Every finding on record at Park Manor Bee Cave

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's code status on her care plan based on her wishes and OOH DNR signed by her legally authorized representative. This failure could place residents at risk of individualized medical and nursing needs not being met resulting in injury and the residents' end-of-life wishes not being respected.Findings included: Record review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included acute respiratory failure with hypoxia (low oxygen in the body's tissues), pneumonia (infection in the lungs that can cause difficulty breathing, fever and cough), chronic kidney disease stage 4 (gradual loss of kidney function), and pain. The face sheet reflected an advance directive of DNR/Do Not Attempt Resuscitation. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #1's physician orders reflected an order with a start date of [DATE] DNR/ Do Not Attempt Resuscitation. Record review of Resident #1's EMR reflected a Out of Hospital Do Not Resuscitate (OOH DNR) Order - Texas Department of State Health Services form signed by the resident's provider and authorized family member/ decision maker on [DATE]. Record review of Resident #1's care plan reflected a focus initiated on [DATE] and revised [DATE] Resident #1 has elected full code status with interventions that included: Initiate full code measures in case of cardiac arrest to include CPR and AED use Update residents' chart to reflect elected code status, staff must be aware of code status election. During an interview on [DATE] at 01:11 PM with Resident #1's family member, she stated it was Resident #1's wishes to be DNR. She stated it was a conversation that she had with Resident #1 long ago and as an authorized representative helped make her wishes known to the facility. She stated she expected all of Residents #1's records to reflect her wishes of being DNR. During an interview on [DATE] at 02:35 PM with LVN A she stated the purpose of a care plan was to know the best way to treat a patient and how to take care of them. She stated that the care plan was to be continuously updated to reflect the care a resident presently required. LVN A stated that code status was a part of the care plan. She stated in the event of an emergency nurses pass along information to EMS which included knowing a residents code status. She stated a potential negative outcome of not having updated code status information would be it could cause confusion; if someone is supposed to be DNR and you bring them back it could be really bad, and you would not be honoring their wishes. She stated nursing staff was responsible for updating the care plan. During an interview on [DATE] at 03:14 PM with the DON she stated the purpose of the care plan was to have resident centered care and to follow guidelines. She stated it was the expectation that care plans were updated to maintain accuracy. She stated if care plans were not updated it could affect different things depending on who is looking at it. She stated Resident #1 has been DNR since the beginning of the year that she knew of and it should have been updated. She stated that in full transparency, she recently replaced the nursing staff member responsible for updating the care plans because she noticed a few were not getting updated. She stated they were working on auditing all care plans and getting them updated presently. During an interview on [DATE] at 03:43 PM with the ADM, he stated the purpose of the care plan was to provide and outline guidance for the care needs of the resident and should be person centered. He stated if a care plan was not updated to reflect the care needed it could prevent the fulfillment of the need that was impacted. He stated a residents code status should be reflected in the care plan. He stated it was the MDS and nursing staff that were responsible for updating the care plan. Record review of the facility Advance Directives and Associated Documentation policy last revised 04/2025 reflected:It is the policy of this facility that a residents choice about advance directives will be recognized and respected. The facility recognizes and respects the residents right to choose their treatment and make decisions about care to be received at the end of their life. Do Not Resuscitate- indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) have directed that no cardiopulmonary resuscitation (CPR) is to be attempted. Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the residents medical record and communicated to members of the care plan team. Advance care planning will occur periodically (at least quarterly, annually, and on a change of condition) to review the advance directive and/or preferences regarding treatment options with the resident or their representative to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded in the medical record. Record review of the facility Comprehensive Person Centered Care Planning policy last revised 12/2023 reflected: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The residents comprehensive plan of care will be reviewed and/ or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. Review of the facility CMS's RAI version 2.0- Formulation of the care plan policy/guidance revised 12/2002 reflected: The care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving. The care plan is an interdisciplinary communication tool. The comprehensive care plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. The care plan must be periodically reviewed and revised, and the services provided or arranged must be in accordance with each residents written plan of care.

Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of five (5) residents (Resident #1) reviewed for reasonable accommodation of needs. The facility failed to ensure CNA C was not wearing earbuds while working on the floor on 02/10/2026 and failed to assist Resident #1 to bed when requested. This failure had the potential to place all residents at risk of not having their needs met timely and decreased dignity.Findings include: Record review of Resident #1's Face Sheet, dated 02/19/2026, reflected the resident was an 86 year old female who admitted on [DATE] and readmitted on [DATE]. Diagnoses included morbid severe obesity; type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to prolonged high blood sugar levels); generalized anxiety disorder; monoplegia of the upper limb (type of paralysis that affects one arm); other abnormalities of gait and mobility; and need for assistance with personal care. Record review of Resident #1's Quarterly MDS Assessment, dated 12/18/2025, reflected moderate cognitive impairment with a BIMS score of 12 and that Resident #1 required assistance for self care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, undated, reflected the resident had an ADL self care performance deficit related to limited mobility, with interventions listing requires substantial/maximal x 1 assistance of staff for transfers and transfer chair to bed transfer. During an interview on 02/19/2026 at 10:15 a.m., Resident #2 stated he had been sitting at a dining table with Resident #1 on 02/10/2026 after lunch when Resident #1 said she was tired and wanted to return to bed. Resident #2 stated he attempted to get Resident #1 help and he repeatedly asked CNA C for assistance, but CNA C had earbuds in and appeared to be talking on her cell phone. He stated CNA C told him, I hear you, you don't have to keep hollering. I heard what you said.I'll get to her (Resident #1) when I get to her, and then walked off without assisting Resident #1 or coming back to help. Resident #2 stated he found another staff, CNA D, to help after waiting with Resident #1 for approximately 35 minutes to one hour without assistance. Resident #2 stated he felt mad and ignored by CNA C because he could see she had earbuds in and talking on her phone. He further stated he had frequently seen CNA C fail to assist Resident #1 when requested as his room was on the same hallway as Resident #1. During an interview on 02/19/2026 at 10:15 a.m., Resident #1 stated she recalled sitting at the dining room table with Resident #2 on 02/10/2026 but did not recall asking for help to go to bed. She stated she had seen a CNA on her hallway wear earbuds and stated she did not like it because the CNA could not hear her requests for help and it made her feel ignored and not good. Resident #1 did not know the name of the CNA. During an interview on 02/19/2026 at 10:31 a.m., LVN A stated staff were not allowed to use personal cell phones or wear earbuds while working on the floor. She stated earbuds were sometimes worn on breaks but not while providing care. She stated CNA staff needed more training. During an interview on 02/19/2026 at 10:49 a.m., the MA stated she did not know the facility's policy but stated she would not wear earbuds while working because she would not be able to hear residents' requests for help and her focus should be on her residents. During an interview on 02/19/2026 at 10:53 a.m., the RN stated she was the MDS coordinator and was not sure if the facility had a policy prohibiting earbuds, but she did not allow staff to wear them. She stated there had recently been in service training about cell phone and earbud use not being allowed while working. During an interview on 02/19/2026 at 11:38 a.m., LVN B stated he had worked at the facility since 2018 and staff could not use personal cell phones or earbuds while working. During an interview on 02/19/2026 at 11:47 a.m., CNA E stated she had been trained that personal cell phones and earbuds were not allowed on the floor because they could interfere with resident care. During an interview on 02/19/2026 at 12:15 p.m., the SC stated she had been trained that personal cell phones and earbuds were not allowed on the floor because they could interfere with resident care. During an interview on 02/19/2026 at 12:34 p.m., CNA C stated she had not received training on cell phone or earbud use. She stated she used earbuds on the floor, particularly in the mornings to help her wake up. She denied taking calls using her earbuds and stated her phone was on vibrate. She stated she might have been in a resident's room with earbuds in but whatever she was listening to would have been paused. She stated the earbuds or headphones might have been around her neck when assisting residents. She denied yelling at a resident or refusing assistance but stated it was possible she had told a resident Give me a minute if she had been assisting someone else. During an interview on 02/19/2026 at 1:25 p.m., CNA D stated she had seen CNA C wear earbuds all the time and had seen her not respond to residents' requests for assistance because she was talking on her cell phone. CNA D stated that on or about 02/10/2026 after lunch, she was walking towards the dining room and Resident #2 came up to her and asked for assistance with Resident #1. Resident #2 told CNA D that he had requested help from CNA C, but CNA C told him, I'll get to her in a second. I'll get to her later, but did not help Resident #1. CNA D stated she assisted Resident #1 back to bed and Resident #1 told her she had been asking for help for a while but could not say how long she had waited. She stated she had told CNA C several times not to wear earbuds, but CNA C ignored her and walked off. She stated she reported this to a nurse but did not know the nurse's name, but nothing happened. She stated it was important for staff not to wear earbuds or talk on personal cell phones because doing so could prevent staff from hearing residents, which could result in residents falling, choking, being in pain, or needing a nurse without being able to get help. During an interview on 02/19/2026 at 2:17 p.m., the DON stated the facility did not have a direct policy about earbuds but stated she would ask staff to remove them if she saw them. She stated personal cell phone use was not allowed on the floor. She stated earbuds could prevent staff from hearing residents' requests for help and would not meet her expectations for customer service. She stated she had never seen CNA C wearing earbuds but noted CNA staff arrived at 6 a.m. and management arrived around 8 a.m. She stated she was not aware of the incident involving CNA C and that the CNA would have been terminated had the DON known. During an interview on 02/19/2026 at 2:44 p.m., the ADM stated the facility had a cell phone policy prohibiting personal cell phone use while working on the floor but did not address earbuds or Bluetooth devices. He stated the facility did not allow staff to use personal cell phones or earbuds unless approved. He stated CNA C did not have approval to use earbuds and he was not aware she was wearing them while working on the floor. The ADM stated earbuds could cause distractions, possible HIPAA violations, and could affect the care being provided. The ADM stated he viewed the behavior as malicious intent to violate rules and stated he would be terminating CNA C. He stated he had already begun in service training regarding the cell phone policy and no earbuds on the floor. Record review of the facility policy titled Personal Cell Phone/Electronic Communication Device Use By Employees dated 01/01/2024 and 02/01/2025 reflected that use of personal cell phones or electronic communication devices was prohibited while employees were working unless approved by administration. Record review of the facility policy titled Resident Rights revised 02/2025 reflected residents had the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. Record review of the facility in-service training titled Earbuds dated 02/19/2026 reflected, Earbuds/headphone are not allowed while on the hall or in patients rooms while providing care.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for infection control. The facility failed to maintain infection control practice and proper hand hygiene when preparing meals. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. Findings Included: An observation was conducted on 09/17/2025 at 11:15AM in the kitchen. During the observation, [NAME] A had started the meal preparation for the puree foods. [NAME] A had put on a pair of gloves and placed the menu item food into the blender. When the menu item, bread, was pureed, [NAME] A removed their gloves, rinsed their hands off and grabbed new gloves. [NAME] A did not wash their hands or use hand sanitizer after removing the gloves. After [NAME] A put the new gloves on. [NAME] A washed, rinsed, and sanitized the blender. [NAME] A then removed his gloves and placed them into the trash can, grabbed new gloves and put those on. [NAME] A grabbed a new menu item food and started the puree process again in the blender. [NAME] A finished the puree of the pasta noodles and cleaned the blender while wearing the same pair of gloves. [NAME] A did not remove his gloves or use proper hand hygiene between washing the blender and prepping the new menu item of alfredo sauce. [NAME] A continued to use the same pair of gloves until [NAME] A finished pureeing the alfredo sauce. An interview was conducted on 09/17/2025 at 11:30AM with the KM. The KM stated they had been employed at the facility for 13 months and had received training on hand hygiene and the puree process. The KM described the hand hygiene policy as:Wash hands between tasks.Wash hands when you enter the kitchen.Gloves should be changed every 4 hours of when staff go from handling one food item to another food item. The KM stated that not following proper hand hygiene and glove wearing, it could negatively affect a resident by the increased risk of cross contamination. The KM stated that [NAME] A should have discarded the gloves that were worn in between food items and performed proper hand hygiene. An interview was conducted on 09/17/2025 at 1:12PM with [NAME] A with the KM as an interpreter due to a language barrier. [NAME] A stated they had been employed at the facility for a while now. [NAME] A stated he had received training for hand hygiene. [NAME] A described the hand hygiene process asScrubbing hands with soap and water for 20 seconds. Removing gloves after staff washed the dishes. Performing hand hygiene after wearing gloves.Cook A stated that not performing proper hand hygiene and using dirty gloves, could negatively impact a resident by the possibility of infecting the food with cross contamination. [NAME] A stated he was aware that he kept on the gloves to prepare the food after washing the dishes and explained it was because he forgot. [NAME] A stated that he was nervous and did not follow proper hand hygiene protocol.An interview was conducted on 09/17/2025 at 2:50PM with the DON. The DON stated they had been employed at the facility for 1 year and 3 months. The DON stated the KM provides training for staff in the kitchen. The DON stated the expectation is to perform hand hygiene before service, after service, and in between tasks in the kitchen. The DON stated that not performing proper hand hygiene could negatively affect residents by the increased risk of cross contamination. The DON stated it was not effective practice for [NAME] A to wear the same gloves after prepping the food, washing the dishes, and prepping more food. The DON stated that [NAME] A should have discarded the gloves and perform hand hygiene after prepping the food and starting the dishes. An interview was conducted on 09/17/2025 3:10PM with the ADM. The ADM stated they had been employed at the facility for 1 year and 1 month. The ADM stated he had received training on resident rights and described their rights as the right for self-determination, make their own choices and the right to choose their care. The ADM stated that the KM provides the training to kitchen staff. The ADM stated the expectation for hand hygiene in the kitchen was to perform it before, during and after the service. The ADM stated a negative impact it could have on residents if hand hygiene were not followed accurately could be infection control issues, cross contamination issues, and potentially make the residents sick. The ADM stated that it was not effective practice for [NAME] A to wear the same gloves during food preparation, washing the dishes, and continuing food preparation. The ADM stated gloves should have been removed when switching tasks or finishing a task. The ADM also stated that gloves should have been switched when leaving food prep to wash the dishes. Record review of an undated document titled 228.37 (10)(D)(vi)(I) revealed the document reflected the following information:Food Employees shall keep their hands and exposed portions of their arms clean. Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms:Rinse under clean, running warm waterApply cleaning compound recommended by the cleaning compound manufacturer. Rub together vigorously for 10-15 secondsThoroughly rinse under clean, running warm water Immediately follow the cleaning procedure with thorough drying using a method as specified under 2287.175(c)Food Employees shall clean their hands and exposed portions of their arms as specified under subsection b immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles andAfter touching bare human body parts other than clean hands and clean exposed portions of armsAfter handling soiled equipment or utensilsDuring food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Before donning (put on) gloves to initiate a task that involves working with food

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each for 3 of 8 residents (Residents #44, #45 and #74) and 2 of 4 medication carts (100/300-hall nurses' cart and 600-hall med aide' cart) reviewed for pharmacy services. A) The facility failed to ensure expired medication Refresh eye P.M. Ointment for Resident #44 opened on 8/10/25, was removed from the 600-hall med aide medication carts after 30 days of opening. B) The facility failed to ensure an expired medication bottle of nitroglycerin tablets sublingual 0.4 mg was removed from the 100/300-hall nursing cart.C) The facility failed to ensure an insulin pen for Resident #74 was labeled with an open date. The failures could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from expired supplies. Record review of Resident #44's admission record, dated 09/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), memory deficit following cerebral infarction (when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients), dysphagia (difficulty swallowing) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #44's order summary, dated 09/17/2025, reflected an active order for Refresh P.M. Ointment (White Petrolatum-Mineral Oil) instill 1 ribbon in both eyes at bedtime for dry eyes ordered on 05/16/2022. Observation on 09/16/2025 at 03:36 PM of the 600-hall med aide's medication cart revealed one tube of sterile lubricant eye ointment with open date of 08/10/2025. During an interview on 09/16/2025 at 03:38 PM, MA E stated the nurses' medication cart was to be checked weekly on a schedule for expired medications and supplies, though she was unsure of the schedule or who was responsible for checking the carts. MA E reviewed the eye ointment found in her medication cart and confirmed it was expired. She stated that according to the facility's policy she was trained that all eye drops and ointments should be removed from the medication cart and discarded after one month post opening. She stated if medication was used on a resident after the medication's expiration date, then the medication may not be as effective and the resident may not receive the intended benefits from the medication, or the resident may have an adverse reaction to the medication. Record review of Resident #74's admission record, dated 09/17/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #74 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood) and type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). Record review of Resident #74's order summary, dated 09/17/2025, reflected an active order for Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 23 unit subcutaneously one time a day for DM2 proscribed on 08/26/2025. Observation on 09/16/2025 at 03:15 PM of the 100/300-hall nurses medication cart revealed one insulin pen with Lantus insulin for Resident #74 was opened but not labeled with an open date. During an interview on 09/16/2025 at 03:18 PM, LVN G stated the nurses' medication cart was to be checked weekly on a schedule for expired medications and supplies. She stated that she was responsible for dating the insulin pen once it had been opened. She revealed that she was away for a few days, and it was her first day to come back and she usually dated all insulin pens right away and today she was very busy and forgot. She stated if an insulin pen was opened and not dated the medication may not be as effective and the resident may not receive the intended benefits from the medication, or the resident may have an adverse reaction to the medication. The record review of undated facility policy on Insulins and storage requirements for Insulin Glargine (Lantus) revealed insulin should be labeled immediately after opening and stored once opened on medication cart once in use and not refrigerated for 28 days. Record review of Resident #45's admission record, dated 09/17/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included: spinal stenosis (a condition where the spinal canal, the space within the spine that houses the spinal cord and nerve roots, becomes narrowed), type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs). Record review of Resident #45's order summary, dated 09/17/2025, reflected an active order for Nitroglycerin Tablet Sublingual 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for Chest Pain x 3 doses ordered on 08/13/2024. Observation on 9/16/2025 at 04:32 PM of the 100-hall nurses medication cart revealed one medication bottle of nitroglycerin tablets sublingual 0.4 mg with an expiration date [DATE] prescribed to Resident #45. During an interview on 09/17/2025 at 03:22 PM, DON stated the staff responsible for the medication cart were responsible for checking for expired medications in the cart every shift. She stated the pharmacy consultant ensured all expired medications were removed from the medication carts, but she was unsure of the frequency. She stated that ADONs also randomly picked medication carts for audit on a weekly basis. The DON stated if expired medications were administered to residents, then the resident would not get the therapeutic dose of the medication. She confirmed that according to the facility policy expiration date for eye drops was 30 days once opened and dated. She stated that nurses were required to date insulin once opened and date it to ensure it stored on the nursing cart for up to 28 days. Record review of the facility's policy titled Policy/Procedure- Nursing Clinical. Medication access and storage, dated 05/09/2007, reflected: Outdated, contaminated, or deteriorated medications removed from stock, disposed according to procedures for medication destruction, and reordered from the pharmacy if a current order exist.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 6 medication and treatment carts. The facility failed to ensure that a treatment cart located in the activity room area between the 100 and 200 halls was locked with keys left on the cart accessible to anybody including residents in the facility. The failure could place residents at risk of injury if medications and biologicals left unsecured were consumed.During an observation on 09/15/2025 from 09:31 PM - 10:05 AM revealed a nurse's treatment cart was left unlocked and unattended with keys left on the top of the cart near the activity room between the 100 and 200 halls. During the observation multiple nursing staff passed the cart without securing the cart and taking the keys. At 10:05 AM the MDS nurse approached the cart and secured it and took the keys with her. The cart drawers were opened by the surveyor to verify that the cart was unlocked. During an interview on 09/15/2025 at 10:05 AM, the MDS nurse stated she did not know who left the keys on the nursing treatment cart which was a spare treatment cart, and these keys were a spare set of keys too. She stated that leaving the cart unlocked could potentially harm the residents if they opened drawers and accessed potentially hazardous items like sharp tools and strong cleaning solutions. She confirmed that unauthorized access to the treatment cart could compromise a sterile environment, patient and staff safety, and maintaining inventory control. During an interview on 09/16/2025 at 3:12pm, LVN G stated that nursing staff assigned to the medication or treatment carts were responsible for locking the carts to prevent potential risk to residents' health. She stated that she was in- serviced regarding the facility's policy on Medication Access and Storage which required securing medication carts. During an interview on 09/16/2025 at 3:45pm, the MA E stated that she always secured her medication cart when not using it and was in-serviced regarding the policy of Medication Access and Storage. She stated that the potential risk to residents' health if left the nursing cart unattended and unlocked would be them getting into the cart and swallowing the medications and potentially poisoning themselves. During the interview on 09/17/2025 at 1:55PM, the DON stated her expectation of staff when they walk away from the medication or treatment carts was to lock them and not leave keys unattended. She confirmed that staff who was assigned to work on those carts are responsible for locking them. DON could not identify who was assigned to that treatment cart as it was a spare treatment cart. She stated herself, her ADONs and charge nurses visually monitor nursing, medication and treatment carts daily. She stated that if left unlocked medication or treatment carts can be accessed by residents and potentially consume medications or biologicals kept on the cart which could cause the harm to their health. Record review of undated facility policy Policy/Procedure - Nursing Clinicals. Care and Treatment: Medication Access and Storage revealed Procedure 2: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1's brief was changed, and she was put back in bed after she was transferred to her wheelchair on [DATE] at 8:45 AM until approximately 6:00 PM which resulted in skin breakdown on her sacral area. This failure could place residents at risk of not receiving adequate care, harm, or injuries. Findings included: Review of Resident #1 face sheet dated [DATE] reflected a [AGE] year old female admitted on [DATE] and discharged on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia following nontraumatic subarachnoid hemorrhage (difficulty with speaking due to brain bleed), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing), chronic respiratory failure (condition where lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period), muscle wasting and atrophy (loss of muscle tissue, size and strength), muscle weakness, other lack of coordination, and nontraumatic subarachnoid hemorrhage (bleeding in the brain without external trauma). Review of Resident #1's initial care plan dated [DATE] reflected Resident #1 had pressure ulcer or potential for pressure ulcer development on sacrum related to bed bound status and poor nutritional station. Goal included pressure ulcer will show signs of healing and remain free from infection by / through review date, and Resident #1 will have intact skin, free of redness, blisters or discoloration by/through review date Interventions included roll left and right, sit to lying, and lying to sitting on side of bed. Review of Resident #1's MDS 5-day assessment dated [DATE] reflected Resident #1 had a short-term and long-term memory problem. Review of functional abilities reflected at admission Resident #1 was dependent of for all ADLs (eating, oral hygiene, toileting hygiene, shower/bathing). Further review reflected Resident #1 was dependent for chair/bed-to-chair transfers, going from sitting to lying position, and rolling left and right and. Review also reflected that resident was always incontinent of bowel and bladder. Review of MDS skin conditions reflected Resident #1 had no pressure ulcer/injury upon admission and was at risk for developing pressure injuries or ulcers. Review reflected resident had other open lesions or rashes and moisture associated skin damage. Review of Resident #1's initial admission record dated [DATE] reflected Resident #1 used alternating air mattress and pressure re-distributing overlay mattress. Resident #1 was admitted alert to person, but was not alert to place or time and was unable to follow simple commands. Further review reflected resident was incontinent of bowel and bladder and required briefs. Skin problems noted upon admission included traumatic tongue wound prior to admission and surgical site from ankle fracture. Review of Resident #1's skin assessment dated [DATE] reflected Resident #1 had a traumatic tongue wound prior to admission and surgical site to right ankle. There were no other skin issues noted on the assessment. Review of grievance resolution form dated [DATE] reflected Resident #1's family had concerns regarding frequency of checks and new redness to perineal area. Resolution reflected that the DON spoke with family and implemented check and change for frequent rounding. Review of visual/bedside Kardex (electronic health record) report for Resident #1 dated [DATE] reflected under the skin section resident needed monitoring/remining/assistance to turn or reposition. Review reflected Resident #1 required 2 person mechanical lift for all transfers. Review of POC (plan of care) response history for Resident #1 reflected incontinence care was marked as provided on [DATE] at 3:32 AM and 11:41 PM. Review reflected incontinence care was marked as not provided on [DATE] at 11:38 AM. Review of 1 hour checks for Resident #1 reflected sections titled Check, Change, Suctioning and Trach Care. Review for 09-05-2025 hour checks reflected change was not selected between 9:00 am and 6:00 PM. Note on the document reflected Qhour Checks: Please indicate care provided during rounding. Review reflected Resident #1 was checked each hour between 9:00 am and 6:00 pm. Review reflected resident had suctioning completed at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM,6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review reflected tracheostomy care was provided at 4:00 AM, 8:00 AM, 10:00 AM (nebulizer treatment), 2:00 PM (nebulizer treatment), 6:00 PM (nebulizer treatment), 7:00 PM (nebulizer treatment), 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review of occupational therapy treatment encounter note dated [DATE] reflected OT checked Resident #1's brief and it was dry and fresh. Review reflected OT then transferred Resident #1 with mechanical lift from bed to geriatric chair. OT then informed ADON that Resident was in chair with mechanical lift sling beneath her. Observation of facility recorded camera footage for Resident #1 room dated [DATE] revealed footage started at 5:53 AM and ended at 6:30 PM. Observation revealed mechanical lift was taken into Resident #1's room by OT at 8:45 AM. OT exited Resident #1's room at 9:07 AM. Observation of footage revealed a mechanical lift was not returned into Resident #1's room until 5:45 PM. Observation of Resident #1 video camera footage dated [DATE] at 10:48 AM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:00 PM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:55 PM revealed Resident #1 was transferred from geriatric chair to bed. Observation of picture dated [DATE] at 6:07 AM reflected sacral area (area at the base of the spine) revealed a shallow, broken skin that was light pink with spots of darker red and white flakey skin on the gluteus area. A darker spot shallow opening in the skin was observed in the fold of the gluteus. Review of change of condition evaluation dated [DATE] reflected upon discharge Resident #1 had a rash to right buttock and left buttock. Review of the hospital notes dated [DATE] reflected Resident #1 had wound care evaluation on [DATE]. Resident #1 was admitted with small area of partial skin thickness injury from moisture and from flaky skin loss due to fungal irritation. Orders placed for groin, perineal and perianal/wound areas to decrease fungal irritation. During an interview on [DATE] at 11:49 AM, the FM stated that Resident #1 was no longer at the facility and FM had requested Resident #1 be sent to the hospital. The FM stated that on [DATE] Resident #1 was left in her wheelchair for hours and had not been changed. The FM stated that there was a camera in Resident #1's room and Resident #1 was not transferred into bed until other family arrived on [DATE]. During an interview on [DATE] at 3:27 PM, the OT stated that he transferred Resident #1 from bed to wheelchair on [DATE] in the morning. The OT stated that he checked Resident #1's brief prior to transfer and that Resident #1 was dry and did not observe any skin redness. The OT stated that after Resident #1 was placed in the geriatric chair he notified ADON as ADON was right outside Resident #1's room. The OT stated that usually therapy did not put resident back in wheelchair after assisting them unless nursing staff specifically asked. The OT stated, it sounds like she was up in the chair all day from what I was told. The OT stated he was unsure where he heard this information from or who. During an interview on [DATE] at 3:29 PM, CNA B stated she was familiar with Resident #1. CNA B stated that Resident #1 was not able to talk and wore briefs. CNA B stated that she noticed normal irritation on Resident #1's perineal area and denied any open areas or bleeding. CNA B stated normal irritation was some redness. CNA B stated that she put barrier cream on Resident #1 during brief changes for the redness. CNA B stated the last time she worked with Resident #1 was the day she went to the hospital ([DATE]). CNA B stated that any changes or open areas observed were reported to the nurse immediately. CNA B stated Resident #1 had an extra list that every time she was changed or checked the staff were required to mark off on a piece of paper. During an interview on [DATE] at 4:08 PM, CNA A state she recalled working with Resident #1 and providing care for Resident #1. CNA A stated that the last time she worked with Resident #1 was on [DATE] during the 6:00 PM to 6:00 AM shift. CNA A stated when she arrived Resident #1 was sitting in the geriatric chair in her room. CNA A stated when she arrived CNA C tried to put Resident #1 in the bed, but the mechanical lift's battery was dead. CNA C stated she charged the battery and the put Resident #1 into bed. CNA A stated she changed Resident #1's brief and the only skin issues were some redness, but it was not open or bleeding. CNA A stated that any new redness or open areas would be reported to the charge nurse. During an interview on [DATE] at 4:21 PM, CNA C stated she was familiar with Resident #1. CNA C stated that she took over the shift on [DATE] around 3:00 PM for CNA D. CNA C stated that she was unsure why CNA D did not tell her that Resident #1 was in the geriatric chair. CNA C stated Resident #1 never came out of her room and it was her first day getting up out of bed. CNA C stated that she did not know Resident #1 was out of bed in the geriatric chair that day. CNA C stated Resident #1's family would notify staff if they needed something and they did not call CNA C until around 5:30 PM because they wanted Resident #1 to be transferred in bed. CNA C stated that she tried to use the mechanical lift, but the battery was dead and she went to find another mechanical lift, but they were being used. CNA C stated it was after 6:00 PM and she let the next shift know Resident #1 needed to be transferred and then left. CNA C stated that prior to 5:30 PM she had not seen Resident #1 during the shift and did not provide care to Resident #1. CNA C stated that CNA D told her all the residents had already been changed. CNA C stated that Resident #1's FM told her that Resident #1 had been in the chair all day. CNA C stated she wished CNA D told CNA C that Resident #1 was in the chair before CNA D left the shift so Resident #1 could have been transferred back in bed. During an interview on [DATE] at 6:45 PM CNA E stated she normally works 6:00 am to 6:00 pm shifts. CNA E stated she was familiar with Resident #1 and had worked with Resident #1 several times. CNA E stated the most recent time she worked with Resident #1 was when she was going to leave her shift and the night she needed help to put Resident #1 in bed. CNA E stated that she had changed Resident #1's brief and did not observe any open area or bleeding. CNA E stated that residents who required a mechanical lift to transfer would have to be laid back down in bed to have their brief changed. CNA E stated residents cannot be left in a chair for nine hours as the resident could be really soaks and get a skin rash or they could slip out of the chair and fall. CNA E stated that rounds were done every two hours and during rounds residents were checked and changed and laid down for a nap with they were up. CNA E stated changes in a Resident's skin would be reported to the nurse. During an interview on [DATE] at 1:29 PM, RN F stated she was the wound care nurse. RN F stated that residents who required mechanical lift should be checked on at least every two hours and this included checking their brief and more frequently if needed. RN F stated perineal care cannot be performed in a chair and the resident would have to be transferred with the mechanical lift to complete perineal before bed. RN F stated residents who required a mechanical lift were not able to reposition themselves and would be more vulnerable for skin breakdown. RN F stated that it was not okay for a resident to be in a chair for 9 hours and not changed for 9 hours. RN F stated a resident that was left in a chair for hours could have issues with their skin integrity and that risk for skin breakdown. RN F stated that residents need to be turned and have perineal care. RN F stated that she was familiar with Resident #1 and that she had some redness in her perineal area and it was blanchable (skin turns pale or white when pressure is applied and then returns to normal color). RN F stated Resident #1's last skin assessment was done on [DATE] and she had redness to her sacral area, but it was not open. During an interview on [DATE] at 2:08 PM, RN G stated that residents who required a mechanical lift to transfer were supposed to sit in their wheelchair between one to two hours at a time, but no more than 2 hours. RN G stated 9 hours was way too long and that the position could be challenging for a resident. RN G stated that perineal care could not be done unless a resident was transferred via mechanical lift back to their bed. RN G stated residents who used a mechanical lift for transfers were at a higher risk for skin breakdown and are often incontinent which can mean skin is more prone to breakdown. RN G stated he worked with Resident #1 on [DATE] from 6:00 pm to 6:00 am. He stated that he did not provide any perineal care or incontinent care and that the aides provided that care. RN G stated that he worked with CNA A and that she did not report any changes in skin to him. RN G stated during his shift rounds were conducted hourly for Resident #1 and that he and CNA A alternated the rounds. RN G stated that any changes would have been reported to the DON or ADON. During an interview on [DATE] at 3:07 PM, LVN H stated that resident who required the mechanical lift to transfer were usually laid back down in bed to give their bottom a rest, but the resident required incontinent or perineal care every two hours. LVN H stated it was not okay for a resident to be in a wheelchair for nine hours as sitting on their bottom would not allow for good circulation. LVN H stated residents who used a mechanical lift to transfer were at a higher risk for skin breakdown. During an interview on [DATE] at 3:31 PM, CNA D stated that she worked with Resident #1 on [DATE] and she left early. CNA D stated that Resident #1 was in her room most of the day. CNA D stated the last time she saw Resident #1 was before breakfast time and she did not see Resident #1 after breakfast at all as CNA D left around 10:00 am or 11:00 am. CNA D stated she did not change Resident #1's brief during her shift on [DATE]. CNA D stated she worked with Resident #1 in previous days and she did not observe any skin breakdown or redness that she could recall. CNA D stated she never transferred Resident #1 in or out of bed. CNA D stated the amount of time residents remain in their wheelchair depended on what therapy said how long the resident could tolerate. CNA D stated that nine hours was too long to be in the chair and stated I bet it is uncomfortable. CNA D stated Resident #1 would have to be transferred with the mechanical lift to have her brief changed in bed. CNA D stated rounds were done at least every two hours and during that time residents were turned and their brief was checked. CNA D stated when she checked on Resident #1 during rounds she was usually went and needed to be changed. CNA D stated it was everyone's responsibility to ensure that a resident was transferred back into bed. CNA D stated any skin changes would be documented and reported to the charge nurse. During an interview on [DATE] at 4:11 PM, the ADON stated that Resident #1's family requested that she be checked on every hour for tracheostomy care and suctioning and in general to ensure Resident #1 was okay. The ADON stated on [DATE] therapy, aides and the ADON were in Resident #1's room. The ADON stated she did not change Resident #1's brief on [DATE]. The ADON stated therapy provided perineal care for Resident #1 on [DATE] and that it was around 10:30 AM or 11:00 AM. The ADON stated that CNA D was the aide for half the shift and then CNA C took over. The ADON stated that Resident #1 was in the geriatric chair when her family arrived and they asked to have her put to bed around 5:00 PM. The ADON stated that Resident #1's family around after lunch time. The ADON stated they were not able to transfer Resident #1 at that time because the mechanical lift battery died and the other lifts were being used so she informed the family the next shift would be notified. The ADON stated that she did not know if any transfers occurred for Resident #1 between 11:00 am to 5:00 pm. The ADON stated she assumed the check off for Resident #1 was for the nurses until she looked at the document and saw it had check and change. The ADON stated that Resident #1 would have had to be transferred from her wheelchair to her bed within an hour to be changed. The ADON stated that typically residents who rely on mechanical lift to be transferred are in the wheelchair for a couple of hours and then they are put in bed, laid down and changed. The ADON stated if a resident cannot verbalize that they want to stay in bed or get back up staff will leave the resident laying down to rest and then get them back up. The ADON stated that residents who required the mechanical lift for transfers were at a high risk for skin breakdown. The ADON stated if they are sitting on that spot of a long time they have decrease circulation and boney areas have pressure. The ADON stated that it was not acceptable for a resident to be in the wheelchair from 10:00 am to 5:00 pm. The ADON stated she left around 6:30 pm on [DATE] and that night shift went into Resident #1's room around 6:00 pm and transferred her. During an interview on [DATE] at 4:35 PM, the NP stated that she saw Resident #1 the day after she admitted to the facility. She stated that it was not generally okay for Resident #1 to sit in a wheelchair for nine hours unless Resident #1 was verbally able to say she did not want to get into bed. The NP stated that Resident #1 was not able to verbalize her needs when she saw Resident #1. The NP stated Resident #1 was a higher risk for skin breakdown because she was not able to care for herself. The NP stated that Resident #1 was able to move around a bit, but required a mechanical lift to transfer. The NP stated at her visit Resident #1 had not been out of bed. The NP stated if Resident #1 sat in a chair she could have had breakdown and irritation for nine hours and for sure MASD was possible. The NP stated redness would have most likely occurred. During an interview on [DATE] at 4:51 PM, the DON stated that Resident #1 was dependent on the mechanical lift for transfers. The DON stated that typically when a resident was in a wheelchair it was for a max of two hours unless therapy has cleared the resident for [NAME] time or they have wound care. The DON stated that she expected Resident #1 to be transferred with the mechanical lift to bed for any type of care they might have needed. The DON stated that residents who were dependent on mechanical lift for transfers were at higher risk for skin breakdown and if they were not used to being up. The DON stated that the resident could also be at a risk if they were incontinent and if they urinated the entire time they were up in the chair. The DON stated that it did not meet her expectation that resident be up in a wheelchair for nine hours. The DON stated it was ultimately the responsibility of the charge nurse to ensure the resident was transferred up to the wheelchair or laid down. The DON stated the house checks came about because on [DATE] the family was concerned regarding perineal care. Resident #1 was assessed by wound care and had slight excoriation (irritation) on her perineal area and frequent rounding was implemented. The DON stated that it was designed for the nurse or CNA to check and/or change Resident #1 and to see if she needed anything or was okay. The DON stated that staff checked off if they performed care listed for Resident #1. The DON stated that she interviewed staff and staff sated that they went in and did checks and changes with Resident #1 on [DATE]. The DON stated that some staff said they forgot to check it off, but she could only speak to what the staff told her. The DON stated no change of condition was reported to her prior to Resident #1 going out to the hospital and it was by family request that she went to the hospital on [DATE]. The DON stated Resident #1 returned within 4 hours and family refused any care and requested she be sent out again to the hospital. The DON stated that when she spoke with Resident #1's family they referenced [DATE] and that Resident #1 was up in the chair all day. The DON stated that it was reported to her about Resident #1 being in the chair mid-morning on [DATE]. During an interview on [DATE] at 5:15 PM, the ADM stated that there were hour checks for Resident #1 because her family had concerns about frequency of checks and wanted continuous care and more one-on-one level. The ADM stated that from his understanding and based on the logs she was checked on hourly. The ADM stated that staff were expected to see if the resident or family needed anything and if Resident #1's brief was dry. The ADM stated that when he tried to speak with Resident #1 she could not respond verbally. The ADM stated on [DATE] therapy put Resident #1 in her wheelchair and she had not been put in a chair before. The ADM stated that staff reported she was more responsive and able to use her call light after she was up. The ADM stated that when he reviewed the hourly check he believed there was a gap on that particular day. The ADM stated that he did not know how long Resident #1 was in her chair that day and stated he knew she was in chair a good part of the day and did not think she was in the chair for nine hours. The ADM stated that Resident #1 used a mechanical lift to transfer and would have expected staff to have transfer her from her wheelchair to provide care as they could not do if she was in her chair. The ADM stated the risk of Resident #1 being in her chair for an extended time was skin breakdown, pressure, ulcers, pain and being uncomfortable in general. The ADM stated that he did not think Resident #1 was able to make her needs known. Review of facility policy dated 02/2025 titled Resident Rights reflected residents had the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. Review of facility in-services for last sixty days [DATE], [DATE] and [DATE] reflected no in-services were conducted on rounding or check and change rounding for Resident #1.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 6 residents observed for infection control. The facility failed to ensure RN G performed hand hygiene before and during tracheostomy care glove changes for Resident #2. The facility failed to ensure RN G did not test the yankauer in an open container of clear fluid and then suction Resident #2. The facility failed to ensure RN G sanitize the area prior to placing sterile supplies for tracheostomy care performed for Resident #2. These failures placed residents at an increased risk of exposure to infections, development of infections, decreased quality of life and/or hospitalizations.Findings included: Review of Resident #2 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anoxic brain damage (occurs when brain is deprived of oxygen for an extended period), acute respiratory failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide), dysphagia (difficulty swallowing), and tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing). Review of Resident #2 physician orders dated 09/09/025 reflected an order for an x-ray due to increased secretions. Review reflected and order dated 07/01/2025 to check and record oxygen saturation every shift while suctioning for Resident #2. Further review reflected an order dated 07/01/2025 for tracheostomy care as needed and every shift. Review reflected continuous oxygen at 8 liters per minute to maintain oxygen saturation of 92% and above dated 07/22/2025. Review of Resident #2 September 2025 MAR reflected oxygen saturation was checked each shift (twice a day) from 09/01/2025 through 09/09/2025. Further review reflected Resident #2's oxygen saturation was checked while suctioning every shift from 09/01/2025 to 09/09/2025 and remained above 92%. Review reflected tracheostomy care was provided for Resident #2 each shift from 09/01/2025 to 09/09/2025. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had a short term and long-term memory problem. Review of Resident #2 care plan dated 08/15/2025 reflected a goal to have no signs of symptoms of infection with interventions of administer oxygen as ordered. Further review of care plan reflected Resident #2 has oxygen therapy with no signs or symptoms of poor oxygen absorption with interventions to provide oxygen per physician orders. Observation on 09/09/2025 at 1:16 PM revealed RN G donned surgical mask, donned gown and donned gloves without performing hand hygiene. RN G grabbed yankauer from packaging in Resident #2's bedside table and placed it in an open container of clear liquid that sat on Resident #2's bedside. Observation of the container reflected there was no label to indicate a date or contents of the container. RN G suctioned oxygen mask of Resident #2 and cleared mucus. RN G then placed yankauer in open container of clear liquid and placed it back in packaging in Resident #2's bedside table. RN G doffed the gown and gloves and washed his hands. Observation on 09/09/2025 at 2:29 PM revealed an open container of clear fluid placed on Resident #2's bedside table, the container was undated and unlabeled. Further observation revealed a container of normal saline placed on the beside table. Observation and interview on 09/10/2025 at 12:15 PM revealed RN G gathered 2 100 ml bottles of normal saline, 1 tracheostomy with [NAME] gloves kit and a vinyl gown. RN G entered Resident #2's room washed his hands in the bathroom and returned to the medication cart just outside Resident #2's room door. RN G donned a gown, surgical mask and gloves. RN G proceeded to lock his medication cart with the gloves on, touch the light switch and closed Resident #2's room door with the same gloves on. RN G approached Resident #2's bedside and opened the tracheostomy kit over the bedside table. RN G did not sanitize the bedside table and had other items (towel, plastic syringe) that remained on the table. RN G raised the bedside table with the same gloves on and lowered the oxygen to 4 liters per minute. RN G laid a towel across Resident #2's chest. RN G opened a bottle of saline and poured contents in one section of the tracheostomy tray kit and opened a second bottle of saline and poured contents into the other section of the tracheostomy tray kit that sat on the tray table. RN G turned his back to the sterile field (tray table with open saline) and disconnected tracheostomy oxygen mash (no hand hygiene or gloves changed prior). RN G grabbed yankauer from package in Resident #2's beside table and attempted to suction thick light yellow secretions and it was revealed that no contents were suction out of the oxygen mask. RN G then placed tip of yankauer in open contain of clear fluid on Resident #2's bedside table. RN G then moved a switch on suction device and placed tip of yanauer again in open contain of clear fluid. RN G placed the yankauer back in packaging in Resident #2's bedside table and stated it was not working. Without performing hand hygiene or changing gloves, RN G removed dressing from around tracheostomy site and doffed gloves. RN G donned sterile gloves without performing hand hygiene and picked up q-tips and pipe cleaner from supplies and dropped in saline basin. RN G laid out the gauze, grabbed q-tip from saline solution and wiped the upper portion around the tracheostomy and disposed q-tip in trash. RN G grabbed a new q-tip from saline in trap and wiped the bottom part of Resident #2's tracheostomy, grabbed gauze and wiped the right side of the tracheostomy, then disposed of gauze and used his right hand to remove the inner cannula and placed it in the saline. RN G's gown was observed touching the outside of his gloves. RN G grabbed pipe cleaner from salutation and used the pipe cleaner to clease inside of the inner cannula. RN G used a dry pipe cleaner to dry the inside of the inner cannula twice and then disposed in the trash. RN G used his right hand to replace the inner cannula inside the outer cannula of the tracheostomy. Clear sputum (mixture of saliva and mucus) was observed handing from the tracheostomy. RN G picked up gauze and cleaned the sputum from the outer cannula and disposed of gauze. RN G picked up new gauze and placed under the flange of the tracheostomy. RN G adjusted the tracheostomy tie and it was observed to be secure on both sides. RN G cleaned oxygen collar with clean, dry gauze and disposed of the gauze. RN G placed oxygen collar over the tracheostomy, and doff gloved, donned new gloves (without performing hand hygiene). RN G increased oxygen to 8 liters per minute and placed call light on Resident's chest. RN G doffed gloves and washed his hands. RN G did not utilize pulse oximeter to monitor oxygen during care. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have the gown pulled over them on the wrist or anything touching the outside of the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/09/2025 at 6:06 PM, RT stated that hand hygiene should be performed prior to providing tracheostomy care and between glove changes. RT stated that sterile saline should be used during tracheostomy care and the yankauer should be flushed with saline and discarded after use. During an interview on 09/10/2025 at 1:29 PM, RN F stated she has received training on tracheostomy care and stated that she would knock, enter the resident's room, wash hands, don a gown, gloves and mask. RN F stated she would have a sterile field set up with tracheostomy cleaning supplies, but prior to placing the supplies she would sanitize the tray table. RN F stated she would then wash her hands again and don gloves. RN F stated she would clean around the trach area, check for signs of infection and then doff gloves and perform hand hygiene and don sterile gloves. RN F stated she would clean the outer trach and would rinse it, let it dry and would then doff gloves, perform hand hygiene and don gloves and insert the outer trach back in. RN F stated when staff wore sterile gloves the gown should not be over the gloves because the gown could have been contaminated. RN F stated that there is usually a canister of water at bedside, and it should be covered and dated and replaced every twenty-four hours. RN F stated that items should be grabbed from the medication cart with gloves on and then go to perform care because it was an infection control issue. RN F stated the yankauer should have been tested prior to started tracheostomy care and the value should be check and tested with water. RN F stated if the yankauer is observed to not be working staff were not to proceed with care. RN F stated staff were supposed to have a pulse oximeter on the resident because extra secretions can cause oxygen levels to decrease. RN F stated she would not turn oxygen down because it could decrease during care. During an interview on 09/10/2025 at 2:08 PM, RN G stated that he worked at the facility PRN and started working full time again two or three weeks ago. RN G stated when he retuned he did not complete tracheostomy care training. RN G stated that he usually turned lights on with his elbow and was not supposed to touch the environment or lights with gloves on then perform care. RN G stated that during tracheostomy care the dirty part (cleaning) happened first and then sterile gloves were put on. RN G stated that he had cleaned the tray table in the morning when he started his shift and that is why he put a paper down on the area next to the el. RN G stated he did not sanitize the area and that it should have been sanitized. RN G stated when he changed gloves he was not supposed to wash his hands or use hand sanitizer only before he was going to start providing care. RN G stated that sterile gloves should not be touching anything including the gown. RN G stated he was supposed to stay facing the sterile filed because you have items there and it could be contaminated if you are not watching it. RN G stated that he normally turned the oxygen down because this is what he was taught in school for tracheostomy care. RN G stated he was supposed to check oxygen saturation during tracheostomy care and he did not check Resident #2's because he probably forgot. RN G stated that he usually checked oxygen when suction and stated he had a pulse oximeter in his pocked today (09/10/2025). RN G stated the yankauer was working previously and that he was supposed to check if it was working properly before providing care and that is why there was water at the bedside. RN G stated he did not think the water had to be sterile and that he did not think the water had to be covered and it got changed out every shift and it was supposed to be dated and have the time. RN G stated he could tell the water was brand new just by looking at it. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have gown over them or anything touching the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/10/2025 at 3:15 PM, CNA E stated that hand hygiene should be performed before and after care. CNA E stated that when she wore glove, she performed hand hygiene put the gloves on, performed care, threw the gloves away, performed hand hygiene and put on new gloves. CNA E stated it was important to perform hand hygiene to prevent spreading germs. During an interview on 09/10/2025 at 3:31 PM, CNA D stated hand hygiene should be performed before and after working with a resident, before entering a resident room and after exiting. CNA D stated that in between glove changes hand hygiene should also be performed. CNA D stated that it was important to do hand hygiene to not spread any germs to the resident and get the resident sick. During an interview on 09/10/2025 at 4:11 PM, the ADON stated that she expected hand hygiene to be performed prior to putting gloves on and after taking them off. The ADON stated that the yankauer should be tested prior to tracheostomy care. The ADON stated it should have been tested by suctioning a small amount of water and that the water should be sterile. The ADON stated it was not acceptable for staff to test the yankauer in an open container on a resident's bedside table. The ADON stated that sterile water should be poured into a small basin to test. The ADON stated if a yankauer was not working tracheostomy care should be stopped and a new yankauer should be retrieved and that the yankauer should be tested prior to started tracheostomy care so if it is not working the sterile field is not broken. The ADON stated that oxygen should have been monitored during tracheostomy care with a pulse oximeter placed on the resident's finger. The ADON stated oxygen is not decreased or increased and stayed the same. The ADON stated that nothing besides the sterile field should be touching sterile gloves and a sterile field should never leave sight of vision. The ADON stated a gown should not have touched sterile gloves. The ADON stated gloves should have been changed after gathering supplies and hand hygiene performed when the gloves were changed. The ADON stated hand hygiene was important to prevent cross contamination because residents with tracheostomy had a decreased immune system. The ADON stated that the areas for sterile supplies should be sterilized before the supplies were laid out and that nothing else should be on the same area that is not being used for that care. During an interview on 09/10/2025 at 4:35 PM, the NP stated that the yankauer should be tested prior to use and staff can hear it was working by turning it on.The NP stated staff could use water to clear the link of the yankauer and it was okay to use water and not saline since staff were not doing anything with the patient and just to clear the tube. The NP stated that when staff did deeper suctioning sterile gloves were used, but not when providing routine tracheostomy care and stated its an open hole so its not really sterile. The NP stated she used to have to have sterile gloves to clean the inner cannula, but she was not sure what the protocol was anymore. The NP stated that she expected staff to use hand sanitizer any time they walked into a resident's room and prior to donning gloves and after doffing gloves. The NP stated that gloves from a hallway or touching the environment was not generally a good thing and that staff really should not put on gloves until they were ready to perform care. During an interview on 09/10/2025 at 4:51 PM, the DON stated she expected staff to perform hand hygiene before and after patient care, before entering a room, when hands were soiled or dirty and in between glove changes. The DON stated she expected staff to use sterile gloves for tracheostomy care and foley changes. The DON stated she expected staff to test the yankauer prior to starting tracheostomy care and it could be tested by touching the tip of the yankauer to the staff's gloved thumb. The DON stated she personally would not test the yankauer in an open container of water and staff should have opened a new sterile water container. The DON stated that prior to set up, the area that items were paced on should have been sanitized and a sterile field should not have been taken out of the staff's line of vision. The DON stated staff should not have touched the nurse's cart or light switch without performing hand hygiene prior to providing resident care and changing gloves. The DON stated hand hygiene was important to not introduce infection to the resident. The DON stated that oxygen was monitored during tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they are on enhanced barrier precautions, handling meals, before and after perineal care and before and after putting on gloves. The ADM stated that he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON. Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care. Review of facility policy titled Infection Prevention and Control Program with revision date of 10/2022 reflected facility staff will conduct themselves and provide care in a way that minimizes the spread of infection and staff will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Review of facility policy titled Hand Hygiene with revision date of 04/2025 reflected hand hygiene is a general term that applies to hand washing antiseptic hand wash and alcohol-based hand rub. Review reflected to use alcohol-based hand rub before and after direct contact with residents, before performing any non-surgical invasive procedures, before donning sterile close, before handing clean or soiled dressings, after handling used dressings, and after removing gloves.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for three (Resident #2, Resident #3, and Resident #4) of six residents reviewed for respiratory care. The facility failed to ensure RN G did not test the yankauer (tool for suctioning) in an open container of water prior to suctioning Resident #2's tracheostomy. The facility failed to ensure RN G monitored Resident #2's oxygen during tracheostomy care. The facility failed to ensure RN G did not continue with tracheostomy care when the yankauer was not functioning for Resident #2. These failures could place residents at risk of inadequate care, respiratory distress and hospitalization. Review of Resident #2's face sheet dated 09/09/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anoxic brain damage (occurs when brain is deprived of oxygen for an extended period), acute respiratory failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide), dysphagia (difficulty swallowing), and tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing). Review of Resident #2's physician orders dated 09/09/025 reflected an order for an x-ray due to increased secretions. Review reflected and order dated 07/01/2025 to check and record oxygen saturation every shift while suctioning for Resident #2. Further review reflected an order dated 07/01/2025 for tracheostomy care as needed and every shift. Review reflected continuous oxygen at 8 liters per minute to maintain oxygen saturation of 92% and above dated 07/22/2025. Review of Resident #2's September 2025 MAR reflected oxygen saturation was checked each shift (twice a day) from 09/01/2025 through 09/09/2025. Further review reflected Resident #2's oxygen saturation was checked while suctioning every shift from 09/01/2025 to 09/09/2025 and remained above 92%. Review reflected tracheostomy care was provided for Resident #2 each shift from 09/01/2025 to 09/09/2025. Review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a short term and long-term memory problem and having tracheostomy present. Review of Resident #2 care plan dated 08/15/2025 reflected a goal to have no signs of symptoms of infection with interventions of administer oxygen as ordered. Further review of care plan reflected Resident #2 has oxygen therapy with no signs or symptoms of poor oxygen absorption with interventions to provide oxygen per physician orders. Review of chest x-ray results for Resident #2 dated 09/09/2025 reflected lungs are clear and well inflated bilaterally with no findings. Observation on 09/09/2025 at 12:45 PM revealed Resident #2 laid in bed with continues oxygen via tracheostomy flowing at 8 liters per minute. Resident #2 was observed to have drool around her mouth and oxygen mask with white colored mucus. Observation on 09/09/2025 at 1:16 PM revealed RN G donned surgical mask, donned gown and donned gloves without performing hand hygiene. RN G grabbed yankauer from packaging in Resident #2's bedside table and placed it in an open container of clear liquid that sat on Resident #2's bedside. Observation of the container reflected there was no label to indicate a date or contents of the container. RN G suctioned oxygen mask of Resident #2 and cleared mucus. RN G then placed yankauer in open container of clear liquid and placed it back in packaging in Resident #2's bedside table. RN G doffed the gown and gloves and washed his hands. Observation on 09/09/2025 at 2:29 PM revealed an open container of clear fluid placed on Resident #2's bedside table, the container was undated and unlabeled. Further observation revealed a container of normal saline placed on the beside table. Observation and interview on 09/10/2025 at 12:15 PM revealed RN G gathered 2 100 ml bottles of normal saline, 1 tracheostomy with [NAME] gloves kit and a vinyl gown. RN G entered Resident #2's room washed his hands in the bathroom and returned to the medication cart just outside Resident #2's room door. RN G donned a gown, surgical mask and gloves. RN G proceeded to lock his medication cart with the gloves on, touch the light switch and closed Resident #2's room door with the same gloves on. RN G approached Resident #2's bedside and opened the tracheostomy kit over the bedside table. RN G did not sanitize the bedside table and had other items (towel, plastic syringe) that remained on the table. RN G raised the bedside table with the same gloves on and lowered the oxygen to 4 liters per minute. RN G laid a towel across Resident #2's chest. RN G opened a bottle of saline and poured contents in one side of a two-sided tracheostomy tray kit. RN G opened a second bottle of saline and poured contents into the other section of the tracheostomy tray kit that sat on the tray table. RN G turned his back to the sterile field (tray table with open saline) and disconnected tracheostomy oxygen mash (no hand hygiene or gloves changed prior). RN G grabbed yankauer from package in Resident #2's beside table ad attempted to suction thick light yellow secretions and it was revealed that no contents were suction out of the oxygen mask. RN G then placed tip of yankauer in open contain of clear fluid on Resident #2's bedside table. RN G then moved a switch on suction device and placed tip of yankauer again in open contain of clear fluid. RN G placed the yankauer back in packaging in Resident #2's bedside table and stated it was not working. Without performing hand hygiene or changing gloves, RN G removed dressing from around tracheostomy site and doffed gloves. RN G donned sterile gloves without performing hand hygiene and picked up q-tips and pipe cleaner from supplies and dropped in saline basin. RN G laid out the gauze, grabbed q-tip from saline solution and wiped the upper portion around the tracheostomy and disposed q-tip in trash. RN G grabbed a new q-tip from saline in trap and wiped the bottom part of Resident #2's tracheostomy, grabbed gauze and wiped the right side of the tracheostomy, then disposed of gauze and used his right hand to remove the inner cannula and placed it in the saline. RN G's gown was observed touching the outside of his gloves. RN G grabbed pipe cleaner from salutation and used the pipe cleaner to cleanse inside of the inner cannula. RN G used a dry pipe cleaner to dry the inside of the inner cannula twice and then disposed in the trash. RN G used his right hand to replace the inner cannula inside the outer cannula of the tracheostomy. Clear sputum (mixture of saliva and mucus) was observed handing from the tracheostomy. RN G picked up gauze and cleaned the sputum from the outer cannula and disposed of gauze. RN G picked up new gauze and placed under the flange of the tracheostomy. RN G adjusted the tracheostomy and it was observed to be secure on both sides. RN G cleaned oxygen collar with clean, dry gauze and disposed of the gauze. RN G placed oxygen collar over the tracheostomy, and doff gloves, donned new gloves (without performing hand hygiene). RN G increased oxygen to 8 liters per minute and placed call light on Resident's chest. RN G doffed gloves and washed his hands. RN G did not utilize pulse oximeter to monitor oxygen during care. Review of Resident #3'a face sheet dated 09/10/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of traumatic subdural hemorrhage with loss of consciousness (serious condition where blood forms between brain and inner layer of skull causing pressure and loss of consciousness), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing), and chronic respiratory failure (condition where lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period. Review of Resident #3's physician orders reflected an order with a start date of 07/15/2025 for tracheostomy care every shift and as needed. Review of Resident #3's care plan dated 08/21/2025 reflected Resident #3 had a tracheostomy related to injury with a goal to have no signs or symptoms of infection. Review of Resident #3's admission MDS dated [DATE] reflected Resident #3 had a BIMS of 0 which indicated severe cognitive impairment. Observation of Resident #3 on 09/09/2025 at 4:38 PM revealed Resident #3 laid in bed and did not respond to questions. Further observation revealed an open container of clear liquid placed on Resident #3's bedside that was undated and unlabeled. Review of Resident #4's face sheet dated 09/10/2025 reflected a [AGE] year-old-man admitted on [DATE] with diagnoses of anoxic brain damage(occurs when brain is deprived of oxygen for an extended period), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing) and compression of brain (increased pressure on the brain tissue caused by buildup of fluid, blood or a tumor). Review of Resident #4's physician orders reflected and order dated 07/03/2025 to provide tracheostomy care every shift and as needed. Review of Resident #4's care plan dated 07/08/2025 reflected Resident #4 had tracheostomy and pulled at tracheostomy with goal to be free from signs or symptoms of infection. Review of Resident #4's significant change MDS dated [DATE] reflected Resident #4 had a BIMS of 0 which indicated severe cognitive impairment. Observation on 09/09/2025 at 4:43 PM revealed Resident #4 laid in bed and did not respond to questions. Further observation revealed an open container of clear liquid on bedside that was unlabeled and undated. During an interview on 09/09/2025 at 2:17 PM, LVN H stated if she needed to suction a resident she would wash hands when she entered the room, get gloves and gather supplies. LVN H stated she would have saline ready and that you do not suction for a long time just a short time and allow the resident to recover. LVN H stated that you are supposed to check oxygen with a pulse oximeter after you suction the resident. LVN H stated that the yankauer is cleared with saline prior to use and you were supposed to clean it first before you suction and after you suction to ensure it was working properly. LVN H stated that it should be cleared with a new bottle of saline every time. LVN H stated it was important to wash hands prior to doing tracheostomy care for infection control and that you did not want to introduce any infection and cause potential respiratory infection to the resident. During an interview on 09/09/2025 at 2:32 PM, RN I stated before suctioning a resident or before tracheostomy care, staff were supposed to wash their hands in the bathroom. RN I stated everything was supposed to be sterile. RN I stated that it was important to use sterile gloves because if you are doing anything respiratory staff had to prevent infection for the resident. RN I stated every time staff suctioned the resident, they were supposed to get new saline and that was located in the nurses cart. During an interview on 09/09/2025 at 6:06 PM, the RT stated that hand hygiene should be performed prior to providing tracheostomy care and between glove changes. The RT stated that sterile saline should be used during tracheostomy care and the yankauer should be flushed with saline and discarded after use. During an interview on 09/10/2025 at 1:29 PM, RN F stated she has received training on tracheostomy care and stated that she would knock, enter the resident's room, wash hands, don a gown, gloves and mask. RN F stated she would have a sterile field set up with tracheostomy cleaning supplies, but prior to placing the supplies she would sanitize the tray table. RN F stated she would then wash her hands again and don gloves. RN F stated she would clean around the trach area, check for signs of infection and then doff gloves and perform hand hygiene and don sterile gloves. RN F stated she would clean the outer trach and would rinse it, let it dry and would then doff gloves, perform hand hygiene and don gloves and insert the outer trach back in. RN F stated when staff wore sterile gloves the gown should not be over the gloves because the gown could have been contaminated. RN F stated that there was usually a canister of water at bedside, and it should be covered and dated and replaced every twenty-four hours. RN F stated that items should be grabbed from the medication cart with gloves on and then go to perform care because it was an infection control issue. RN F stated the yankauer should have been tested prior to started tracheostomy care and the value should be check and tested with water. RN F stated if the yankauer was observed to not be working staff were not to proceed with care. RN F stated staff were supposed to have a pulse oximeter on the resident because extra secretions can cause oxygen levels to decrease. RN F stated she would not turn oxygen down because it could decrease during care. During an interview on 09/10/2025 at 2:08 PM, RN G stated that he worked at the facility PRN and started working full time again two or three weeks ago. RN G stated when he returned he did not complete tracheostomy care training. RN G stated that he usually turned lights on with his elbow and was not supposed to touch the environment or lights with gloves on then perform care. RN G stated that during tracheostomy care the dirty part (cleaning) happened first and then sterile gloves were put on. RN G stated that he had cleaned the tray table in the morning when he started his shift and that was why he put a paper down on the area next to the towel. RN G stated he did not sanitize the area and that it should have been sanitized. RN G stated when he changed gloves he was not supposed to wash his hands or use hand sanitizer only before he was going to start providing care. RN G stated that sterile gloves should not be touching anything including the gown. RN G stated he was supposed to stay facing the sterile field because you hafpve items there and it could be contaminated if you are not watching it. RN G stated that he normally turned the oxygen down because this was what he was taught in school for tracheostomy care. RN G stated he was supposed to check oxygen saturation during tracheostomy care and he did not check Resident #2's because he probably forgot. RN G stated that he usually checked oxygen when suctioning and stated he had a pulse oximeter in his pocked today (09/10/2025). RN G stated the yankauer was working previously and that he was supposed to check if it was working properly before providing care and that ias why there was water at the bedside. RN G stated he did not think the water had to be sterile and that he did not think the water had to be covered and it got changed out every shift and it was supposed to be dated and have the time. RN G stated he could tell the water was brand new just by looking at it. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have the gown pulled over them on the wrist or anything touching the outside of the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/10/2025 at 4:11 PM, the ADON stated that she expected hand hygiene to be performed prior to putting gloves on and after taking them off. ADON stated that the yankauer should be tested prior to tracheostomy care. The ADON stated it should have been tested by suctioning a small amount of water and that the water should be sterile. The ADON stated it was not acceptable for staff to test the yankauer in an open container on a resident's bedside table. The ADON stated that sterile water should be poured into a small basin to test. The ADON stated if a yankauer was not working tracheostomy care should be stopped and a new yankauer should be retrieved. The ADON stated that the yankauer should be tested prior to started tracheostomy care so if it is not working the sterile field is not broken. The ADON stated that oxygen should have been monitored during tracheostomy care with a pulse oximeter placed on the resident's finger. The ADON stated oxygen is not decreased or increased and stayed the same. The ADON stated that nothing besides the sterile field should be touching sterile gloves and a sterile field should never leave sight of vision. The ADON stated a gown should not have touched sterile gloves. The ADON stated gloves should have been changed after gathering supplies and hand hygiene performed when the gloves were changed. The ADON stated hand hygiene was important to prevent cross contamination because residents with tracheostomy had a decreased immune system. The ADON stated that the areas for sterile supplies should be sterilized before the supplies were laid out and that nothing else should be on the same area that is not being used for that care. During an interview on 09/10/2025 at 4:35 PM, the NP stated that the yankauer should be tested prior to use and staff can hear it was working by turning it on. The NP stated staff could use water to clear the link of the yankauer and it was okay to use water and not saline since staff were not doing anything with the patient and just to clear the tube. The NP stated that when staff did deeper suctioning sterile gloves were used, but not when providing routine tracheostomy care and stated its an open hole so its not really sterile. The NP stated she used to have to have sterile gloves to clean the inner cannula, but she was not sure what the protocol was anymore. The NP stated that she expected staff to use hand sanitizer any time they walked into a resident's room and prior to donning gloves and after doffing gloves. The NP stated that gloves from a hallway or touching the environment was not generally a good thing and that staff really should not put on gloves until they were ready to perform care. During an interview on 09/10/2025 at 4:51 PM, the DON stated she expected staff to perform hand hygiene before and after patient care, before entering a room, when hands were soiled or dirty and in between glove changes. The DON stated she expected staff to use sterile gloves for tracheostomy care and foley changes. The DON stated she expected staff to test the yankauer prior to starting tracheostomy care and it could be tested by touching the tip of the yankauer to the staff's gloved thumb. The DON stated she personally would not test the yankauer in an open container of water and staff should have opened a new sterile water container. The DON stated that prior to set up, the area that items were paced on should have been sanitized and a sterile field should not have been taken out of the staff's line of vision. The DON stated staff should not have touched the nurse's cart or light switch without performing hand hygiene prior to providing resident care and changing gloves. The DON stated hand hygiene was important to not introduce infection to the resident. The DON stated that oxygen was monitored during tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they were on enhanced barrier precautions, handling meals, before and after perineal care and before and after putting on gloves. The ADM stated that he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON. Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care. Review of facility policy with subject Tracheostomy, Care and Cleaning of with revision date of 05/2007 reflected This is a STERILE procedure. Further review reflected staff should wash hands prior to beginning the procedure, open plastic bag and cuff and place within reach so you do no to reach across the sterile field to discard items. Review of undated skills check off titled Tracheal Suctioning reflected perform hand hygiene and follow any necessary infection control guidelines, prepare suction equipment, turn on suction machine, open the suction catheter and sterile basin and fill with sterile normal saline. Review also reflected to preoxygenate the individual to maximize oxygen saturation in preparation for suctioning. Further review reflected remove gloves and perform hand hygiene.

Based on interview and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and efforts and did not incorporate the recommendations from the PASRR evaluation report into the resident's assessment, care planning, and transition of care for 1 of 1 resident (Resident #1) reviewed for PASRR. The facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal within 20 business days after the Interdisciplinary Team (IDT) meeting for Resident #1. This failure could place residents at risk of not receiving necessary care or specialized services, which could diminish their quality of life and ability to achieve the highest practical level of functioning.Record review of Resident #1's admission record, dated 08/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included aphasia (communication disorder), chronic kidney disease, muscle wasting, generalized weakness, dysphagia (difficulty swallowing), malnutrition, anemia (shortage of healthy red blood cells), and a history of cerebral infarction (past strokes).Record review of Resident #1's Quarterly MDS assessment, dated 08/10/2025, documented a BIMS score of 00, which indicated severely impaired cognitive function.Record review of Resident #1's Habilitation Service Plan, dated 03/14/2025, reflected in Section 5 the Outcome Action Plan to identify NF specialized services PT, OT, and ST.Interview with the DOR on 08/18/2025 at 4:19 PM revealed NFSS should be completed within 14 days after the IDT meeting. The DOR stated that failure to submit NFSS in a timely manner could result in the resident losing access to therapy services, limiting health improvement.Interview with the Administrator on 08/18/2025 at 5:14 PM revealed uncertainty regarding the NFSS submission timeframe after the IDT meeting.Record review of the facility's PASRR Level I Screening report reflected Resident #1's screening dated 09/10/2024. PASRR Screening reflects that there is evidence or indicators that Resident #1 has a Developmental Disability other than an Intellectual Disability. The PASRR Evaluation Summary report reflected Resident #1's Level II evaluation completed 04/15/2025. This report reflects that Resident #1 was recommended for the following Nursing Facility Specialized Services (IDD Only). Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) Specialized Assessment Speech Therapy (ST), Specialized Assessment Physical Therapy (PT), Specialized Assessment Occupational Therapy (OT). Record review of the PASRR Nursing Facility Specialized Services report reflected Resident #1's NFSS form was not submitted until 05/14/2025. The NFSS form was submitted 217 days later which is more than 20 business days past the required timeframe.Staff within the HHSC PASRR Unit reflected per 26 TAC Chapter 554, Subchapter BB S554.2704(i)(7), the facility failed to submit a complete and accurate NFSS request in the LTC Online Portal within the required timeframe.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's mental and psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to immediately notify the physician/provider when Resident #1 was found with the belt of her robe around her neck and tied to her bed rail on 05/31/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services. Findings include: Review of Resident #1 face sheet dated 06/02/2025 reflected a 52- year-old woman re-admitted on [DATE] with original admission date of 02/25/2025 with diagnoses of bipolar disorder (mental health condition characterized by extreme mood swings), generalized anxiety disorder (mental health condition characterized by persistent and excessive worry), mild cognitive impairment (condition where individuals experience noticeable but not severe memory and thinking problems), paranoid schizophrenia (mental health condition characterized by delusions and hallucinations), schizoaffective disorder (bipolar type) (mental health condition with symptoms of both schizophrenia and bipolar disorder), paranoid personality disorder (mental health condition characterized by pattern of distrust or suspicion of others as have malicious intentions), and legal blindness. Review of Resident #1 discharge MDS date 05/25/2025 reflected Resident #1 had a memory problem and had moderately impaired daily decision making. Review of Resident #1 psychological service progress note reflected Resident received initial diagnostic assessment on 03/12/2025 and established treatment goals. Review of Resident #1 social services assessment dated [DATE] reflected Resident #1 was re-referred to psychiatric and psychological services for medication management and emotional support following readmission from hospital stay. Review of Resident #1 care plan dated 04/03/2025 reflected Resident #1 had a potential for psychosocial well-being problem related to paranoid schizophrenia and schizoaffective disorder with intervention added 06/01/2025 that Resident #1 was placed on 1:1 for self-harm attempt. Resident #1 care plan dated 06/02/2025 reflected Resident had ineffective coping related to bipolar, schizophrenia and depression. Interventions included psych services as indicated and ordered. Review of Resident #1 progress note by RN A dated 05/31/2025 at 11:43 PM reflected a CNA called RN A into Resident #1's room and that Resident #1 had tied her neck with belt of her nightgown and tied it to the bed rail and applied slight traction and stated she did not want to live. RN A's note read that the belt was removed, and Resident #1 was assessed with no changes in her vital signs. RN A's note read that on-call (ADON) was contacted and Resident #1 was put on 15-minute checks. Further review of Resident #1 progress note, by DON dated 06/01/2025 reflected that 1:1 was initiated, and DON notified NP at 8:32 AM. Review of 15-minute check sheet for Resident #1 dated 05/31/2025 to 06/01/2025 reflected Resident #1 had no further incidents and remained on 15-minute checks until 8:30 AM on 06/01/2025 and was put on 1:1 supervision. Review of Resident #1's PHQ-9 assessment date 05/30/2025 reflected she had no signs or symptoms of depression or thoughts she would be better off death. Review of Resident #1's psychological progress note date 05/23/2025 reflected Resident #1 indicated no risk factors of suicide or self-injury. Review of statement by CNA B dated 06/01/2025 reflected that CNA B reported RN A placed CNA B on 1:1 with Resident #1 after her self-harm attempt. CNA B reported that she remained on 1:1 with Resident #1 throughout her shift and during her 30-minute break RN A was 1:1 with Resident #1. During an interview on 06/02/2025 at 1:20 PM, LVN F stated that she did not observed any changes or signs or symptoms of depression or anxiety with Resident #1. LVN F stated that during her shift on 06/01/2025 Resident #1 stated she was okay and appeared relaxed. LVN F stated that she assessed Resident #1 for suicidal ideation and Resident #1 stated she would never do it again. An interview was attempted with CNA B on 06/02/2025 at 1:35 PM, but no call was returned on 05/30/2025. During an interview on 06/02/2025 at 2:02 PM, CNA C stated he worked with Resident #1 stated that Resident #1 was pleasant during his shift and denied that Resident #1 was tearful. During an interview on 06/02/2025 at 2:18 PM, LVN D stated that Resident #1 was not tearful during her shift on 05/29/2025. LVN D stated Resident #1 returned from the hospital on this day. LVN D stated that Resident #1 was alert and talkative during her shift. LVN D stated that Resident #1 did not mention wanting to harm herself and did not mention not wanting to live during her shift. During an interview on 06/02/2025 at 2:26 PM CNA E stated that she worked with Resident #1 on 06/01/2025 following the incident. CNA E stated Resident #1 was in a good mood and CNA E asked Resident #1 how she was feeling and what happened the evening before (05/31/2025). CNA E stated that Resident #1 stated that she wanted to harm herself last night but no longer felt that way. CNA E stated that she felt Resident #1 was sad when she talked about her family. CNA E stated Resident #1 was not tearful or crying during their conversation. CNA E stated that she and LVN F alternated 1:1 with Resident #1. CNA E stated that someone was in the room with Resident #1 at all times and if other residents had needs she and LVN F would switch. During an interview on 06/02/2025 at 2:43 PM, NP stated that she saw Resident #1 on 05/30/2025 and there were no indications of suicidal ideation or self-harm. NP denied that the facility reached out to the on-call provider on 05/31/2025 after Resident #1 was found with a belt around her neck. NP stated if there was a self-harm attempt, she would have expected the facility to communicate to the provider, but not for suicidal ideation. During an interview on 06/02/2025 at 2:58 PM, RN A stated that the CNA reported that Resident #1 had the belt from the nightgown around her neck and the bed rail. RN A stated that the belt was loose around Resident #1's neck and he assessed Resident #1 for any injuries, and none were noted. RN A stated Resident #1 had no redness or bruising on her neck and her vitals were normal. RN A stated he contacted on-call nurse manager who was ADON. RN A stated he did not contact the NP or MD and was instructed by ADON to initiate 15-minute checks. RN A stated that MD or NP is contacted when anything happens with a resident or if there was an emergency or change of condition. RN A stated in the moment he did not consider what happened with Resident #1 an emergency because she was stable, the belt was loose and there were no injuries. During an interview on 06/02/2025 at 3:10 PM, ADON stated that he received a call from RN A regarding suicidal ideation of Resident #1 and instructed RN A to initiate 15-minute checks. ADON stated that he understood that Resident #1 expressed suicidal ideation with no plan or action. ADON stated that RN A did not report that Resident #1 had a belt around her neck. ADON stated that he expected that RN A would have called the provider due to Resident #1's actions. ADON stated that 911 was contacted on 06/01/2025 and Resident #1 was declined to be taken by EMS. ADON stated that 911 was called again and Resident #1 wanted an evaluation, so she was sent out for further evaluation. During an interview on 06/02/2025 at 3L25 PM, SW stated that after a resident is readmitted from the hospital they were re-referred to psychiatric or psychological services. SW stated that Resident #1 struggled with depression and anxiety. SW stated that Resident #1 did not express wanting to harm herself or that she wanted to harm herself. SW stated she last saw Resident #1 on 05/23/2025 when she was re-referred to psych services after she returned from the hospital. During an interview on 06/02/2025 at 3:34 PM the DON stated that she was notified of the incident with Resident #1 the morning of 06/01/2025 after she checked in with ADON and ADON stated there was suicidal ideation with Resident #1. The DON stated she reviewed the notes and saw it was more than ideation at that point. The DON stated that upon investigation with RN A and CNA B that CNA B remained in the room with Resident #1 and RN A remained outside of Resident #1's room throughout the remained of their shifts. The DON stated she would have expected RN A to notify the provider that Resident #1 was found with a belt around her neck and tied to her bed. During interviews on 06/02/2025 between 2:00 PM and 4:12 PM, 4 CNAs, 2 LVNs and 1 RN stated that they received an in-service on signs and symptoms of depression, recognizing signs or symptoms of suicidal idea and in-service on what to do if a resident has suicidal ideation or suicidal attempt. Interviewed staff listed changes in behavior, isolation, stating someone wished they were no long here as signs or symptoms to look for. Interviewed staff stated that they would report any of these symptoms or signs to the charge nurse, ADON, DON and ADM immediately. Interviewed LVNs and RN stated they would notify the physician immediately, as well as the DON and ADM, initiate 1:1 with the resident, remain with the resident and call 911 for any attempted self-harm displayed by a resident. During an interview on 06/02/2025 at 4:54 PM, the ADM stated that the difference between suicidal ideation were thoughts, loneliness, sadness and stating one did not want to be here versus a self-harm attempt was to have a plan and going from emotion to action. The ADM stated even if a resident could not execute the plan, even if they were bed bound, if the resident expressed they had a plan it would be considered an attempt. The ADM stated he expected staff to notify the provider for a self-harm attempt. Review of in-services reflected in-services was completed with staff on what to do if a resident had suicidal ideation and suicidal attempt each dated 06/01/2025. In-service reflected any attempt or suicidal ideation need to notify the proper channels and included the resident's nurse, on-call provider, DON and ADM. Review of QAPI meeting sign-in dated 06/01/2025 reflected NP, DON, ADON, ADM and corporate leaders was held to discussed incident with Resident #1. Review of facility policy titled Change in Condition with revision date of 04/2025 reflected [t]here will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached.

Based on interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure nurses were documenting the oxygen flow rate or response to oxygen therapy for Resident #1. The facility failed to have an ongoing system of monitoring Resident #1 as her oxygen saturations dropped below 92% on several occasions, she could no longer participate in therapy, her CO2 lab value was 40 (normal range was 23-31), and she continued to be short of breath days prior to hospitalization on 04/12/25 where she was diagnosed with acute and chronic hypoxic (low levels of oxygen in your body tissues) and hypercapnic (an excess of carbon dioxide in the blood stream) respiratory failure and CHF exacerbation. This deficient practice could place residents at risk for inadequate care, respiratory distress, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), unspecified heart disease, and dependence on supplemental oxygen. Review of Resident #1's admission MDS assessment, dated 03/31/25, reflected a BIMS of 15, indicating she was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected she required oxygen therapy. Review of Resident #1's admission care plan, dated 03/24/25, reflected she had asthma and COPD with an intervention of monitoring for s/sx of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest. Review of Resident #1's preadmission clinicals, dated 03/17/25, reflected she was on continuous use of oxygen at 2 liters for chronic respiratory failure. Review of Resident #1's physician order, dated 03/25/25, reflected O2 at 2-4 L/Min prn to keep sats >= 90% and avoid 4 liters if possible as she retained CO2. Review of Resident #1's lab results, dated 04/09/25, reflected a critically high CO2 level of 40 (Reference Range: 23-31 mEq/L). Review of Resident #1's NP note, dated 04/09/25, reflected the following: Chief Complaint: abnormal lab, increased SOB, pain . [Resident #1] reports increased dyspnea (shortness of breath), which she notes began around the same time she started using an inhaler . She is currently on 3 L of oxygen and uses a BiPAP machine due to hypercapnia. She mentions that her oxygen levels dropped during the night, and she has been experiencing difficulty taking deep breaths, describing it as laborious. . Physical Exam: General: Dyspneic, in bed, color wnl Resp: Oxygen saturation 91-95% on 3 liters of oxygen, diminished breath sounds throughout, decreased to 87% on 2 liters; no wheezing auscultated; labored breathing noted. Review of Resident #1's IDT Care Plan Review, dated 04/10/25, reflected the following: Additional Comments: [Resident #1] and FM A were concerned about the level of O2 she has been on and said that they would like her to go back to using 2 liters of O2 rather than 4. . Therapy Services Plan of Care: [OT B] participated care plan for [Resident #1] with IDT and [FM A] in order to communicate regarding recent change in condition (extreme fatigue and headache) and decreasing oxygen saturation (79%), resulting in limited participation in therapy this week, functional levels and treatment outcomes prior to this week with strength, balance, and hygiene focus, and frequency in OT and PT. Review of Resident #1's NP note, dated 04/11/25, reflected the following: Chief Complaint: abnormal urine, hypoxia . Nursing reported that [Resident #1]'s oxygen saturation was 84% this morning but is currently 92%. She is using BiPAP but is unhappy with the current mask size and request a medium-sized mask. DON was notified of [Resident #1] asking for a different mask and this was obtained almost immediately . She is still feeling more SOB than her baseline and CXR was ordered and completed and showed no acute cardiopulmonary disease. Physical Exam: Resp: Labored, expiratory wheezing throughout. Additional Notes: Chronic obstructive pulmonary disease with acute lower respiratory infection Worse/Exac: - Oxygen sat 91-92% on 3 liters during visit. - Increased prednisone dosage: starting at 40 mg daily for 3 days, then titrating down by 10 mg every 3 days. - Initiated Brovana and budesonide via Nebulizer twice a day. - Continues on DuoNeb 4 times a day and albuterol every 4 hours as needed. - Continue on roflumilast. - Discontinued AirSupra as nebulizers provide more effective medication delivery. - Patient advised to avoid exertion and use BiPAP as needed to alleviate shortness of breath. - Can wear bipap all the time for now to assist with CO2 retention. - Follow-up scheduled for Monday to assess patient's condition and response to treatment. - Instructed to ask to go the hospital if she feels like she's not getting better or is getting worse. . New lower extremity edema - may need diuretics with elevated CO2 and treating UTI will f/u Monday. Heart Failure - Now with edema which is new today. [Resident #1] has a history of mild congestive heart failure. Review of Resident #1's x-ray results, dated 04/11/25, reflected the following: There is no abnormal radiopaque foreign body. The cardiac silhouette is enlarged. There is no pneumothorax visible. There is no radiographic evidence of pulmonary edema. There is no radiographic evidence of pneumonia. IMPRESSION: There is no radiographic evidence of acute disease. Review of Resident #1's Infection Surveillance assessment, dated 04/11/25, reflected she had a new or increased cough, and her oxygen saturation was less than 94% on room air or a reduction in oxygen saturation of >3% from baseline with an onset of 04/10/25. She was started on Cipro (antibiotic) on 04/11/25. Review of Resident #1's progress note, dated 04/12/25 at 5:37 AM and documented by LVN C, reflected the following: CNA notified this nurse that [Resident #1] was experiencing difficulty breathing. Upon immediate assessment, [Resident #1] was noted to be in respiratory distress with O2 saturation at 54% on pulse oximeter. [Resident #1] observed with labored breathing and cyanosis (blue/purple in color) to lips. 911 was called immediately. EMS arrived promptly and initiated oxygen therapy; [Resident #1]'s O2 saturation improved to 97% following their interventions . Review of Resident #1's progress notes, from 03/24/25 - 04/12/25, reflected the nurses were not documenting the flow rate she was receiving or her response to the oxygen therapy. Review of Resident #1's hospital paperwork, dated 04/12/25, reflected the following: [Resident #1] had noticed worsening shortness of breath for the last 2-3 days . [Resident #1] was requiring increasing oxygen requirements, had to increase her O2 to 4L, received IV furosemide. . Carbon Dioxide - 39 . Final Result: Findings of CHF/volume overload. . [Resident #1] admitted to the ICU with acute and chronic hypoxic and hypercapnic resp failure and CHF exacerbation. During a telephone interview on 05/27/25 at 4:29 PM, FM A stated on multiple occasions, Resident #1 would tell the NP, I do not feel good, I feel like I need to go to the hospital. She stated the NP would respond, I cannot stop you from going to the hospital, but I think you should wait. She stated she was notified on occasions where her oxygen saturations would drop in the 80's (percent). She stated because she had COPD, they were used to them dropping low, but when they did, she was always sent to the hospital in the past. She stated she knew it was common for someone with COPD to develop CHF and that was what she was worried about because the last time Resident #1 was hospitalized , the doctor had told her she had the beginning stages of CHF. She stated instead of trying to treat what was wrong, they (facility staff) just kept increasing the liters of oxygen she was receiving. She stated at the facility, the NP would tell her everyone with COPD had CHF, and she believed that was not a reason to not treat her. She stated she received a call on 04/12/25 at 5:30 AM informing her Resident #1 was being sent to the hospital. She stated she was diagnosed with full-blown CHF with fluid on her heart and lungs. She stated the doctor at the hospital told her if Resident #1's oxygen had dropped below 88 (percent) at any time, she should have been sent to the hospital. She stated the facility did not take Resident #1 seriously, she was suffocating and drowning with the fluid build-up. She stated Resident #1 was currently at a rehab facility and would not be returning to (facility). During a telephone interview on 05/28/25 at 12:07 PM, the MD stated ideally, it would be important to document how many liters of oxygen a resident was on because it would be hard to treat a resident without knowing. She stated if a resident had a critical lab value for their CO2 levels, it would depend on what condition they were in as to what she would have done next. She stated if the resident had diagnoses of COPD or hypoxia, she would have evaluated their mental status at that time and if they were continuing to complain of shortness of breath. She stated if a resident was in hypercapnic failure, their mental status would normally be altered, and oxygen saturations would be low. She stated Resident #1 had requested a new mask which they (staff) obtained for her. She stated despite placing the new mask, she could have continued to deteriorate due to underlying issues such as pneumonia. She stated her severe obesity could play a part for how she was compensating for her hypercapnia failure, but they (staff) did the right thing by changing the mask. She stated with Resident #1 continuing to have her oxygen desaturating and with the critical level of her CO2, it would have been prudent to have sent her to the ER for further assessments/care. During an interview on 05/28/25 at 12:25 PM, Resident #1's NP stated it would sure help and make it nice for nurses to document how liters of oxygen a resident was receiving so they could tracker her oxygen saturations and on how many liters. She stated symptoms of a high CO2 level would be increased confusing, increased shortness of breath, low oxygen saturation, and lethargy. She stated some people tend to run high (CO2 levels) and it more so depended on how they were presenting. She stated in some people, an increase in CO2 could lead to death. She stated if a resident was taking off their bipap or cpap or not wearing it regularly, it could make their CO2 levels increase. She stated she was never notified of Resident #1 taking off her bipap. She stated for someone with COPD, you wanted to keep it on the lowest level of oxygen possible with still maintaining 92 percent saturations, as you did not want an unnecessary amount of oxygen. She stated Resident #1 was normally on 2-3 liters of oxygen. She stated on 04/11/25, a nurse told her she had been at 84% that morning, so she started her on prednisone (worked as an asthma treatment). She stated that same day (04/11/25), Resident #1 was more wheezy, short of breath, and more anxious. She stated if someone was short of breath, that would be the reason they were more anxious. She stated any kind of decline in someone's health could make heart failure worse, including increased levels of CO2. She stated she had not ordered for Resident #1 to be sent to the hospital sooner because sometimes going to the hospital could be worse for the residents. She stated she never told Resident #1 she could not go to the hospital. She stated her blood work had been okay, chest x-rays were fine, she started her (on 04/11/25) an antibiotic for a possible UTI, and ordered prednisone. During an interview on 05/28/25 at 2:28 PM, OT B stated Resident #1 started presenting with fatigue and headache on 04/08/25. She stated that was also when her oxygen saturations started being affected (dropping). She stated she started to not want to get out of bed and they could not encourage her to get up . She stated the nursing staff knew, and she brought it up in her care plan meeting on 04/10/25. During an interview on 05/28/25 at 3:03 PM, the DON stated the nurses would probably document the amount of liters of oxygen a resident was receiving in their skilled nursing note. She stated it was important to document so they would know how they were doing each day. She stated if a resident had abnormal lab values, she would always follow the provider's orders. She stated the NP was very involved in Resident #1's care because she was here so often. She stated her CO2 level was elevated, but because her COPD was so severe, it was not too abnormal to see that. She stated her chest x-rays had been normal and believed the next step would be starting Lasix. She stated she knew her oxygen saturations were dipping from time-to-time, but that was to be expected, especially in therapy. She stated she believed they (staff) were managing her symptoms pretty well. She stated she would expect the nurses to monitor Resident #1's oxygen saturations more often, especially if they were lower than 92 percent. She stated she believed they were doing that but should have absolute been documented in her EMR. She stated not monitoring her oxygen saturations more often could lead to a decline in her health. She stated symptoms of hypercapnia were higher CO2 levels and shortness of breath, but hypercapnia was usually figured out by blood levels which were only done in the hospital. During an interview on 05/28/25 at 3:16 PM, LVN D stated she worked with Resident #1 the day before she went to the hospital on [DATE]. She stated she remembered her oxygen saturations being in the 80's that morning and she notified the NP. She stated she could not remember how many liters of oxygen she was receiving. She stated whenever someone had low oxygen, she would re-check it and re-check it. She stated she had been fairly new to the facility and was still learning their EMR system and admitted she failed to document when she re-checked her oxygen saturation levels and the oxygen flow rate . She stated in her opinion, Resident #1 did not seem to be struggling to breathe or having a change in condition that day. Review of the facility's undated Oxygen Administration Policy reflected the following: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. . 16. Document all appropriate information in medical record. A. Oxygen therapy B. Respiratory assessment findings C. Method of oxygen delivery D. Flow Rate E. Resident's response

Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 was administered her prescribed Keppra (anticonvulsant), Buprenorphine (for pain), and Buspirone (for depression and anxiety) until five hours after the scheduled administration time on 04/22/25 causing her to be in increased pain, anxiety, and continuous spasms in her legs. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, post-traumatic stress disorder, chronic pain, and generalized anxiety disorder. Review of Resident #1's quarterly MDS assessment, dated 03/06/25, reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 01/14/25, reflected she was taking anti-anxiety and anti-depressant medication with an intervention of giving anti-anxiety and anti-depressant medications as ordered by the physician. Review of Resident #1's physician order, dated 01/07/25, reflected Buprenorphine HCl - Give one film sublingually every 12 hours for pain. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Buprenorphine was scheduled for 8:00 AM but not was administered until 1:01 PM by the ADON. Review of Resident #1's physician order, dated 02/18/25, reflected Buspirone HCl Oral Tablet - 10 MG - Give two tablets by mouth two times a day related to major depressive disorder and generalized anxiety disorder. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Buspirone was scheduled for 8:00 AM but not was administered until 12:55 PM by the ADON. Review of Resident #1's physician order, dated 04/17/25, reflected Keppra Oral Tablet - 250 MG - Give one tablet by mouth one time a day for anticonvulsants. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Keppra was scheduled for 8:00 AM but not was administered until 12:55 PM by the ADON. During an interview on 04/29/25 at 9:29 AM, Resident #1 stated medications were administered late very often. She stated she had not received her morning medications yet. She stated it was frustrating because not getting her medications on time, especially her Cerebral Palsy medications, truly affected her. She stated one day a week prior, morning medications were not administered until 1:00 PM. She stated she could not function or get out of bed. She stated she was in so much pain, was extremely anxious, and her legs would not stop jerking uncontrollably which was very uncomfortable. She stated she felt like she was going to have a panic attack just waiting for her medications. During a telephone interview on 04/29/25 at 1:04 PM, NP A stated some medications were not as time sensitive as others. She stated usually missing a dose by an hour or two would not be that big of a deal. She stated regarding Resident #1 and her diagnoses and the medications she was on, not getting her medications until five hours after they were scheduled could definitely cause her a lot of pain, anxiety, and for her legs to have increased jerking/spasming. She stated anxiety was one of her main issues and she hoped being administered medications that late was a rare occasion. During a telephone interview on 04/29/25 at 1:38 PM, NP B stated usually scheduled medications were to be administered within an hour before or an hour after the scheduled time. If a resident did not receive their medication until after a five-hour timeframe from the scheduled time she would expect for them to be in increased pain, primarily. During an interview on 04/29/25 at 2:15 PM, the ADON stated he did not normally pass medications. He stated he was new to the facility and did pass medications on 04/22/25. He stated he probably was late with administering the medications because he was training with the DON. He stated he was not running on time due to him explaining all the medications to the residents. He stated medications should be administered punctually. He stated normally the orders have a window (timeframe), but Resident #1's medications did not. He stated it was more important that she received the medications than not get the medications. He stated not getting the medications all together would be a more serious situation. During an interview on 04/29/25 at 2:47 PM, the DON stated her expectations on medication administration was that they were administered effectively per the residents' MAR. She stated she wanted to make all the medication times liberalized so that the timeframe would be, for example, between 7:00 AM and 12:00 PM for morning medications. She stated on 04/22/25 it was the ADON's first day being trained all the medication cart. She stated he was trying to explain all of the medications to the residents, and she realized they ran late with the administration . She stated a negative outcome of receiving medications late could be increased pain or anxiety. She stated, however, Resident #1 was always experiencing pain and anxiety. Review of the facility's Medication Administration Policy, revised 11/13/18, reflected the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. . Medications are administered within (60 minutes) of scheduled time . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's transfer status was accurate in her care plan as it did not reflect she required a mechanical lift. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur (thigh bone), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected she was dependent with transfers, utilized a manual wheelchair, and did not require a mechanical lift. Review of Resident #1's admission care plan, dated 11/06/24, reflected she had ADL self-care performance deficit related to impaired mobility with an intervention of requiring total assistance with transfers. Review of Resident #1's Daily Skilled with Self-Care Mobility Assessment, dated 01/09/25, reflected Limited ROM requires x2 persons assist to transfer bed to chair, bed and into the wheelchair. Mechanical lift to transfer [sic]. During an interview on 01/10/25 at 9:34 AM, LVN A stated Resident #1 required a mechanical lift transfer with two staff members assistance for all transfers as she was unable to bear weight. During an interview on 01/10/25 at 12:21 PM, the DON stated it was the nursing department's responsibility to ensure the MDS and care plan matched the residents' transfer status. She stated it was her expectation that they were up to date, matched, and staff knew how to properly transfer each resident. She stated it was important to ensure they were providing the best care to the residents. She stated a negative outcome of the assessments not matching would depend on the situation, but it was important for safety reasons. Review of the facility's Nursing Services - ADLs Policy, revised 05/2007, reflected the following: Each resident is assessed for their ability to perform ADLs and the assistance needed, and a plan of care is developed and interventions are implemented based on their needs, goals of care and preferences. Each resident receives adequate supervision and assistive devices as needed.

Based on interview and record review the facility failed to have assessments that accurately reflected the status for one (Resident #1) of five residents reviewed for assessment accuracy. The facility failed to ensure Resident #1's transfer status was accurate in her MDS as it did not reflect she required a mechanical lift. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur (thigh bone), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected she was dependent with transfers, utilized a manual wheelchair, and did not require a mechanical lift. Review of Resident #1's admission care plan, dated 11/06/24, reflected she had ADL self-care performance deficit related to impaired mobility with an intervention of requiring total assistance with transfers. Review of Resident #1's Daily Skilled with Self-Care Mobility Assessment, dated 01/09/25, reflected Limited ROM requires x2 persons assist to transfer bed to chair, bed and into the wheelchair. Mechanical lift to transfer [sic]. During an interview on 01/10/25 at 9:34 AM, LVN A stated Resident #1 required a mechanical lift transfer with two staff members assistance for all transfers as she was unable to bear weight. During an interview on 01/10/25 at 12:21 PM, the DON stated it was the nursing department's responsibility to ensure the MDS and care plan matched the residents' transfer status. She stated it was her expectation that they were up to date, matched, and staff knew how to properly transfer each resident. She stated it was important to ensure they were providing the best care to the residents. She stated a negative outcome of the assessments not matching would depend on the situation, but it was important for safety reasons. Review of the facility's Nursing Services - ADLs Policy, revised 05/2007, reflected the following: Each resident is assessed for their ability to perform ADLs and the assistance needed, and a plan of care is developed and interventions are implemented based on their needs, goals of care and preferences. Each resident receives adequate supervision and assistive devices as needed.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Hall 200) of 2 Medication storage rooms reviewed for drug storage. The facility failed to ensure 2 expired I.V. PICC Line Stat lock Plus Stabilizations devices, 1 expired Covid 19 Test, and 3 expired laboratory bacterial swabs were removed from the Hall 200 medication storage room. These failures could place residents who needed I.V. medications at risk to have unsecured IV PICC Lines, which could cause the resident to have an unnecessary invasive PICC replacement procedure or put them at risk of infection. Expired Covid test and lab swabs could lead to inaccurate diagnosis and worsening of resident's health due to inaccurate and ineffective treatments. Use of these supplies would not meet acceptable standards of medical practice and could result in resident's harm. Findings include: Observation on [DATE] at 9:20 am of the Medication Room on hall 200 revealed the following: 2 I.V. PICC Line Stat lock Plus Stabilizations Devices-Expiration date of [DATE]. Lab supply: 1 Covid 19 Test Kit-Expiration date of [DATE] Lab supply: 3 Bacterial Swabs-Expiration date of [DATE] In an interview on [DATE] at 9:33 am LVN-A stated, the risk of using expired items is they may not be effective for treatment. Resident lab testing may not get appropriate result and an expired Stat Lock may not stick to the skin to maintain sterility and this could increase the risk of infection. LVN-A stated expired lab swabs and Covid Test may not catch accurate results. In an interview on [DATE] at 1:33 pm the DON stated, the policy for expired medical supplies is to destroy them. She stated this is important because they create a risk for altered lab results and identification of the wrong bacteria causing infections. The DON stated the negative outcome to residents would be infections, wrong medications, or wrong diagnosis of Covid. In an interview on [DATE] at 1:48 pm the ADM stated, the policy for expired medical supplies in the medication storage area is for them to be disposed of as the manufacturer recommends. He stated this is important because the supplies may not work as the manufacturer intended and that could cause infections for residents, or some items could lose potency if expired. Record review of the undated facility policy titled, Medication Storage reflected, Medications that are discontinued, expired, or deteriorated .are removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures.

Based on observations, interviews, and record review the facility failed to ensure a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 of 3 residents (Residents #20, 46, and 298). The facility failed to ensure Resident #20's, #46's, and #298's oxygen tubing and humidifier bottles were dated to ensure they were changed weekly. This failure placed the residents at risk of developing a respiratory infection from contamination of the tubing and humidifier water. Findings include: Record review of Resident #20's undated face sheet reflected he was a [AGE] year-old male admitted [DATE] with diagnoses of Orthostatic Hypotension (unstable blood pressure), Malnutrition, COPD (lungs do not exchange oxygen well), Diabetes, Anxiety Disorder, Legal Blindness, Tumor of Pancreas, and Obesity. Record review of Resident #20's initial MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated the resident's cognition was intact. The MDS also reflected the need for Oxygen treatments. Record review of Resident #20's Care Plan, reflected a Focus area was initiated 7/5/2024 for risk for skin impairment related to morbid obesity, limited mobility and oxygen use with a goal to maintain intact skin. Record review of Resident #20's Orders reflected a 7/4/2024 order for Oxygen at 3 Liters/Minute via nasal canula continuous flow. The orders also reflected an order to change oxygen tubing and humidifier bottle weekly, every Sunday night shift. Observation on 8/6/2024 at 10:28 am revealed Resident #20 with humidified oxygen connected to a nasal canula tubing with a flow rate of 3 liters/minute. The tubing and the humidifier water bottle did not have a date to indicate when they were last changed. Record review of Resident #46's undated face sheet reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lungs do not exchange oxygen well), Chronic Respiratory Failure with hypoxia (low oxygen), Reflux, Anemia, Malnutrition, weakness, and a 2nd degree burn. Record review of Resident #46's initial MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #46's Care Plan, reflected a Focus area was initiated 7/3/2024 for her breathing disease, COPD. The goal was to avoid rehospitalization and the interventions included oxygen therapy as ordered by the physician. Record review of Resident #46's Orders reflected a 6/20/2024 order for Oxygen at 2-4 Liters/Minute via nasal canula continuous flow. The orders also reflected a 6/20/2024 order to change oxygen tubing and humidifier bottle weekly, every Sunday night shift. Observation on 8/6/2024 at 10:12 am revealed Resident #46 with humidified oxygen connected to nasal canula tubing with a flow rate of 3 liters/minute. The tubing and the humidifier water bottle did not have a date to indicate when they were last changed. Record review of Resident #298's undated face sheet reflected he was a [AGE] year-old male admitted [DATE] with diagnoses of Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), left side paralysis, COPD (lungs do not exchange oxygen well), Chronic Respiratory Failure, Heart Failure, and Myocardial Infarction (heart attack). Record review of Resident #298's initial MDS assessment dated [DATE], reflected that the resident was too severely impaired to perform a BIMS. Resident was non-verbal himself and extremely limited in non-verbal responses. Record review of Resident #298's Care Plan, reflected a Focus area was initiated 7/21/2024 for Tracheostomy related to acute respiratory failure secondary to a stroke. The goal was to remain free of infection and the intervention included, Administer oxygen as needed. Record review of Resident #298's Orders reflected a 7/28/2024 order to change all respiratory connecting tubing, suction catheters, water trap, mask weekly, every Wednesday night shift. Observation on 8/6/2024 at 10:03 am revealed Resident #298 with humidified oxygen connected to tracheostomy tubing. Neither the tubing nor the humidifier bottle had a date to indicate when they were last changed. In an interview on 8/8/24 at 1:33 pm the DON stated the policy for changing oxygen tubing and the humidifier bottle was to change every 7 days on Wednesday night. She stated, changing it timely was important to prevent bacteria and infection. The DON stated, if it was not changed the resident would be at risk for an infection. In an interview on 8/8/24 at 1:48 pm the ADM stated, the policy for changing oxygen tubing and the humidifier bottle was that they are generally changed 1 x per week and changing it timely was important for infection control and preventing bacteria from growing. The ADM stated the negative outcome to residents if it was not changed, would be infections. Record review of the facility policy titled Oxygen Administration (Mask, Cannula, Catheter) with a last revised date of 05/2007 reflected the following: Oxygen tubing is to be replaced every 7 days. Oxygen mask or nasal prongs are to be replaced every 7 days. Replace disposable humidifiers every 7 days or as needed when empty. the policy did not address the labeling/dating.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's mental and psychosocial needs for 5 of 8 residents (Residents #14, 32, 74, 76, and 77) reviewed for care plans. The facility failed to ensure the care plans for Residents #14, 32, 74, 76, and 77 included person-centered goals and interventions for activities. This failure placed residents at risk of not having their recreational and social needs met. Findings included: Review of the undated face sheet for Resident #14 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Major depressive disorder, generalized anxiety disorder, dementia, lack of physical exercise, muscle weakness, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #14 dated 04/17/24 reflected a BIMS score of 15, indicating intact cognition. Review of the care plan for Resident #14 dated 05/08/24 reflected no care planning for activities. It reflected the following: Potential for adjustment issues due to admission. Will maintain the ability to seek social contact and stimulation through the review date. Will receive daily opportunities for social contact through the review date. Encourage ongoing family involvement. Invite family to attend special events, activities, meals. o Encourage to participate in conversation with staff, other residents daily. o Introduce to residents with similar background, interests and encourage/facilitate interaction. Review of the undated face sheet for Resident #32 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, type two diabetes mellitus, major depressive disorder, muscle atrophy (wasting or thinning of muscle mass), muscle weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, fatigue, and mild cognitive impairment. Review of the quarterly MDS assessment for Resident #32 dated 07/01/24 reflected a BIMS score of 12, indicating moderate cognitive impairment. Review of the care plan for Resident #32 dated 7/15/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t Physical Limitations. Will attend/participate in activities of choice by next review date. Will maintain involvement in cognitive stimulation, social activities as desired through review date. There were no interventions related to specific activities enjoyed by Resident #32. Review of the undated face sheet for Resident #74 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spinal stenosis (a condition that narrows the space inside the backbone, putting pressure on the spinal cord and nerves), radiculopathy (pinched nerve), low back pain, generalized anxiety disorder, major depressive disorder, multiple sclerosis (potentially disabling disease of the brain and spinal cord), cognitive communication deficit, and chronic pain syndrome. Review of the quarterly MDS assessment for Resident #74 dated 06/06/24 reflected a BIMS score of 13, indicating intact cognition. Review of the care plan for Resident #74 dated 06/28/24 reflected no care planning related to activities. It reflected the following: Potential for a psychosocial well-being problem r/t Anxiety, insomnia and depression for which no medication interventions are required at this time. Will identify individual strengths by the review date. Will demonstrate adjustment to nursing home placement by/through review date. Allow time to answer questions and to verbalize feelings perceptions, and fears. o Consult with: Social services, Psych services as indicated. o Monitor/document resident's usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leaves to fate, or luck. o Needs assistance/supervision/support with identification of potential solutions to present problems. o Observe for side effects and adverse reactions of hypnotic medications: burning or tingling in the hands, arms, feet, or legs, change in appetite, constipation, diarrhea, difficulty with balance, dizziness, weakness, drowsiness, dry mouth, headache, GI upset, stomach pain or tenderness, uncontrollable shaking of a body part, unusual dreams o Provide opportunities for family to participate in care. Review of the undated face sheet for Resident #76 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included infection and inflammatory reaction due to indwelling urethral catheter, methicillin-resistant staphylococcus aureus infection, mild persistent asthma, chronic obstructive pulmonary disease, fatigue, nausea, lack of coordination, unsteadiness on feet, cognitive communication deficit, blindness of right eye, reduced mobility, functional quadriplegia (complete inability to move without damage or injury to the spinal cord), congestive heart failure, delusional disorders, psychophysiological insomnia (heightened worries about sleep), and malignant neoplasm of scrotum (scrotal skin cancer). Review of the quarterly MDS assessment for Resident #76 dated 07/12/24 reflected a BIMS score of 15, indicating intact cognition. Review of the care plan for Resident #76 dated 10/11/23 reflected the following: [Resident #76] is Dependent on staff for activities, cognitive stimulation, social interaction r/t Physical Limitations. Will attend/participate in activities of choice by next review date. Invite to scheduled activities. Needs assistance/escort activity functions. There were no interventions related to specific activities enjoyed by Resident #76. Review of the undated face sheet for Resident #77 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included rheumatoid arthritis, chronic pain syndrome, major depressive disorder, unsteadiness on feet, dementia, cognitive communication deficit, and muscle weakness. Review of the quarterly MDS assessment for Resident #77 dated 06/21/24 reflected a BIMS score of 15, indicating intact cognition. Review of the care plan for Resident #77 dated 08/25/23 reflected the following: [Resident #77] is Dependent on staff for activities, cognitive stimulation, social interaction. Will attend/participate in activities of choice by next review date. Invite to scheduled activities. Needs assistance/escort activity functions. There were no interventions related to specific activities enjoyed by Resident #77. During an interview on 08/08/24 at 03:14 PM, the MDSN stated she had been in the position for a week and a half. She stated part of her role and responsibility was to create care plans from the MDS care area assessments. The MDSN stated she needed to gather information from the other department heads, especially in the area of activities, to create person-centered care plans. The MDSN stated generic care planning for activities was not consistent with policy, and the care plans should have been personalized and specific. The MDSN stated ensuring care plans were personalized would be her responsibility, but she and the DON were both new, so they had not created a system yet. The MDSN stated the potential impact of not having personalized care plans was that the resident might not have the best care possible . During an interview on 08/08/24 at 03:24 PM, the ADM stated care plans should have been personalized. He stated ultimately the care plans were the DON 's responsibility, but the whole interdisciplinary team should have been involved. Review of facility policy dated 12/23 and titled Comprehensive Resident Centered Care Plan reflected the following: It is the policy of this facility that the interdisciplinary team should develop a comprehensive person-centered care plan for each resident that includes measurable objectives, and time frames to meet a residents. Medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The facility IDT will develop and implement a comprehensive person centered, culturally, competent, and trauma informed care plan for each resident . And will include resident needs identified in the comprehensive assessment, and residence, goals, and desired outcomes, preferences for future discharge, and discharge plan.

Based on observation, interview, and record review, the facility failed to ensure a nourishing snack was served at bedtime, when more than 14 hours and up to 16 hours elapsed between a substantial evening meal and breakfast the following day for 3 of 6 halls (100, 200, and 300 halls on the long-term care unit) reviewed for evening snack. The facility failed to offer or serve a substantial snack on the evening of 08/07/24 after dinner was served at 05:15 PM and breakfast was not served the next day until 08:00 AM (14.75 hours between meal services). This failure placed residents at risk of hunger and weight loss. Findings included: Observation on 08/07/24 at 07:30 PM revealed a snack tray on the long-term care side of the facility nurse's station (the station serving halls 100, 200, and 300) with sandwiches, bananas, oatmeal cream pies, pudding, juice, and peanut butter crackers at the nurse's station. The nurse's station had an open area where staff sat and documented and could see out and where residents could see in. There was another area of the nurse's station that was behind a wall and not visible to anyone not behind the desk. The snack tray was on the desk behind the wall where no residents could have seen it. There was a total of 20 food snacks and five cups of juice. Observation from 07:30 PM to 08:00 PM revealed the snacks were not offered to any resident, and no resident asked for the snacks. During an interview on 08/07/24 at 07:34 PM, CNAs E and F stated dining set out a snack tray at the nurse's station for residents to come get a snack if they wanted one. They stated they did not usually go around to each room and offer a snack. CNA E stated if every single resident wanted a snack, there would only be a snack on the tray for half the residents on that side of the facility. Observation on 08/07/24 at 07:37 PM revealed no tray of snacks on the skilled nursing side of the facility (halls 400, 500, and 600). During an interview on 08/07/24 at 07:35 PM, CNA C stated she was not sure who passed out snack on the skilled nursing side of the facility. During an interview on 08/07/24 at 07:40 PM, LVN D stated there had been snacks on the skilled side of the facility that night and they were being passed out. During interviews on 08/07/24 between 07:45 and 08:00 PM six anonymous residents stated they did not receive snacks regularly around bedtime and had not received any snacks that night and did not know there were any available. Each of the six residents stated they did want snacks and would have enjoyed having a snack at bedtime. During an interview on 08/08/24 at 01:06 PM, the DM stated dinner had been served at 05:15 PM the night before and breakfast served that morning at 08:00 PM. He stated he prepared the snack trays for bedtime hour, but he did not ensure they were offered. He stated snacks should have been offered at night, because there were more than 16 hours between supper and breakfast. He stated a potential impact of not offering snacks was they might get hungry or not have their nutritional needs met. During an interview on 08/08/24 at 03:24 PM, the ADM stated snacks should be offered to residents at night, not just sit at the nurse's station for people to come request. The ADM stated he had already talked to the DON about how snacks should have been offered and that bowls of snacks should be more available. A potential negative impact of not offering snacks at bedtime was residents might be hungry or depressed. A facility policy on Snacks was requested but not provided by the time of exit.

Based on interview and record review, the facility failed to ensure residents' right retain and use personal possessions for 3 of 8 residents (Residents #56, 68, and 74) reviewed for rights. The facility failed to ensure the former administrator introduced herself and requested permission to search the rooms of Residents #56, 68, and 74 prior to doing so on an undisclosed date. This failure placed residents at risk of misappropriation and feelings of indignity. Findings included: Review of the undated face sheet for Resident #56 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, anxiety disorder, history of transient ischemic attack (temporary blockage of blood flow to the brain), muscle weakness, and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #56 dated 05/20/24 reflected a BIMS score of 15, indicating intact cognition. During an interview on 08/06/24 at 03:45 PM, Resident #56 stated she had walked in on the former administrator in her room looking through her things. Resident #56 stated the former administrator did not ask permission or even notify Resident #56 that she would be looking through her things. Resident #56 stated the former administrator confiscated some body spray and some lotion, and Resident #56 was annoyed by it. She stated the former administrator had said something about having to remove items that someone could use to harm themselves if they had dementia and wandered into a room. Resident #56 stated she did not care that much about the items themselves, but it was the principle of having her room searched without permission. Review of the undated face sheet for Resident #68 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included seizures, epilepsy, major depressive disorder, Wernicke's encephalopathy (neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves), anxiety disorder, insomnia, muscle weakness, cognitive communication deficit, and bipolar disorder. Review of the quarterly MDS assessment for Resident #68 dated 07/12/24 reflected a BIMS score of 15, indicating intact cognition. During an interview on 08/06/24 at 04:40 PM, Resident #68 stated the former administrator had come into her room looking for e-cigarettes. Resident #68 stated the former administrator did not ask permission to look in her room. Resident #68 stated she never had an e-cigarette in her room or anywhere else and knew they were against the rules. Resident #68 stated she did not think the search of her room was fair, and the former administrator did not introduce herself. Review of the undated face sheet for Resident #74 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spinal stenosis (a condition that narrows the space inside the backbone, putting pressure on the spinal cord and nerves), radiculopathy (pinched nerve), low back pain, generalized anxiety disorder, major depressive disorder, multiple sclerosis (potentially disabling disease of the brain and spinal cord), cognitive communication deficit, and chronic pain syndrome. Review of the quarterly MDS assessment for Resident #74 dated 06/06/24 reflected a BIMS score of 13, indicating intact cognition. During an interview on 08/07/24 at 09:30 AM, Resident #74 stated two weeks prior, she had felt bad and was resting in her bed in the middle of the day. She stated the former administrator walked into her room without knocking, did not introduce herself, and began looking through Resident #74's belongings. Resident #74 stated the former administrator was looking in her cabinets and closet and through all her things. Resident #74 stated she asked the former administrator what was going on, and the former administrator said there was a black purse missing in the facility. Resident #74 stated she had a black purse that belonged to her so Resident #74 became upset and told the former administrator she did not have the purse. Resident #74 stated the former administrator staid it was a mistake and left the room. Resident #74 stated she would have given the former administrator permission to look through her things if she had asked. Resident #74 stated it made her feel insulted. An attempt was made to interview the former administrator by telephone on 08/07/24 at 05:15 PM. A voicemail was left but no return contact was made. During an interview on 08/08/24 at 03:24 PM, the ADM stated if they needed to search a resident's room, they had to ask for permission and could not confiscate items without resident permission. The ADM stated the potential impact on residents was financial, and it was a rights violation. A facility policy on Personal Privacy was requested but not provided by the time of exit.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to follow up on concerns and requests expressed in resident council meetings from May 2024 through June 2024 . This failure placed residents at risk of not having their preferences honored. Findings included: Review of Resident Council minutes reflected the following with no documentation of the facility's responses to the grievances: 05/31/24 Dietary: suggestion when they bring certain things can we please have condiments. Had salad for two weeks with no dressing. They work hard, but they don't understand exactly how to put things for better. I think that it would be good to have one designated person to speak English for better communication. Dry pinto beans. Too much salt and too much pepper. Food has been overcooked and dried out lately. Eggs were undercooked. Dark place on ticket that says what we don't want, but nobody reads it. The dressing to the salad is never available but we don't have a choice. Maybe if we change a few things at a time and fix those problems we can move onto the next set of issues. Resident said the food is horrible and there is no fruit. Sloppy cake and nasty noodles. Maintenance: (former maintenance director) does everything he's supposed to do and (former maintenance director) needs help. Nursing: they desperately need some CNAs and extra help because they have not had any help on the floor. CNA came in and threw something in the room and walked out. Resident said we only have one CNA for both halls five and six at nighttime. If they can close the door when they are changing people. There was a girl in there who didn't like me, and she was very rude. CNAs are pathetic at nighttime. Resident said she's about to go to the state because some CNAs are working two and three hallways by themselves. 06/26/24 Dietary: the food here is very unhealthy, everything is fried. The apple juice and cranberry juice are watered down. Resident want someone who can communicate in English to be in the kitchen at all times. The residents were informed the facility is not willing to spend the money on healthier options. Everything is fried. Maintenance: things have not been getting fixed very good. One resident had to clean her own filter in her A/C. Another resident said the A/C never gets cleaned. Nursing: 'so we got a new DON.' The CNAs are overworked. The residents want a new doctor on staff or PA . 07/29/24 Nursing: expressed a desire for a consistent nurse on the 200 hall and inquired about a particular nurse absence. They also want to know the status of the (local hospital) contract and requested regular CNAs instead of relying solely on agency staff. Laundry: residents requested stain ed sheets and towels be replaced. Tattered fitted sheets. Also need to be discarded. One resident reported that her blue towel was bleached. Dietary: residents collectively agreed that the food has improved. However, when resident reported not receiving silverware with her meals, and another complaint of receiving duplicate meals in her room. Concerns were also raised about the cleanliness of the fryer and the flavor of the pasta, which has shown some improvement During a Resident Council meeting on 08/06/24 at 04:06 PM, eight anonymous residents stated the facility used to be really good but had become horrible. They all stated they notified staff about the problems and were always told we're working on it. They all stated they were not aware of any method by which the facility management provided resolutions to the concerns that came up in the resident council minutes. They all stated most of the complaints were about the food, the facility being short staffed, and the maintenance of the physical environment. They stated they did not have meal of the month or discuss their rights during meetings. They stated they had never seen any kind of written paper or grievance form that reflected their concerns and requests during resident council or explained any resolution. They stated they had become tired of saying anything to the staff, because nothing ever changed. They stated the AD did a great job and listened to them, and they did not feel the problem was with the AD. They stated the problem was because there had been a revolving door of administrators, and they never knew who was in charge. They stated they had just learned that a new administrator had started that day, and they hoped he would do something about all the issues they had. One resident stated they wanted a public restroom for the inmates. The other seven residents stated they felt like calling themselves inmates and not residents. During an interview on 08/07/24 at 03:42 PM, the AD stated she had worked at the facility for one year. She stated she attended the Resident Council and wrote down minutes for the meetings. She stated when the residents at Resident Council had a concern or a problem, she wrote it down and turned it in to the department head responsible. The AD stated she spoke to the DON or the former director of nursing, to the DM or the former dietary manager, or to the MAINT or the former maintenance director. The AD stated the DON had only been working at the facility for one month, the DM had only been working at the facility for two weeks, and the MAINT had only been working at the facility for about three weeks. The AD stated she thought the concerns were written down on paper after they were brought to the department head responsible, but she did not see any official forms that were ever turned back into her or submitted. The AD stated the concerns about the food, the nursing staff, the maintenance issues, and the lack of supplies were all documented in the Resident Council minutes, and she did not know how the issues were resolved or what was communicated to the Resident Council. The AD stated things were not being fixed when they were broken, and she had conveyed that to the former administrator. The AD stated the former director of nursing, and the former administrator told her they were handling the concerns, and she did not have the authority to question that. The AD stated the former dietary manager and maintenance director took the concerns, but she did not know what she did with them. The AD stated most of what she reported about maintenance and dietary were reported directly to the former administrator. The AD stated the resolution of concerns had been a roller coaster for the residents due to the staff turnover, but she felt the new team would become stable and fix the issues that had not yet been fixed. The AD stated she had not reported all the issues from six months of Resident Council minutes to the new department heads, but she had been to them with new concerns. The AD stated the ADM had just started the day before, so she had not reported anything to him. The AD stated she had developed her method for addressing Resident Council concerns herself and had not been trained in any other method. She stated she was responsible for holding the Resident Council itself, but the department heads were responsible for resolutions to problems in their departments. She stated the potential negative impact of not having resolutions to their concerns was that Resident Council members might feel like they had no power in their homes. During an interview on 08/08/24 at 12:07 PM, the DON stated she had seen none of the concerns from Resident Council, because everything was going through the former administrator. The DON stated she had only been working at the facility for one month and did not know how the Resident Council concerns were addressed prior to her being at the facility. During an interview on 08/08/24 at 03:24 PM, the ADM stated the procedure for Resident Council ought to have been whoever was there should have documented and readdressed the resolutions with the Council. The ADM stated it was only his third day in the position, so he had not had a chance to develop a system for addressing Resident Council concerns, but the interdisciplinary team should have followed up with the Council regardless of the system in place. The ADM stated the AD was responsible for hosting the Resident Council meetings, but he would need to work with his team to figure out how follow up with the Council occurred and with whom. The ADM stated the potential impact of not having the Resident Council receive follow up on their concerns was psychological in that it could make them feel defeated. Review of facility policy dated 12/23 and titled Grievances reflected the following: It is the policy of this facility to establish a grievance process that allows the residents a way to execute their right to voice concerns or grievances to the facility or other agencies/entity without fear of discrimination or reprisal. General concerns may be voiced at resident and/or family council meetings. Review of facility policy dated 07/07 and titled Resident Council Meeting reflected the following: It is the policy of this facility to 1. Provide a forum, through which constructive suggestions, ideas and concerns may be offered and projects initiated for the mutual benefit of the institution and the residents of the facility; 2. Provide information to the residence on action taken on recommendations made at the resident council meetings; and 3. Give residents a certain degree of self-determination, the planning of upcoming recreational events, outings, and contributions to schedule activities.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for two (Resident #1 and Resident #2) of four residents reviewed for pain. The facility failed to provide effective pain management for Residents #1 and #2 as they went multiple days without their pain medication leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. While the IJ was removed on 07/21/24 at 12:50 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Resident #1 Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, muscle wasting and atrophy (wasting away), and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 04/26/24, reflected a BIMS of 15, indicating she was cognitively intact. Section J (Health Conditions) reflected she received a scheduled and PRN pain medication regimen and was frequently in pain. Review of Resident #1's quarterly care plan, dated 07/01/24, reflected she was currently prescribed an opioid medication for her history of pain with an intervention of administering opioids as prescribed. Review of Resident #1's physician order, dated 06/06/24, reflected Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain. Review of Resident #1's Mar, July 2024, reflected from 07/05/24 - 07/07/024 she missed five doses due to the medication being unavailable. From 07/14/24 - 07/17/24 she missed 11 consecutive doses due to the medication being unavailable. Review of Resident #1's documented pain scale from 07/05/24 - 07/07/24 reflected her highest rating was a 7. Review of Resident #1's documented pain scale from 07/14/24 - 07/17/24 reflected her highest rating was a 10. Review of Resident #1's progress notes, dated 07/05/24 at 3:25 AM and documented by LVN A, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Medication unavailable. Last Pill taken 7/5/24 at 10:00 PM. Nurse on duty does not have pyxis (emergency kit) access. Review of Resident #1's progress notes, dated 07/06/24 at 9:50 AM and documented by LVN A, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablets by mouth four times a day for chronic pain . not available. Review of Resident #1's progress notes, dated 07/07/24 at 2:44 PM and documented by LVN B, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . waiting for pharmacy. Review of Resident #1's progress notes, dated 07/14/24 at 11:28 PM and documented by LVN C, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . medicine reorder- and stated in 24-hour report. Review of Resident #1's progress notes, dated 07/15/24 at 4:56 PM and documented by LVN D, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Medication not available to administer. Medication has been reordered by previous nurse. Review of Resident #1's progress notes, dated 07/16/24 at 5:40 AM and documented by LVN E, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Waiting for pharmacy to deliver. Review of Resident #1's progress notes, dated 07/16/24 at 10:09 AM and documented by the ADON, reflected the following: This nurse was notified by [Resident #1] that her oxycodone-acetaminophen was out of stock. This nurse asked CMA who informed that they did not in-fact have her routine oxycodone-acetaminophen. This nurse called NP to inform medication was out and triplicate needed to be sent. NP informed this nurse that triplicate was sent day prior. This nurse called pharmacy. Pharmacy stated triplicate not showing on their end. Re-called NP to make aware. This nurse informed script would be re-sent . Medication placed on hold until received. During a telephone interview on 07/19/24 at 11:26 AM, LVN E stated LVN D informed him at shift-change on 07/16/24 that Resident #1 was out of her oxycodone but she had re-ordered it and would come in by that night. He stated he waited but it never came. He stated he did not reach out to the pharmacy or NP. He stated Resident #1 was in pain but she did sleep that night. During a telephone interview on 07/19/24 at 1:20 PM, LVN B stated she was not sure what happened with Resident #1's oxycodone (at the beginning of July) but it was not reordered on time. She stated she was informed that another nurse had reordered it. She stated she believed it arrived on her shift and the resident was administered the medication. She stated when a resident is running low on any medication it should be reordered at least a week in advance. During a telephone interview on 07/19/24 at 2:12 PM, LVN C stated she could not remember what happened with Resident #1's medication on 07/14/24. She stated Resident #1 had run out of her pain medications a few times on different occasions. She stated during the week, staff do not order medications and it was often not there for the weekend shift. She stated Resident #1 was in continuous pain and could not miss a dose. She stated she did not reach out to the NP or the pharmacy. During a telephone interview on 07/19/24 at 2:00 PM, LVN D stated she did receive information regarding Resident #1's pain medication in the 24-hour report but she was shadowing a nurse and she was not her patient. She stated she remembered Resident #1 was asking for her pain mediation and other nurses were saying they were trying to reorder but there was an issue. She stated she did not reach out to the NP or pharmacy. Resident #2 Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, muscle wasting and atrophy, and pain. Review of Resident #2's quarterly MDS assessment, dated 07/03/24, reflected a BIMS of 4, indicating a severe cognitive impairment. Section J (Health Conditions) reflected she received a scheduled and PRN pain medication regimen and was frequently in pain. Review of Resident #2's quarterly care plan, dated 05/08/24, reflected she had chronic pain and was on pain management related to chronic physical disability with an intervention of monitoring/reporting to nurse complaints of pain or requests for pain treatment. Review of Resident #2's physician order, dated 06/01/24, reflected Fentanyl Transdermal Patch - 72-hour 37.5 MCG/HR - apply 1 patch trans dermally every 72 hours for chronic pain and remove per schedule. Review of Resident #2's MAR, July 2024, reflected she went without a fentanyl patch from 07/07/24 - 07/10/24 and on 07/16/24 due to none being available. Review of Resident #2's documented pain scale from 07/07/24 - 07/10/24 and on 07/16/24 reflected her highest rating was an 8. Review of Resident #2's progress notes, dated 07/07/24 at 1:09 PM and documented by RN F, reflected the following: This nurse reports that the time of completing the patch change, he notices that there is no stock to make the change, he proceeds to call the pharmacy . Review of Resident #2's progress notes, dated 07/07/24 at 4:55 PM and documented by RN F, reflected the following: Fentanyl Transdermal Patch 72-hour 37.5 MCG/HR - Apply 1 patch trans dermally every 72 hours for chronic and pain and remove per schedule. This nurse cannot comply with this indication today due to the lack of medication . During a telephone interview on 07/19/24 at 11:30 AM, RN F stated when he went to change Resident #2's fentanyl patch on 07/07/24, there were not any available patches in the cart. He stated he notified the DON and stated to move the order until the next morning and wait for the pharmacy to deliver it. He stated the resident was complaining of pain and he did administer a PRN Tramadol . He stated he did not contact the NP at this time. During an interview on 07/19/24 at 12:04 PM, Resident #1 and #2's NP stated sometimes she was given ample time for medication refill requests from staff and sometimes she was not. She stated sometimes she was made aware of residents going without medications after the fact. She stated she was not aware Resident #1 or #2 went a long period of time without pain medication. She stated if she had known, it would have been handled sooner. She stated the ADON asked her to put Resident #2's fentanyl patch on hold until a new one was delivered and was not sure why it was not put on her until 07/10/24. She stated the nurse could have easily put in a new order to restart the patch. She stated she was in the facility on 07/16/24 when Resident #1 sought her out, was very tearful, and was in moderate/severe pain. She stated she had not been notified by staff that she had been out of her pain medication for several days. She stated Resident#1 had chronic pain and should not miss any doses. She stated she was not always notified in a timely manner and would prefer to be notified of refill requests at least three days in advance. During an interview on 07/19/24 at 1:42 PM, the DON stated it was not her expectations for residents to go multiple days without their pain medications. She stated she expected nurses to re-order medications when there were seven days remaining. She stated it was all of the clinical staff's responsibility this was getting done. She stated a negative outcome of not reordering pain medications in a timely manner was increased pain, could lead to falls, or withdrawals. Review of the facility's Pain Recognition and Management Policy, revised 12/2023, reflected the following: Policy: It is the policy of this to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. .3. Management .c. If the pain management program is not effective, the licensed nurse will contact the resident's physician. The ADM was notified on 07/19/24 at 3:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/20/24 at 6:52 PM: F697: Pain Management: The notification of Immediate Jeopardy states as follows: On 7/19/2024, the facility failed to administer narcotic medication to resident # 1 and #2. 1. Medical Director was notified of the IJ on 7/19/24 at 4:55pm. The Pharmacist was notified of the IJ on 7/19/2024 at 4:58pm. 2. Resident #1 and #2 had pain assessments completed and medication audited on 7/19/2024 by a sister facility DON. 3. 100% audit of every MAR/TAR for pain triggers and that appropriate interventions were completed by a sister facility DON. If pain triggers are noted the auditing nurse will ensure that the appropriate pain meds are available and administered per MD orders or notify the MD to obtain any needed additional orders and ensure the patient is reassessed immediately by the nursing staff and pain is no longer triggering in the assessment. 4. 100% audit that all ordered pain medications are in house, and facility has minimum seven-day supply. Any needed re-orders were initiated on 7/19/24 by a sister facility DON. Pain medications are stored on nursing and CMA carts and in the e-kits. If a pain medication is not available CMA's are to notify the charge nurse and licensed nurses are to notify the MD or NP immediately. 5. In-servicing began on 7/19/2024 for Licensed Nurses and CMA's to include reordering of medications and what to do if a medication is not available and will be completed by 7/20/2024 by DON or designee. Any Nurse or CMA who has not received the in-service will not be allowed to work until in-service has been completed. Any agency, PRN or new CMA or licensed nurse will be in-serviced prior to their shift. In-service completed by DON/Designee. The DON was in-serviced and quizzed by regional consultant on 7/19/24 via phone. The staffing schedule will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. All staff will be in-serviced regarding the process of re-ordering pain medications and signs and symptoms of pain in residents upon hire, annually, and as needed by administrator/DON/designee starting on 7/19/24 and will be ongoing. 6. DON or Designee will monitor MAR/TAR and pain medications stored on carts 2 times per week to ensure pain medication availability. This practice will be ongoing. 7. Train the trainer in-servicing was given to the ED, DON, and RN/ED Cluster Partners by the regional consultant. The training consisted of 1) Process for Reordering Pain Medications, 2) Signs and Symptoms of Pain in Residents. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 7/19/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The Surveyor monitored the POR on 07/21/24 as followed: Observations made on 07/21/24 from 11:30 AM - 11:52 PM revealed three residents' scheduled narcotics matched with the narcotic count sheet on the medication carts. One of the medications was down to four days' worth left and had already been reordered. Resident #2's fentanyl patches (quantity of four) had been delivered on 07/19/24. Observation of the patch on Resident #2's right shoulder revealed the patch with the date of 07/20/24 (which coincides with her MAR). During interviews on 07/21/24 from 11:42 AM - 2:25 PM, one RN, three LVNs, and three MAs from different shifts all stated they had been in-serviced on reordering medications and pain management before working the floor. All stated that any medication needed to be reordered when there was only seven days left of medication. They then stated they would then follow-up with the pharmacy to get an ETA, and if not delivered during their shift, they would notify the NP and DON. They all stated if another staff member informed them they reached out to the pharmacy for a refill, they would not just take their word but would call the pharmacy to verify themselves. Each staff member stated if a resident was in pain, they would administered pain medication immediately. They described several signs and symptoms of non-verbal pain such as facial grimacing, moaning, and agitation. Each staff member stated it was unacceptable for a resident to go without a prescribed medication, especially if they were in pain. Review of the facility's QAPI agenda, dated 07/19/24, reflected the MD, DON, ADM, LNFAML, DON, and RNCL were in attendance. Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, dated 07/19/24 and conducted by the LNFAML, reflected the ADM and DON were reeducated on the process. Review of a Medication Audit of Narcotics, dated 07/20/24, reflected pain medications on all medication carts were audited and accounted for. Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, from 07/20/24 - 07/21/24, reflected all medication aides and nurses were educated on the process. While the IJ was removed on 07/21/24 at 12:50 PM, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services. The facility failed to ensure Residents #1 and #2's pain medication was ordered in a timely manner. On several occasions they went without their pain medication subsequently leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. While the IJ was removed on 07/21/24 at 12:50 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Resident #1 Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, muscle wasting and atrophy (wasting away), and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 04/26/24, reflected a BIMS of 15, indicating she was cognitively intact. Section J (Health Conditions) reflected she received a scheduled and PRN pain medication regimen and was frequently in pain. Review of Resident #1's quarterly care plan, dated 07/01/24, reflected she was currently prescribed an opioid medication for her history of pain with an intervention of administering opioids as prescribed. Review of Resident #1's physician order, dated 06/06/24, reflected Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain. Review of Resident #1's Mar, July 2024, reflected from 07/05/24 - 07/07/024 she missed five doses due to the medication being unavailable. From 07/14/24 - 07/17/24 she missed 11 consecutive doses due to the medication being unavailable. Review of Resident #1's documented pain scale from 07/05/24 - 07/07/24 reflected her highest rating was a 7. Review of Resident #1's documented pain scale from 07/14/24 - 07/17/24 reflected her highest rating was a 10. Review of Resident #1's progress notes, dated 07/05/24 at 3:25 AM and documented by LVN A, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Medication unavailable. Last Pill taken 7/5/24 at 10:00 PM. Nurse on duty does not have pyxis (emergency kit) access. Review of Resident #1's progress notes, dated 07/06/24 at 9:50 AM and documented by LVN A, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablets by mouth four times a day for chronic pain . not available. Review of Resident #1's progress notes, dated 07/07/24 at 2:44 PM and documented by LVN B, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . waiting for pharmacy. Review of Resident #1's progress notes, dated 07/14/24 at 11:28 PM and documented by LVN C, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . medicine reorder- and stated in 24-hour report. Review of Resident #1's progress notes, dated 07/15/24 at 4:56 PM and documented by LVN D, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Medication not available to administer. Medication has been reordered by previous nurse. Review of Resident #1's progress notes, dated 07/16/24 at 5:40 AM and documented by LVN E, reflected the following: Oxycodone-Acetaminophen Oral Tablet 10-325 MG - Give 2 tablet by mouth four times a day for chronic pain . Waiting for pharmacy to deliver. Review of Resident #1's progress notes, dated 07/16/24 at 10:09 AM and documented by the ADON, reflected the following: This nurse was notified by [Resident #1] that her oxycodone-acetaminophen was out of stock. This nurse asked CMA who informed that they did not in-fact have her routine oxycodone-acetaminophen. This nurse called NP to inform medication was out and triplicate needed to be sent. NP informed this nurse that triplicate was sent day prior. This nurse called pharmacy. Pharmacy stated triplicate not showing on their end. Re-called NP to make aware. This nurse informed script would be re-sent . Medication placed on hold until received. During a telephone interview on 07/19/24 at 11:26 AM, LVN E stated LVN D informed him at shift-change on 07/16/24 that Resident #1 was out of her oxycodone but she had re-ordered it and would come in by that night. He stated he waited but it never came. He stated he did not reach out to the pharmacy or NP. He stated Resident #1 was in pain but she did sleep that night. During a telephone interview on 07/19/24 at 1:20 PM, LVN B stated she was not sure what happened with Resident #1's oxycodone (at the beginning of July) but it was not reordered on time. She stated she was informed that another nurse had reordered it. She stated she believed it arrived on her shift and the resident was administered the medication. She stated when a resident is running low on any medication it should be reordered at least a week in advance. During a telephone interview on 07/19/24 at 2:12 PM, LVN C stated she could not remember what happened with Resident #1's medication on 07/14/24. She stated Resident #1 had run out of her pain medications a few times on different occasions. She stated during the week, staff do not order medications and it was often not there for the weekend shift. She stated Resident #1 was in continuous pain and could not miss a dose. She stated she did not reach out to the NP or the pharmacy. During a telephone interview on 07/19/24 at 2:00 PM, LVN D stated she did receive information regarding Resident #1's pain medication in the 24-hour report but she was shadowing a nurse and she was not her patient. She stated she remembered Resident #1 was asking for her pain mediation and other nurses were saying they were trying to reorder but there was an issue. She stated she did not reach out to the NP or pharmacy. Resident #2 Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, muscle wasting and atrophy, and pain. Review of Resident #2's quarterly MDS assessment, dated 07/03/24, reflected a BIMS of 4, indicating a severe cognitive impairment. Section J (Health Conditions) reflected she received a scheduled and PRN pain medication regimen and was frequently in pain. Review of Resident #2's quarterly care plan, dated 05/08/24, reflected she had chronic pain and was on pain management related to chronic physical disability with an intervention of monitoring/reporting to nurse complaints of pain or requests for pain treatment. Review of Resident #2's physician order, dated 06/01/24, reflected Fentanyl Transdermal Patch - 72-hour 37.5 MCG/HR - apply 1 patch trans dermally every 72 hours for chronic pain and remove per schedule. Review of Resident #2's MAR, July 2024, reflected she went without a fentanyl patch from 07/07/24 - 07/10/24 and on 07/16/24 due to none being available. Review of Resident #2's documented pain scale from 07/07/24 - 07/10/24 and on 07/16/24 reflected her highest rating was an 8. Review of Resident #2's progress notes, dated 07/07/24 at 1:09 PM and documented by RN F, reflected the following: This nurse reports that the time of completing the patch change, he notices that there is no stock to make the change, he proceeds to call the pharmacy . Review of Resident #2's progress notes, dated 07/07/24 at 4:55 PM and documented by RN F, reflected the following: Fentanyl Transdermal Patch 72-hour 37.5 MCG/HR - Apply 1 patch trans dermally every 72 hours for chronic and pain and remove per schedule. This nurse cannot comply with this indication today due to the lack of medication . During a telephone interview on 07/19/24 at 11:30 AM, RN F stated when he went to change Resident #2's fentanyl patch on 07/07/24, there were not any available patches in the cart. He stated he notified the DON and stated to move the order until the next morning and wait for the pharmacy to deliver it. He stated the resident was complaining of pain and he did administer a PRN Tramadol. He stated he did not contact the NP at this time. During an interview on 07/19/24 at 12:04 PM, Resident #1 and #2's NP stated sometimes she was given ample time for medication refill requests from staff and sometimes she was not. She stated sometimes she was made aware of residents going without medications after the fact. She stated she was not aware Resident #1 or #2 went a long period of time without pain medication. She stated if she had known, it would have been handled sooner. She stated the ADON asked her to put Resident #2's fentanyl patch on hold until a new one was delivered and was not sure why it was not put on her until 07/10/24. She stated the nurse could have easily put in a new order to restart the patch. She stated she was in the facility on 07/16/24 when Resident #1 sought her out, was very tearful, and was in moderate/severe pain. She stated she had not been notified by staff that she had been out of her pain medication for several days. She stated Resident#1 had chronic pain and should not miss any doses. She stated she was not always notified in a timely manner and would prefer to be notified of refill requests at least three days in advance. During an interview on 07/19/24 at 1:42 PM, the DON stated it was not her expectations for residents to go multiple days without their pain medications. She stated she expected nurses to re-order medications when there were seven days remaining. She stated it was all of the clinical staff's responsibility this was getting done. She stated a negative outcome of not reordering pain medications in a timely manner was increased pain, could lead to falls, or withdrawals. Review of the facility's Controlled Medications Policy, revised 12/2023, reflected the following: Schedule II controlled medications are reordered when a seven-day supply remains to allow time for transmittal of the required original written prescription to the provider pharmacy. The ADM was notified on 07/19/24 at 3:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/20/24 at 6:52 PM: F755: Pharmacy Services: The notification of Immediate Jeopardy states as follows: On 7/19/2024, The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to implement a process for reordering medications in a timely manner. 1. Medical Director was notified of the IJ on 7/19/2024 at 4:55pm. The Pharmacist was notified of the IJ on 7/19/2024 at 4:58pm. 2. Resident #1 and #2 medications audited on 7/19/2024 by a sister facility DON. 3. 100% audit that all ordered pain medications are in house, and facility has minimum seven-day supply and any needed re-orders are completed by sister facility DON. 4. In-servicing began on 7/19/2024 for Licensed Nurses and CMA's to include reordering of medications and what to do if a medication is not available and will be completed by 7/20/2024 by DON or designee. All nurses and CMA's will receive in-service training. Any Nurse or CMA who has not received the in-service will not be allowed to work until in-service has been completed. Any agency, PRN or new CMA or licensed nurse will be in-serviced prior to their shift. In-service completed by DON/Designee. The DON was in-serviced and quizzed by regional consultant on 7/19/24 via phone. If medication is not available CMA's are to notify the charge nurse and licensed nurses are to notify the MD or NP immediately. The staffing schedule will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. 5. DON or Designee will monitor MAR/TAR and pain medications stored on carts weekly to ensure pain medication availability. This will practice will be ongoing. 6. DON/ADON or Designee will review order listing report daily to ensure medication availability. This process will be ongoing. 7. DON/ADON or Designee will review pain medication every Wednesday and order any that have a supply of 7 days or less. This process will be ongoing. 8. Train the Trainer in-servicing was given to the ED, DON, and RN/ED Cluster Partners by the regional consultant. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 7/19/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The Surveyor monitored the POR on 07/21/24 as followed: Observations made on 07/21/24 from 11:30 AM - 11:52 PM revealed three residents' scheduled narcotics matched with the narcotic count sheet on the medication carts. One of the medications was down to four days' worth left and had already been reordered. Resident #2's fentanyl patches (quantity of four) had been delivered on 07/19/24. Observation of the patch on Resident #2's right shoulder revealed the patch with the date of 07/20/24 (which coincides with her MAR). During interviews on 07/21/24 from 11:42 AM - 2:25 PM, one RN, three LVNs, and three MAs from different shifts all stated they had been in-serviced on reordering medications and pain management before working the floor. All stated that any medication needed to be reordered when there was only seven days left of medication. They then stated they would then follow-up with the pharmacy to get an ETA, and if not delivered during their shift, they would notify the NP and DON. They all stated if another staff member informed them they reached out to the pharmacy for a refill, they would not just take their word but would call the pharmacy to verify themselves. Each staff member stated if a resident was in pain, they would administered pain medication immediately. They described several signs and symptoms of non-verbal pain such as facial grimacing, moaning, and agitation. Each staff member stated it was unacceptable for a resident to go without a prescribed medication, especially if they were in pain. Review of the facility's QAPI agenda, dated 07/19/24, reflected the MD, DON, ADM, LNFAML, DON, and RNCL were in attendance. Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, dated 07/19/24 and conducted by the LNFAML, reflected the ADM and DON were reeducated on the process. Review of a Medication Audit of Narcotics, dated 07/20/24, reflected pain medications on all medication carts were audited and accounted for. Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, from 07/20/24 - 07/21/24, reflected all medication aides and nurses were educated on the process. While the IJ was removed on 07/21/24 at 12:50 PM, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, observation, and record review, the facility failed to provide accurate and timely pharmaceutical services to meet the needs of each resident, in that: Three residents (Resident #1, Resident #2, Resident #3) out of six reviewed had not consistently received medications ordered to meet their needs. The facility failed to acquire and administer prescribed drugs as ordered; Resident #1 had not received all doses of his Triamcinolone Cream as ordered, Resident #2 had not received all doses of her sleep-aide medication (Temazepam) and pain medication (Norco) as ordered, and Resident #3 had not received all doses of her pain medication (Morphine Sulfate) as ordered. This failure resulted in unnecessary discomfort and pain, psychosocial distress, and insomnia (trouble falling asleep, staying asleep, or getting good quality of sleep). Findings Included: 1.Record Review of Resident #1s face sheet, dated 11/16/23, reflected a [AGE] year-old admitted on [DATE] from Acute Care Hospital after a diagnosis of Chronic Obstructive Pulmonary Disease (a respiratory disorder that requires ongoing medical attention) exacerbation (a temporary worsening). Resident #1 face sheet reflected a diagnosis of Quadriplegia (paralysis of both arms and both legs), that he was blind in one eye, had a history of Psoriasis (skin condition that causes red, scaley itchy patches and has high rate of recurrence in those afflicted), and had an anxiety disorder. Record review of Resident #1s Care Plan entry dated 10/10/2023 reflected Focus: Potential for behavioral problems AEB (as evidenced by) verbal complaints about facility as well as adjustments to medications per resident's request with later statements that medications are not being given the way he requested. Record review of Resident #1s Care Plan entry dated 10/06/2023 reflected Focus: Resident #1 has adjustment issues due to admission and medication administration and prefers to have medications given by nurses. Record review of Resident #1s Order Summary Report dated 11/16/2023 reflected that Triamcinolone Acetonide External Cream 0.5% was ordered on 10/03/2023 by the Physician to be applied to affected areas (where his rash was present) two times a day. The order was active on investigation date and had been ongoing since it was initially ordered on 10/03/2023. Record review of EMAR for November 2023 reflected that the Triamcinolone Cream Acetonide External Cream 0.5% was not applied on 11/02/2023, that it was applied one time on 11/03/2023, that it was not applied 11/11/2023, 11/12/2023, 11/13/2023, and that one dose was applied on 11/14/2023. Resident #1 was observed and interviewed on 11/16/2023 at 11:00 AM Resident #1 was observed to have red scaly rash to chest, arms, shoulders, and back. Resident #1 stated the rash itched a lot and made him feel miserable. Resident #1 stated the rash was very itchy. Resident #1 stated he had not been able to get his Triamcinolone Cream applied as it was ordered. Resident #1 stated it was ordered by the doctor to be applied two times a day and he had been told many times by the nursing staff that the cream was not available. Resident #1 was unable to give specific dates and scheduled doses that were missed but stated it happens all of the time. I blame the facility. They don't order my medications on time and then it is time to give them, and they (the medications) aren't here. 2.Record review of Resident #2s face sheet dated 11/16/2023 reflected an [AGE] year-old admitted on [DATE] from Acute Care Hospital with diagnoses of Pain in Unspecified Joint, Insomnia (difficulty falling asleep, staying asleep, and/or the quality of sleep is poor), Polyneuropathy (the malfunction of nerves throughout the body, symptoms include burning and/or pins-and needles type of pain, numbness, lack of sensation), Cognitive deficit (difficulty remembering, speaking, and understanding), and Alzheimer's Disease (a progressive disease that destroys memory and other mental functions). Record review of Resident #2s Care Plan dated 06/15/2023 reflected the resident has chronic pain. The interventions for chronic pain dated 06/15/2023 included Administer analgesia medication as per orders. Anticipate need for pain relief and respond immediately to any complaint of pain. Record review of Resident #2 Order Summary Report dated 11/16/2023 reflected that Norco, generic name Hydrocodone/Apap (Hydrocodone, the opioid component and Apap also known as Acetaminophen, the Tylenol component) 10/325 (strength) was ordered by Physician on 03/15/2023 as one tablet by mouth four times daily. The order was active and had been ongoing since initial order date. The scheduled times for administration were listed as: 07:00 AM, Noon, 4:00 PM, and 8:00 PM. Record review of Resident #2 Order Summary Report dated 11/16/2023 reflected that Temazepam 15 mg by mouth at bedtime was ordered by Physician on 05/16/2023 and was active and had been ongoing since initial order date. The scheduled time for Temazepam was 7:00 PM. Record review of Resident #2 EMARs for September, October, and November 1-16, 2023 revealed the following missed doses: September 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 09/11/2023 at the 07:00 AM, Noon, and 4:00 PM dosage times. The record review of the EMAR and nurses' notes for these time periods had not indicated the reason that the dosages were not given. October 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 10/02/2023 noon dose; on 10/05/2023 at noon, on 10/26/2023 at 8:00 PM, and on 10/31/2023 at noon. The record review of the EMAR and nurses' notes for these time periods had not indicated the reason that the dosages were not given. November 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 11/03/2023 at noon. The record review of the EMAR and nurses' notes for this time-period had not indicated the reason that the dosage was not given. -Temazepam 15 mg was not given on 11/07/2023. A code 7 was entered on the EMAR and CMA A initials were reflected on EMAR for this dose which corresponded to Other/See Nurses' Notes. The record review of the EMAR and nurses' notes for this time-period did not reflect a reason that the dose was not given. An interview was attempted with Resident #2 on 11/16/2023 at 2:30 PM, Resident #2 verbalized that she wanted to take a nap and did not wish to be bothered with an interview. An interview with FM of Resident #2 was conducted by telephone on 11/16/2023 at 2:30 PM. The FM stated that it was important that Resident #2 get her pain medication, Norco (an opioid analgesic, hydrocodone, combined with acetaminophen), and her sleep aide medication, Temazepam (a benzodiazepine, a medication that is used to help with relaxation) on time and consistently as Resident #2 had taken these medications for many years. Both medications had the potential for physical dependence to be developed in the user. The FM stated that Resident #2 has had opioid-withdrawal symptoms when she had not received her pain medication on time and consistently. The FM stated that Resident #2 relied on Temazepam to help her sleep. The FM stated that Resident #2 had missed a dose or two of Norco in September 2023, had missed a dose or two in October 2023, and had missed a dose on 11/07/2023. The FM further stated that in the past few months she was told by (unknown) facility staff (on unknown date) that the facility did not have Resident #2's pain medication, that they had run out. The FM of Resident #2 stated that she was told by (unknown) facility staff member that the reason that the medication runs out at times was due to a lack of communication. The FM of Resident #2 was unclear what this meant. The FM of Resident #2 stated that she could not indicate who had failed to communicate, but this was the reason given to her by an unknown facility staff member. The FM of Resident #2 stated that she was told another time in the past few months (by unknown staff, unknown date) that they could get the sleeping pill out of the emergency kit (a locked emergency drug kit where nurses pulled medications that have just been ordered and/or were otherwise unavailable). The FM of Resident #2 stated that this was done, however, Resident #2 still had to wait a long time before she received the medication at 2:00 - 3:00 am. The FM of Resident #2 stated that these events have caused stress to Resident #2. The FM of Resident #2 stated that she had observed Resident #2 in the facility when she experienced withdrawal symptoms from not having received her Norco. The FM of Resident #2 stated that Resident #2 was distressed on another occasion as she did not get sleep the night before, attributed to not receiving her Temazepam as scheduled. The FM of Resident #2 stated that Resident #2 experienced withdrawal symptoms of headache, restlessness, and agitation when she had not received her Norco. The FM of Resident #2 stated that when the Temazepam was given late or not at all, Resident #2's sleep pattern was interrupted which caused her to be in a bad mood the next day. During the interview with FM of Resident #2, it was stated that she felt that the medication was not being reordered timely and this had caused the facility to run out. 3.Record review of Resident #3s Face Sheet dated 11/16/2023 reflected an [AGE] year-old admitted to the facility on [DATE] from Acute Care Hospital. The record review of Resident #3 Face Sheet reflected that Resident #3 diagnoses of Chronic Pain Syndrome (everyday symptoms beyond pain alone, including anxiety and depression, and must be treated), Anxiety, and Depression. An interview was conducted with Resident #3 on 11/16/2023 at 2:45 PM. Resident #3 stated that she has had Morphine Sulfate (an opioid analgesic) scheduled for her pain condition. Morphine Sulfate was a drug which could lead to physical dependence and cause symptoms of withdrawal in someone who had taken it routinely. Resident #3 stated that she had not always received her pain medication and had missed a dose five times in the past few months. Resident #3 stated that she had chronic pain related to a prior hip and leg surgery. Resident #3 stated that her pain level was a 5-6 out of a 1-10 scale (10 being the worst pain experienced, 1 being no pain) all of the time, even when she received her Morphine Sulfate as scheduled. Resident #3 stated that her pain level had risen on the pain scale when she had not received her pain medication. Resident #3 stated that she had required scheduled dosing to keep her comfortable enough to get through each day at a 5-6 pain level. Resident #3 added that she was not the only resident who had not received their pain medication. Resident #3 offered that she was familiar with Resident #2 and witnessed when Resident #2 had not received her pain medication on one occasion and she that she had witnessed Resident #2 when she screamed at the nurse due to the pain medication being unavailable. Resident #3 stated that she had witnessed Resident #2 Family Member being very upset when she was told that Resident #2's pain medication was not available. Resident #3 stated that she had witnessed them both being upset, loud, and angry, when they blamed the staff verbally for not having provided a scheduled dose of pain medication to Resident #2. Resident #3 stated that she had chosen not to say anything to the facility staff about her own missed doses as she felt that it would not have done any good. Resident #3 stated that she felt it was the fault of the CMAs that she had missed doses of her medication, that the CMAs had not been mindful of getting the medication reordered. Resident #3 stated that it seemed that the events of missed doses usually happened on the weekends. Record review of Order Summary Report dated 11/16/2023 for Resident #3 reflected that Morphine Sulfate ER (extended release, pain relief effect lasted longer) 10 mg by mouth two times a day was ordered by Physician for pain on 07/01/2022, was an active order and had been ongoing since it was first ordered. The medication was scheduled for 07:00 AM and 7:00 PM. Record review of EMAR for month of August 2023 reflected that on 08/02/2023, the morning dose and the evening dose were not given. A code 2 was reflected on the EMAR and initialed by LVN A for the AM dose not given and a code 7 on the EMAR and initialed was reflected by CMA B for the PM dose not given. A code 2 indicated Hold/See Nurses Notes and a code 7 indicated Other/See Nurse Notes; the number codes corresponded to a key found on the EMAR reviewed. No nurses' notes were found which indicated why the medications were held for this time-period. Record review of the EMAR codes dated 08/01/2023 - 11/16/2023 reflected that a checkmark along with initials of person who had administered medications appeared in entry boxes where medications had been administered. This same system was present on all EMARS reviewed when medications were administered. An interview was conducted with the DON on 11/16/2023 at 3:40 PM the DON stated that when a medication was not available, there was the capability to have a medication sent over stat (promptly) from the pharmacy. The DON stated she was aware of one dose of Resident #2's Temazepam which had not been given and when she was informed, she was able to get the medication sent over stat (promptly) from the pharmacy. The DON stated medications were reordered five days before they ran out. The DON stated controlled medications (those with stricter federal regulations to have them controlled) such as Temazepam, Morphine Sulfate, and Norco are audited at each medication cart each morning and medications that needed to be reordered were flagged. The DON stated that medications that needed triplicate prescriptions (an added measure of security to prevent drug diversion; Morphine Sulfate and Norco/Hydrocodone require a paper prescription in triplicate) are ordered by Nurse Practitioner A or Nurse Practitioner B right away when they are needed. Record review of the facility policy Medication Ordering and Receiving from Pharmacy Provider dated 11/13/2018 stated that Schedule II (a I-IV number assigned to a controlled drug based on risk for abuse) controlled substance medications, such as Morphine Sulfate and Hydrocodone/Apap , are reordered when a seven-day supply remained to allow for transmission of the required original written prescription to the pharmacist. The policy reflected that other medications should be reordered seven days in advance to assure an adequate supply was on hand. The policy also reflected that the Administrator, Director of Nursing, and provider pharmacy establish a daily delivery and pick-up schedule for medication orders.

Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to change Resident #1's foley catheter bag or collect a specimen from him for urinalysis according to physician orders. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including morbid obesity, spinal stenosis (a condition where the space for the spinal cord and nerves in the spine becomes narrow causing pressure and pain), and muscle wasting and atrophy (wasting away). Resident #1 was discharged from the facility on 09/13/23. Review of Resident #1's admission MDS assessment, dated 08/21/23, reflected a BIMS score of 11, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter. Review of Resident #1's admission care plan, dated 09/21/23, reflected he had an indwelling catheter related to urinary retention with an intervention of changing the catheter bag and tubing as ordered and monitoring/recording/reporting to MDS for s/sx of UTI: pain, burning, tinged urine, cloudiness, etc. Review of Resident #1's NP note in his EMR, dated 08/31/23, reflected a UA C&S was ordered due to sedimentation (crystals, bacteria, or blood exiting through the urine) noted to indwelling foley catheter and purulent (discharge) drainage to urethra (a tube that connects the urinary bladder to the urinary meatus (opening of the urethra) for the removal of urine from the body) noted. Review of Resident #1's physician order, dated 08/31/23, reflected to change the urinary catheter bag one time only for increased sedimentation for one day. Review of Resident #1's physician order, dated 08/31/23, reflected a UA C&S one time only for penile discharge and increased urinary sedimentation for one day. Review of Resident #1's TAR in his EMR, from August of 2023, reflected the UA C&S was not collected nor was the urinary foley catheter bag changed as ordered. Review of Resident #1's TAR in his EMR, from September of 2023, reflected staff documented they were monitoring for signs and symptoms of a UTI. Review of Resident #1's NP note in his EMR, dated 09/05/23, reflected UA and C&S not collected, reordered. Sedimentation noted and purulent drainage from urethra noted. Ordered for nursing to exchange tubing and bag for foley catheter. Review of Resident #1's laboratory results, on 10/11/23, reflected his urine was collected on 09/06/23 by the facility, the laboratory received the urine on 09/07/23, and the results were reported to the facility on [DATE]. The results reflected Resident #1 had a UTI. Review of Resident #1's physician order, dated 09/09/23, reflected an order for Cefepime HCl Infection Solution Reconstituted 2 GM. Use 2 gram intravenously two times a day for Pseudomonas aeruginosa (an infection requiring antibiotics) more than 2,000,000 for 10 days untiled finished. During a telephone interview on 10/11/23 at 11:26 AM, Resident #1's NP stated she did put in orders for a change of his foley catheter bag as well as collecting a sample of urine for a UA on 08/31/23 due to sediment in in his foley catheter tubing and bag. She stated her expectations were that these orders were followed through when they were ordered. She stated on 09/05/23 she noticed neither order had been followed and she re-wrote the orders. She stated she was not sure why they weren't followed through, as there was no documentation indicating Resident #1 had refused. She stated she normally wrote orders for the changing of a foley catheter bag when she wanted to ensure it was draining properly and to be able to monitor more closely if the sedimentation was decreasing or not. She stated not changing the foley catheter right away as ordered would not affect the treatment but would hinder the effectiveness of monitoring appropriately. She stated not ensuring a UA was conducted right away, as it was ordered to be done, would not have exacerbated or worsened the UTI symptoms, but would put a delay in treatment. During an interview on 10/11/23 at 2:22 PM, the IDON stated if the NP's orders should have been followed through the same day unless the resident refused. She stated if the order was not a STAT order for the collection of specimens for a UA, her expectations would be that it was at least collected by the same night so that specimens could be sent to the lab the following morning. She stated a negative outcome of not following NP orders promptly could result in a delay in treatment. Review of the facility's Medications and Treatment Orders Policy, revised May of 2007, reflected it focused on following medication orders and did not address UA or foley catheter physician orders.

Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one of four residents (Resident #1) reviewed for pressure injuries, in that: The facility failed to ensure weekly skin checks were being done accurately which caused Resident #1 to develop a stage III pressure injury on her sacrum and two unstageable pressure injuries to her left and right buttocks. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection and pain. The deficient practice was determined to be past non-compliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. Findings included: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS of 13, which indicated no cognitive impairment. It further reflected she required substantial/maximal assistance with bed mobility, which included rolling left to right on the bed, sit to lying, chair/bed-to-chair transfers, etc. Additionally, it reflected she was at risk of developing pressure ulcers/injuries but did not currently have an unhealed pressure ulcer/injury. Record review of Resident #1's care plan, revised 6/29/22, reflected she had the potential for skin breakdown related to impaired mobility, incontinence, and history of shingles and fragile skin. The interventions documented were to keep skin clean and dry and to notify the nurse immediately of any signs of skin breakdown such as redness, blisters, bruises, and discoloration noted during bath or daily care. There was no documentation of any current pressure injuries or skin issues. Record review of Resident #1's weekly skin assessment, dated 6/21/22, reflected a healed surgical wound to her right hip and no other skin issues. Record review of Resident #1's weekly skin assessment, dated 6/28/22, reflected it had not been completed/filled out or signed by the nurse. Record review of Resident #1's EMR, on 7/14/22, reflected she received one shower during the previous 30 days, 6/14/22 - 7/14/22. Record review of Resident #1's Physician/Nursing Communication Form, completed by LVN F on 6/25/22, reflected she had pressure breakdown and pressure sore to her coccyx. [Resident #1] not eating adequately. The WCD was notified, and the form was signed by the NP. Record review of Resident #1's dietary order, dated 6/5/22, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Initial Wound Evaluation Management Summary completed by the WCD, dated 6/29/22, reflected the following: At the request of the referring provider, (Doctor), a thorough wound care assessment and evaluation was performed today. [Resident #1] has a stage 3 pressure ulcer of the right buttock for at least 14 days. There is moderate serous exudate. Site 1: Unstageable pressure injury to sacrum; greater than 14 days; 4.0 cm x 2.5 cm Site 2: Unstageable pressure injury of the left buttock; greater than 14 days; 3.5 cm x 4.0 cm Site 3: Stage 3 pressure injury of the right buttock; greater than 14 days; 1.5 cm x 1.0 cm x 0.1 cm Record review of Resident #1's Initial Wound Evaluation Management Summary completed by the WCD, dated 7/6/22, reflected the following: At the request of the referring provider, (Doctor), a thorough wound care assessment and evaluation was performed today. [Resident #1] has an unstageable (due to necrosis) of the left buttock for at least 20 days duration. There is moderate serous exudate. Site 1: Unstageable pressure injury to sacrum; greater than 20 days; 7.5 cm x 5.8 cm Site 2: Unstageable pressure injury of the left buttock; greater than 20 days; 3.5 cm x 4.0 cm Site 3: Stage 3 pressure injury of the right buttock; greater than 20 days; 2.5 cm x 2.1 cm x 0.1 cm Record review of a wound care order for Resident #1, dated 6/28/22, reflected the following: Stage III wound to coccyx; Every day shift - cleanse with normal saline, apply calcium alginate and cover with foam dressing, secure with tape until healed. Record review of a wound care order for Resident #1, dated 7/7/22, reflected the following: State III wound care to coccyx x3 areas; Every day shift - cleanse with normal saline, apply calcium alginate and cover with foam dressing, secure with tape until healed. During an interview on 7/14/22 at 9:52 AM with Resident #1's Family Member, he stated he was told by nursing staff around the end of June (exact date unknown), that she had a bed sore, but was never told how bad it was. He stated on 7/8/22 he received a call from the facility informing him Resident #1 was not urinating or taking her medications. He stated he requested she be sent to the hospital. He stated at the hospital was when he saw just how bad her sores were. He stated the one located on her coccyx was so large and deep that he could have stuck his fist into it. He stated he was told by the doctor in the hospital that her sacral would was a stage VI, she was severely dehydrated, and she had an infection in her blood. During an interview on 7/14/22 at 11:30 AM with CRN A and CRN B, CRN A stated their company took over the facility from the previous company on 7/1/22. She stated the previous company had hired a wound care nurse, two weeks prior to their acquisition and was not trained. She stated they were made aware of the extent of Resident #1's wounds on 7/4/22. She stated she immediately contacted the WCD who stated he saw Resident #1 on 6/29/22 and would see her again that week. He stated he was not sure why he was not called until 6/28/22 regarding Resident #1's wound, as it had been clear it had been there a long time, greater than 14 days, in his professional opinion. CRN B stated the same day they were notified of Resident #1's wound, they did an entire skin sweep for each resident in the facility. He stated they found a few skin issues they were not aware about, but nothing of major concern. He stated he created a QIT (Quality Improvement Team) tracking form. He stated they have a weekly focused meeting on identified systems for review called their Standards of Care meeting (SOC). He stated their SOC team would be assisting them with the interventions from the QIT to ensure they were conducted and completed timely. During an interview on 7/14/22 at 1:58 PM with CNA E, she stated she cared for Resident #1 a lot. She stated she was often resistive to bed baths and incontinent care. She stated she did see a red area to her sacral area at one point in June but could not remember when. She stated she remembered reporting it to her nurse at the time but could not remember who the nurse was. During an interview on 7/14/22 at 2:09 PM with CRN B, he stated the importance of an effective wound care/treatment system was to ensure the safety, quality of life, and quality of care of the residents. He stated nurse management would continue to over-see the weekly skin-care assessments to ensure they were being completed accurately and would continue to in-service staff. Record review of the facility's QIT Tracking Form, dated 7/4/22, reflected the following: Problem: Skin system noted for incomplete documentation, assessments and structural organization upon company acquisition. Root Cause Analysis: System issues identified - 1. Holes noted in wound care log. 2. Missing care plans for wounds noted. 3. Missing orders on wounds found during initial acquisition audit. 4. Inconsistent practice on weekly skin meetings. 5. Incomplete weekly skin assessments. 6. New wound care nurse two weeks prior to acquisition with no training provided by prior company. 7. Majority of shifts covered by agency nurses. Interventions: - Wound care nurse to bring completed wound log to morning meeting for daily review. Missing care plans, progress notes and orders will be corrected before the end of the morning meeting from the prior day. Date Initiated: 7/4/22 - DON to Monitor Re-Evaluation: SOC scheduled for 7/14/22 - Re-Inservice the wound care nurse and clinical team on wound care documentation P&P. Date Initiated: 7/14/22 - DON to enact post restructurer and skin POC on 7/14/22, DON to monitor for compliance Re-Evaluation: Scheduled for 7/14/22 - Facility skin sweep completed 7/4/22 - Completed 100% audit of wound TARS for accuracy in orders, measurements, and care plans by 7/14/22. - IDT review wound documentation complaice in weekly SOC meeting. - Review of POC in QAPI x 3 months. - Clinical resource consult to review plan with IDT. - On-going training with wound care nurse to include off-site training from cluster partners. Review of two other residents' EMR's (other than Resident #1), with current pressure injuries, reflected no concerns regarding wound assessments, wound treatments, receiving regular showers, or nutrional status. Record review of an in-service, dated 7/5/22, reflected WCN C (a WCN from one of their sister facilities) conducted an in-service to the facility's new WCN, WCN D. Record review of a skills check-off for wound care, dated 7/14/22, reflected WCN D met all criteria without any cueing by WCN C. Record review of the facility's Quality of Care/Skin Management System Policy, revised 3/2015, reflected the following: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures taken to ensure that the resident does not develop pressure ulcers . Record review of the Skin Management System created by CRN B on 7/5/22 and approved by the WCD on 7/12/22 reflected the following: - Nursing to perform weekly skin assessments as per assignments/schedule. These will be documented on the Weekly Skin Assessment form in (EMR). - Document weekly assessments/measurements of all wounds on the back of the Wound Treatment and Progress Note. - The weekly skin report will be updated and sent to the DON, ADM, and MDS team weekly. - The treatment nurse or designee will obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The treatment nurse will assess weekly that proper pressure relief devices and mattresses are in place and functioning appropriately. - Discuss at the weekly SOC meeting all residents with a skin problem (pressure, arterial, PVD, diabetic, rash, skin tear, etc.) and the interventions taken. The resident nutritional status, lab work, present medical conditions to include mobility and incontinence, medication changes, and any possible decline, etc. - DON or designee will ensure that proper documentation is entered in the nurse's notes. - DON/Treatment nurse or designee will conduct random audits to ensure that interventions implemented to prevent the reoccurrence of skin breakdown are in place i.e. turning and repositioning, wheelchair cushions, etc. - DON/Nurse Managers will conduct random audits to ensure that nurses weekly skin assessments are actually completed, and dressings are changed as ordered. - DON/designee will ensure there are current RD notes for residents with wounds - DON or designee will report trends and analysis of all skin issues at the monthly QA meeting.