. The care plan's goal indicated the resident will improve current level of function in ADL through review date. The care plan's interventions included to check nail length, trim and clean on bath day as necessary and report any changes to the nurse. During a subsequent observation on 9/30/2024, at 10:12 a.m. and 1:10 p.m., observed Resident 45's fingernails were long and dirty. Observed resident eating lunch using his hands and putting a piece of porkchop in his mouth. Resident 45's fingernails remained long and dirty. During a telephone interview on 10/2/2024, at 12:15 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45's fingernails were somewhat long and dirty, but the resident refused his fingernails to be trimmed. During an interview on 10/2/2024, 1:26 p.m. with LVN 1, LVN 1 stated nobody told him Resident 45's fingernails were long and dirty. LVN 2 stated it's important to trim residents' fingernails because long and dirty fingernails had bacteria and dirt underneath the fingernails which resident could ingest and cause infection. During an interview on 10/2/2024, at 2:12 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated she could not remember any CNAs reporting Resident 45's long and dirty fingernails. LVN 2 confirmed the resident had no care plan indicating noncompliance to care or refusal of care related to fingernails trimming. During a review of the facility's policy and procedure (P&P) titled, Nail Care, revised 1/25/2025, the P&P indicated, Routine cleaning and inspection of nails will be provided during Activities of Daily Living (ADL) care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Principles of nail care: nails should be kept smooth to avoid skin injury. During a review of the facility's P&P titled, Activities of Daily Living (ADLS), revised 1/25/2024, the P&P indicated, The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

49145 Based on observation, interview and record review, the facility failed to ensure two of 14 sampled residents received effective pain management by: 1.Failing to assess and treat one of three resident's experiencing pain (Resident 11). 2.Failing to ensure Resident 18's pain level assessment is based on the cognitive level (mental process involved in knowing, learning, and understanding things) of the resident. These failures had the potential to put Resident 11 and Resident 18 at risk for pain to go unrecognized and untreated leading to delay of care and treatment. Findings: 1.During a review of Resident 11's Admission Record, the Admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and headaches. During a review of Resident 11's care plan initiated on 2/16/2024, the care plan focus was, Resident 11 had hypertension with goals that included Resident 11 was to remain free from signs and symptoms (s/s) of hypertension. Interventions for Resident 11 included monitoring, documenting, and reporting any s/s of hypertension: headache, visual problems, and confusion. During a review of Resident 11's care plan initiated on 10/2/2024, the care plan focus was Resident 11 complains of constant pain with goals that included Resident 11 will minimize complaints of pain. Interventions for Resident 11 included monitor pain every four hours. During a review of Resident 11's Medication Administration Record (MAR), the MAR indicated monitoring for pain every four hours was not initiated until 10/3/2024 at 4:00 p.m. During an interview on 10/1/2024, at 10:09 a.m., with Resident 11, Resident 11 stated he had a headache since 9:00 a.m. and had not yet received his morning medications and his nurse had not yet been in to see him. During a review of Resident 11's MAR, Resident 11 had Fioricet (medication for tension headaches) scheduled for 8:00 a.m. but was not documented that it was given. During an interview on 10/1/2024 at 11:30 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he did not pass medications for Resident 11 because Resident 11 can be difficult sometimes and he usually asks the nurse in station 1 to pass Resident 11's medications but was not thinking and forgot to ask the other nurse. During an interview on 10/2/2024 at 3:37 p.m., with Registered Nurse Supervisor (RNS) 1, RNS stated it is important to assess for pain, so the resident does not suffer. RNS 1 stated for Resident 11, it's important to assess and treat his headache because he has a history of hypertension, and it could possibly lead to a stroke. During an interview on 10/4/2024 at 3:05 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses are responsible for rounding on the residents every two hours and assessing them for pain. The DON stated Resident 11 should have been assessed and treated for pain because he has hypertension and was complaining of a headache which could possibly lead to complications such as a stroke. 2. During a review of Resident 18's Admission Record, the Admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included Stage 4 pressure ulcer of sacral region (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone on the tail bone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), autistic disorder( developmental disability that affects how people communicate, interact, learn, and behave), and contracture of right and left knee ( stiffening /shortening at ant joint that reduces the joint's range of motion of right and left knees). During a review of Resident 18's History and Physical (H & P) dated 4/15/2024, the H and P indicated the resident did not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated the resident had moderately impaired cognitive skills for daily decision making( decisions are poor and supervision or cues is required), The MDS indicated the resident required substantial assistance with eating, oral hygiene, dressing, toileting, personal hygiene, and bed mobility. During a review of Resident 18's Physician Order dated 9/18/2024, the Physician Order indicated Acetaminophen (Tylenol, medicine used to relieve pain) 325 milligrams (mgs, unit of measurement) 2 tablets by mouth every 4 hours as needed for pain not to exceed three grams (GM, unit of measurement ) in 24 hours. During a review of Resident 18's Medication Administration Record (MAR) for October 2024, the MAR indicated on 10/3/2024, at 7:15 a.m. Resident 18 received acetaminophen 325 mgs. 2 tablets for a pain level of 5. (numerical pain rating scale, pain screening tool used to assess pain severity using a 0-10 scale with zero meaning no pain, 1 to 3 is mild pain,4 to 6 is moderate and 7-10 is severe pain). During a review of Resident 18's Quarterly Pain Interview dated 9/12/2024, the Quarterly Pain Interview indicated the resident was unable to answer when asked if the resident had pain or hurting at any time in the last five days. During a concurrent observation and interview on 10/3/2024, at 9:36 a.m. with Treatment Nurse (TN 1) in Resident 18's room, Resident was moaning and grimacing during change of wound dressing over the sacral area.TN 1 stated the resident had a stage 4 pressure injury on the sacral area. Observed Resident 18 stated No when asked by TN1 and CNA7 if in pain but Resident 18 was moaning louder, grimacing when TN 1 removed and replaced the dressing on the sacral area. Observed Certified Nursing Assistant (CNA7) turned resident to the right side and resident resisted to be turned to the right side and continued to moan as the TN 1 resumed with the dressing change. TN 1 stated Resident 18 received Acetaminophen 325 mgs. at 7:15 a.m. today for pain. During a subsequent observation and interview on 10/3/2024, at 10:28 a.m. at 1:39 p.m. with, LVN 1 stated the Resident 18 pain level was 5/10 when he administered the at 7:15 a.m., was verbally responsive and could give him the intensity of pain level. LVN 1 asked Resident 18 if he was in pain by using numerical pain rating scale and explained to the resident how to use the numerical pain rating scale. LVN 1 stated to the resident if his pain level was 4, Resident 18 responded Yeah and when LVN 1 asked the resident if his pain level was 5 out of 10 and explained again how to use the numerical pain rating scale to the resident, the resident responded Yeah. LVN 1 stated the resident could only answer yes or no but could not carry a conversation. LVN 1 agreed using numerical pain rating scale was not an accurate way of assessing pain level of the resident due to impaired cognitive skills ( a person had difficulty with thinking, learning, remembering, and using judgement).LVN 1 stated he should have monitored nonverbal signs of pain like facial grimacing or moaning when assessing pain level of Resident 18 to determine if he was really in pain or not. During an interview on 10/4/2024, at 11:06 a.m. with RN Supervisor (RNS 1), RNS 1 stated Resident 18 pain level should be assessed using nonverbal signs because he could not talk. RNS 1 stated nonverbal signs of pain are moaning, body movement become tense, stiff, and gripping on the caregiver. RNS 1 stated using numerical pain rating is not a reliable indicator of pain and they would not be able to manage Resident 18's pain adequately because pain was not assessed properly. During an interview on 10/4/29024, at 3:11 p.m. with Director of Nursing (DON), DON stated the staff should use nonverbal signs of pain because Resident 18 had a cognitive impairment and could only answer to questions yes or no. DON stated the facility would not be able to provide effective pain management if the pain assessment was inaccurate. During a review of facility's policy and procedure (P/P) titled Pain management revised 1/25/2024, the P/P indicated the facility staff will observe for nonverbal indicators which may indicate the presence of pain and will use a pain assessment tool which is appropriate for the resident's cognitive status to assist the staff in consistent assessment of resident's pain. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs.

Based on observation, interview and record review, the facility failed to ensure the resident, who underwent an open reduction internal fixation ([ORIF] a surgical procedure that puts pieces of a broken bone into place using screws, plates, sutures, or rods) surgery of the right ankle fracture (break in the bone), did not have the surgical wound infected with exposed surgical hardware (pins, plates, or screws used to help fix a broken bone, torn tendon, or to correct an abnormality in a bone) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure treatment nurses (TN 1 and TN 2) followed Resident 1's orthopedic surgeon's treatment orders to stop using an antibiotic ointment (a substance used on the skin to soothe or heal wounds) on Resident 1's right medical ankle and to use a Betadine (a solution used to prevent infection in minor cuts, scrapes, and burns) soaked gauze treatment to Resident 1's right ankle starting on 2/7/2024. TN 1 and TN 2 continued to apply ointment to Resident 1's surgical wound from 2/7/2024 to 2/10/2024 (three days). 2. Ensure TN 1 and TN 2 followed Resident 1's Care Plan dated 1/19/2024 and 2/1/2024 to notify Resident 1's physician and/or Resident 1's orthopedic surgeon when Resident 1's surgical hardware was observed being exposed through Resident 1's right ankle surgical site on 2/10/2024. 3. Ensure TN 1 documented a Change of Condition (COC-communication tool use to share information about resident) when she identified for the first time Resident 1's surgical hardware was visible through the resident's right ankle surgical incision (a cut that is made in skin during a surgery) on 2/10/2024. 4. Ensure TN 1 notified Resident 1's physician and orthopedic surgeon (a doctor who specializes in the prevention, diagnosis, and treatment of disorders of the bones, joints, ligaments, tendons, and muscles) when identified Resident 1's surgical hardware became visibly exposed through the resident's surgical incision on a right ankle on 2/10/2024. 5. Ensure TN 2 notified Resident 1's physician and orthopedic surgeon when first noted Resident 1's surgical hardware became visibly exposed through the resident's surgical incision on a right ankle on 2/20/2024. These deficient practices resulted in Resident 1's right ankle surgical incision becoming infected and Resident 1's transfer to a General Acute Care Hospital (GACH 1) where Resident 1 underwent a surgical procedure to remove infected hardware with irrigation and debridement (washout and removal of dead, infected, or contaminated tissue) of the infected wound and placement of a wound vacuum (a vacuum device that promotes healing by gently pulling fluid from the wound over time, reducing swelling, cleaning the wound and removing bacteria). Findings: During a review of Resident 1's Change in Condition (COC) dated 12/08/2024, the COC indicated Resident 1 used a shower chair to climb out of a bathroom window and was found sitting on the ground outside of the facility under the window holding her right ankle and grimacing from pain. The COC indicated Resident 1's physician was notified, and the physician ordered for Resident 1 to be transferred to GACH 2 for further evaluation. During a review of GACH 2's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH 2 on 12/08/2024 with a diagnosis of a right tibia (the inner and typically larger of the two bones between the knee and the ankle) and fibula (the outer and usually smaller of the two bones between the knee and the ankle) fracture. During a review of Resident 1's Discharge Summary from GACH 2 dated 1/18/2024, the Discharge Summary indicated on 12/9/2023 Resident 1 ORIF surgery of the right ankle. The Discharge Summary indicated Resident 1 was discharged from GACH 2 on 1/18/2024. During a review of Resident 1's Admission Record (Face Sheet) to the facility, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including a history of falling and a displaced comminuted (type of broken bone where the bone snaps into two or more parts and moves so that the two ends are not lined up straight) fracture of the shaft of the right fibula and right tibia. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/22/2024, the MDS indicated Resident 1's cognitive (thinking and reasoning) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate to maximum assistance from staff to complete most activities of daily living ([ADLs] eating, drinking, toileting, and dressing). During a review of Resident 1's Physician's Order dated 1/19/2024, the Physician's Order indicated to cleanse Resident 1's right medial (toward the middle or center) ankle with normal saline ([NS] a non-toxic solution that does not damage healing tissues), pat dry, apply betadine then cover with a dry island dressing (a dressing that is ideal for the treatment of wounds with light drainage) daily and as needed. During a review of Resident 1's Care Plan dated 1/19/2024, the Care Plan indicated Resident 1 had a potential/actual impairment of the skin integrity to the surgical site on her right medial ankle. The Care Plan indicated Resident 1 had sutures (row of stitches holding together the edges of a wound or surgical incision) to her right medial ankle and was at continued risk for skin breakdown related to her fragile skin and infection. Under this Care Plan a goal was for Resident 1 to have no complications through the next review date (1/27/2024). The Care Plan's interventions included reporting declines in skin integrity to Resident 1's physician. During a review of Resident 1's COC note dated 2/1/2024, the COC note indicated Resident 1's surgical wound on the medial ankle had a moderate amount of pus (thick yellowish or greenish liquid produced from an infected tissue), redness, swelling and warmth. The COC note indicated Resident 1's surgical wound was cleansed with NS, following application of Betadine (a solution that kills germs to prevent infection) and Mupirocin ointment (an antibiotic ointment used to treat bacterial skin infections) according to the wound physician's recommendation. The COC note indicated Resident 1's primary physician was notified of the COC. During a review of Resident 1's Care Plan dated 2/1/2024, the Care Plan indicated Resident 1 had drainage coming from the surgical wound site on the right ankle surgical site. Under this Care Plan the goal for Resident 1 was to be free from any complications related to the surgical site on the right ankle. The Care Plan's interventions included to notify the physician regarding any Resident 1's COC. During a review of Resident 1's Physician's Order dated 2/6/2024, the Physician's Order indicated to apply Mupirocin to Resident 1's right medial suture/wound every day shift, cleanse the wound with NS, pat dry, apply Bactroban (an antibiotic ointment used to treat skin infections) then cover with an abdominal ([ABD] a pad used to absorb discharges from the abdominal and other heavily draining wounds) pad dressing and wrap with a Kerlix (hypoallergenic gauze rolls that provides fast-wicking [quickly moving fluid to the fabric's outer surface] action, superior aeration (circulation of air), and excellent absorbency). During a review of Resident 1's orthopedic surgeon Progress Note dated 2/7/2024, the Progress Note indicated the orthopedic surgeon ordered a Betadine-soaked gauze, no ointment, to apply to Resident 1's right ankle medial incision, every two to three days. During a review of Resident 1's Nursing Progress Notes dated 2/10/2024 and timed at 9:17 a.m., the Nursing Progress Notes indicated a hardware was visible in Resident 1's right lower leg. During a review of Resident 1's Skin and Wound Evaluation dated 2/13/2024, the Skin and Wound Evaluation indicated the hardware was visible in Resident 1's wound bed on the right ankle and the section that indicated if Resident 1's physician was notified was left blank. During a review of the Wound Physician's Consult Note dated 2/13/2024, the Wound Physician's Consult Note indicated Bactroban, and a dry dressing were applied to Resident 1's surgical wound on a right ankle. The Physician's Wound Consult Note indicated there was exposed hardware at the distal (a part of the body that is farther away from the center of the body than another part) end of Resident 1's surgical wound on the right ankle. During a review of Resident 1's Treatment Record dated 2/2024, the Treatment Record indicated the following: 1. From 2/7/2024 - 2/10/2024 Mupirocin and Bactroban was applied to Resident 1's right ankle medial suture/wound daily (when order from orthopedic surgeon on 2/7/2024 indicated no ointment to be used). 2. There was no documentation that Resident 1's right ankle medial suture/wound was treated with a Betadine-soaked gauze every two to three days as ordered on 2/7/2024. During a review of Resident 1's Physician Orders dated 2/7/2024, the Physician's Order indicated Resident 1 had a follow up appointment with the orthopedic surgeon on 2/21/2024 at 9:45 a.m. During a review of Resident 1's orthopedic surgeon Progress Note, dated 2/21/2024, the Progress Note indicated there was no wet to dry (Betadine-soaked gauze) dressing done at the facility, Resident 1's surgical incision was noted with drainage (fluid) and an exposed screw at the surgical incision site on a right ankle. The orthopedic surgeon Progress Note indicated Resident 1 was referred to the emergency room for intravenous ([IV] in the vein) antibiotics and a Wound Care Consult for an exposed screw. During a review of Resident 1's Nursing Progress Notes dated 2/21/2024 and timed at 1:22 p.m., the notes indicated Resident 1 went to orthopedic surgeon appointment and returned with a new order to transfer Resident 1 to the emergency room (ER) due to infected right tibia with exposed hardware. During a review of Resident 1's Physician's Order, dated 2/21/2024 the Physician's Order indicated to transfer Resident 1 to a GACH due to an infected right tibia with exposed hardware. During a review of GACH 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to GACH 1 on 2/22/2024 with diagnoses including a right ankle surgical wound infection with exposed orthopedic hardware. During a review of GACH 1's History and Physical (H&P) dated 2/22/2024, the H&P indicated during the physical exam of Resident 1's right ankle, there was a two centimeter ([cm] a unit of measurement) wound in length with an exposed screw (part of the hardware) on Resident 1's right medial malleolus (the inside of the ankle formed by the tibia). During a review of Resident 1's Orthopedic Medicine Progress Note dated 2/24/2024, the Orthopedic Medicine Progress Note indicated Resident 1's right lower extremity hardware was removed, the wound was irrigated and debrided (the process of removing dead skin and foreign material from a wound), closed and a wound vacuum was placed in the wound. During a review of GACH 1's Discharge Order, dated 2/26/2024, GACH 1's Discharge Orders indicated to leave the dressing to the right ankle in place until follow up appointment with orthopedic surgeon in one to two weeks. During an observation of Resident 1 on 2/29/2024 at 12:15 p.m., at the facility, Resident 1 was observed in her room with a small wound vacuum machine attached to the resident's right ankle with a cannister at the foot of her bed. During an interview on 2/29/2024 at 1:30 p.m., and a subsequent interview on the same day at 3:30 p.m., Treatment Nurse 2 (TN 2) stated Resident 1's right medial ankle surgical wound was treated with Mupirocin from 2/7/2024 until 2/10/2024. TN 2 stated when she (TN 2) was treating Resident 1's wound on 2/20/2024, she could see the top of a metal button that looked like the top of a screw, on Resident 1's right medial lower leg surgical incision. TN 2 stated she was not sure if the metal hardware was supposed to be visible through the incision site, but the incision did not look normal because there was no skin covering the hardware. TN 2 stated she did not notify Resident 1's physician or the orthopedic surgeon that the hardware was visible, and stated she did not create a COC form and could offer no explanation why. TN 2 stated if there was no skin covering Resident 1's wound to protect it, the wound could get infected. During an interview on 2/29/2024 at 2:35 p.m., and a subsequent interview on 3/1/2024 at 2:22 p.m., TN 1 stated on 2/10/2024 she noticed hardware was visible in Resident 1's right ankle surgical wound. TN 1 stated she reported to the wound doctor that the hardware in Resident 1's surgical incision was visible, and he (the wound doctor) did not provide any new orders for treatment of the visible hardware. TN 1 stated she did not notify the orthopedic surgeon on 2/10/2024 when she noticed the visible hardware because Resident 1 had a follow up appointment with the orthopedic surgeon in a few days on 2/21/2024, (11 days after the hardware was noticed in Resident 1's wound) and she thought the surgeon could evaluate it then. TN 1 stated she should have notified the orthopedic surgeon about the visible hardware in Resident 1's surgical wound incision on 2/10/2024 when she first noticed it and documented what she saw as a COC. TN 1 stated she overlooked treating Resident 1's wound with Betadine-soaked gauze and she should have stopped using the ointments (Mupirocin and Bactroban) on Resident 1's incision site, per the orthopedic surgeon's order on 2/7/2024. TN 1 stated the physician's orders should have been carried out as the orders were written and the resident's physician should be called if clarification of the order was needed. During an interview on 3/1/2024 at 4:11 p.m., the Director of Nursing (DON) stated if there was a COC to resident's skin, the nurse should have notified Resident 1's physician and documented that change on a COC form. The DON stated visible hardware was a COC, but she was not sure if Resident 1's physician or the orthopedic surgeon were notified. The DON stated if hardware was visible through Resident 1's incision, that meant the incision was open and there was a higher chance of infection to occur. The DON stated properly transcribing and implementing physician orders helps ensure residents receive proper treatment to promote healing and prevent an infection. During a review of the facility's policy and procedure (P/P) titled, Notification of Changes, dated 12/2022, the P/P indicated the facility must consult with the resident's physician when there is a significant change in the resident's physical condition which may include clinical complications, circumstances that require a need to alter treatment. During a review of the facility's P/P titled Provision of Physician Ordered Services, dated 12/2022, the P/P indicated qualified nursing personnel will administer therapeutic treatments as ordered by the physician. During a review of the facility's Job Description for a Treatment Nurse dated 2003, the Job Description indicated the job functions of the treatment nurse include examining the resident's records and charts and discriminate between normal and abnormal findings to refer the resident to a physician for evaluation and supervision. The treatment nurse's job function included providing assessments and diagnostic services to the residents.

Based on interview and record review, the facility failed to ensure adequate preparation and a safe discharge for one of three sampled residents (Resident 1). Resident 1, who needed a Hoyer lift (brand name of a transfer lift, an assistive device used by caregivers to facilitate safe transfers from or to bed and chair), and was dependent on oxygen, was discharged to a lower level of care, an Assisted Living Facility (ALF) which did not have oxygen and mechanical lift for transfers. As a result, on 8/31/18, five hours after transferring Resident 1 to the ALF with a portable oxygen tank, the oxygen ran out, and Resident 1 became short of breath. The ALF staff called paramedics, and Resident 1 required transferring to General Acute Care Hospital 1 (GACH 1) where she was admitted with a [DIAGNOSES REDACTED]. Finding: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 6/19/18, indicated Resident 1 had severely impaired cognition (ability to think and reasoning), was unable to walk, and required extensive assistance by staff with bed mobility, dressing, eating, toilet use, and personal hygiene. Resident 1 needed two-person physical assistance with transfers (from and to bed or wheelchair). The MDS indicated Resident 1 used a wheelchair as a mobility device. A review of the care plan dated 6/13/18 indicated Resident 1 was at risk for activities of daily living (ADL) decline related to Resident 1 being non-ambulatory (not walking). The goal was for ADL decline be minimized with interventions daily. The approaches identified were to assist with activities of daily living (ADLs - such as dressing, eating, and personal hygiene) as needed and monitor for any decline and provide physical therapy (PT) / occupational therapy (OT) as ordered. A review of Resident 1's Physical Therapy Plan of Care (Evaluation Only) dated 6/14/18 indicated the resident required total assistance (100% assist) with transfers, bed/chair. A review of Resident 1's Respiratory Care Plan, dated 6/21/18 indicated the resident was at risk for respiratory complications due to [MEDICAL CONDITION]. The goal was for complications related to respiratory status/[DIAGNOSES REDACTED]. One of the identified interventions was to monitor oxygen saturation as ordered; oxygen therapy if ordered. A review of the Social Work Progress Note dated 8/30/18 indicated Resident 1 was approved for discharge the next day (8/31/18) to an ALF after an evaluation but did not include who evaluated Resident 1. The note did not include who made the determination an ALF was appropriate for Resident 1. A review of the facility's Social Work Progress Note dated 8/31/18, indicated Resident 1 would be discharged to an ALF and would be followed up by Home Health. There was no information about the Home Health Agency (HHA) and what services the HHA would provide to Resident 1. A review of the physician's orders [REDACTED]. The physician ordered Home Health Agency services and no medical equipment. A Review of the POS [REDACTED]. It consists of a lightweight tube which on one end splits into two prongs placed in the nostrils). A review of the Discharge Summary/Comprehensive Assessment for Resident 1 dated 8/31/18 did not include Resident 1's need of a mechanical lift and two-person assist with transfers. A review of the Nurses' Note dated 8/31/18, timed at 10 a.m., indicated the Social Services Designee (SSD) informed Registered Nurse 1 (RN 1) the ALF staff was aware Resident 1 needed assistance with transfers using the Hoyer lift and was on oxygen. The note did not indicate which ALF staff the DSD spoke with and made arrangement for Resident 1's transfer. There was no documentation the SSD informed the ALF staff about Resident 1's need of a Hoyer lift for transfers and dependence on oxygen. At 4 p.m., the note indicated the facility discharged Resident 1 via transportation van with a portable oxygen tank. There was no documentation the licensed nurses communicated with the ALF's staff about Resident 1's needed care before Resident 1's discharge. A review of the Paramedics Prehospital Care Report Summary Note dated 8/31/18, indicated the ALF called at 9:30 p.m. and arrived at the ALF at 9:33 p.m., due to a chief complaint of Resident 1 having shortness of breath. Resident 1 was found sitting in a wheelchair, complaining of shortness of breath for 30 minutes. The AFL staff stated Resident 1 transported to them without authorization. A review of GACH 1's Emergency Department (ED) Provider Report dated 8/31/18 timed at 10:21 p.m., indicated Resident 1 had prolonged expiratory phase (moving air out of the lungs), diffused rhonchi (low pitched rattling lung sounds) and diffusely scattered wheezes (continuous, coarse, [MEDICATION NAME] lung sound). Resident 1 was stabilized and transported to inpatient services (admitted to the hospital). A review of GACH 1's History and Physical (H&P) Examination dated 9/1/18, indicated Resident 1 was admitted with acute respiratory distress with [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues) and [MEDICAL CONDITION] in acute exacerbation (sudden worsening of [MEDICAL CONDITION] symptoms). Resident 1 received intravenous (inside the veins) steroids (medication to decrease swelling), breathing treatment and a short course of antibiotics. GACH 1 discharged Resident 1 on 9/6/18 back to the facility. On 9/11/18 at 12:10 p.m., during an interview, the Director of Nursing (DON) confirmed there was no documented evidence of evaluation of Resident 1's discharge to the ALF. There was no assessment of Resident 1's medical and physical needs would be met at the ALF. The DON also confirmed there was no documentation about the HHA and if the HHA would be able to provide the necessary care to Resident 1. On 9/11/18 at 12:30 p.m., during an interview, RN 1 stated the SSD verbally informed her on 8/31/18 at around 10:00 a.m. the ALF accepted Resident 1 and would be leaving at 3:00 p.m. the same day. RN 1 stated she did not call the ALF to report Resident 1's discharge because SSD arranged it. On 9/11/18 at 1:50 p.m., during an interview, Resident 1 stated she could not remember the discharge to the ALF. On 9/11/18 at 1:58 p.m., during an interview, the Administrator stated he received a call from the administrator of the ALF on 8/31/18 at 8:47 p.m. (four hours after arrival to the ALF) indicating they could not care for Resident 1. The Administrator stated when he called the ALF back at around 10:00 p.m., Resident 1 was already at GACH 1. On 9/14/18 at 2:15 p.m., during a telephone interview, the Assistant Administrator of the ALF stated they were not aware Resident 1 needed oxygen or needed a lift for transfers. The AFL did not have a lift or oxygen. Resident 1 arrived with one portable oxygen tank, and when the oxygen ran out Resident 1 was short of breath, and they called paramedics (911). A review of the facility's policy titled, Transfer/Discharge Policy and Procedure, dated 11/2016, indicated before the transfer or discharge occurs, the facility must notify the physician, the receiving provider or facility, the resident and if known, the resident's representative, of the transfer, the reason for the transfer or discharge, and document in the resident's clinical record. Social Services will complete the Notice of Proposed Transfer/Discharge form and give it to the resident before the transfer or discharge. The Social Services will document the discharge plan and services per the facility's Discharge Planning Policy and Procedure. A review of the facility's policy titled, Discharging the Resident, revised (MONTH) 2010 indicated if the resident is being discharged to a hospital or another facility, ensure that a transfer summary is complete and telephone report made to the receiving facility.