Every finding on record at Plainview Healthcare Center

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Residents #2 and #3), and 1 of 2 staff members observed for infection control. LVN C failed to ensure infection control with wrist blood pressure cuff and did not clean it between use of residents. The facility failed to ensure Resident #3's catheter bag was not dragging on the floor. C.N.A. E failed to ensure infection control by not changing gloves prior to starting pericare for Resident #3. C.N.A. F failed to ensure infection control by not changing glovers prior to catheter care for Resident #3. C.N.A. G failed to ensure infection control by not changing gloves prior to starting pericare for Resident #2. This deficient practice could put residents at risk for increased infections. Findings include: During observation of medication pass on 06/30/2026 at 7:05 am, LVN C had taken a blood pressure for a resident in RM [ROOM NUMBER]. LVN C laid the blood pressure cuff on top of medication cart. LVN C prepared medications for RM #121. LVN C took the resident's blood pressure with the same wrist blood pressure cuff without cleaning it after the last resident. LVN C laid the blood pressure cuff on top of the cart without cleaning the cuff. LVN C prepared medications for RM #127. LVN C took the blood pressure of the resident in RM #127 with the same wrist blood pressure cuff, without cleaning between residents. During an interview with LVN D on 06/30/2026 at 8:10 am, LVN D stated that they cleaned the pulse oximeters and glucometers with alcohol, but they could not clean the blood pressure cuffs because they were cloth. During an interview with LVN C on 06/30/2026 at 2:18 pm, she stated she cleaned the pulse oximeter, but failed to clean her blood pressure cuff. LVN C stated she knew better, and just failed to do so. A negative effect of not cleaning between resident is cross contamination. Resident #3 Record review of Resident #3's face sheet printed 06/29/2026 revealed an [AGE] year-old male. Resident #3 was admitted on [DATE] with the following diagnoses: acute blood clot of unspecified deep veins of lower extremities bilateral, fluid overload (too much fluid in your body), acute on chronic diastolic congestive heart failure (heart left ventricle becomes stiff and fails to relax properly), difficulty walking, and muscle weakness. Resident # 3's Quarterly MDS, dated [DATE] revealed a BIMS of 13 out of 15 indicating no cognitive impairment. His functionality on his last MDS revealed he required substantial/maximal assistance to complete toileting and transfers. Resident #3 required the use of a catheter. Care Plan dated 03/24/2026 revealed Resident #3 was totally dependent on staff for transfers, toileting, dressing and bathing. The Care Plan revealed: The resident has a 16 fr with a 10 ml retention balloon indwelling Foley connected to bedside drainage resident required a catheter. Date initiated 09/09/2023 Revised on 06/22/2026. Interventions on the care plan revealed position catheter bag and tubing below the level of the bladder and away from the entrance room door. Check tubing for kinks each shift. Change monthly. Record review of Resident #3's physician's orders dated 06/29/2026, revealed: Catheter care every shift Start: 10/02/2023 EBP due to Foley catheter every shift. Start: 06/30/2025. During an observation on 06/30/2026 at 7:50 am Resident #3 's catheter bag was observed on the floor of the dining room under the resident chair. Resident #3 was observed wheeling himself from the dining room down the hall to his room with the catheter bag dragging on the floor under his wheelchair. During an incontinence care observation on 06/30/2026 at 9:30 am for Resident #3, revealed C.N.A. E and C.N.A. F put on PPE due to EBP precautions, washed their hands and put on gloves. The C.N.A.'s removed the blanket from Resident #3, assisted Resident #3 to turn to his left side so they could pull down his pants, then assisted him back to his back, and opened his brief. C.N.A. E, then started pericare without changing her gloves. When C.N.A. E, completed peri-care she stepped back and did not remove her gloves. C.N.A. F, then performed catheter care without changing his gloves. During an interview with C.N.A. E and C.N.A. F on 06/30/2026 at 1:39 pm, the both reported they should have changed gloves prior to starting pericare and catheter care. C.N.A. F voiced that a negative outcome of not changing gloves prior to performing pericare or catheter care could cause infection. During an interview on 07/01/2026 at 8:39 am, CNA H stated she had not been aware Resident #3's catheter bag had been on the floor. She stated the bag should have been secured to the chair and not dragging on the ground. She stated the consequences for not securing the bag were germs. She stated she had been trained for her job by a lot of different people. During an interview on 07/01/2026 at 9:04 am, LVN I stated he had not been aware Resident #3 had his catheter bag on the floor in the dining room. He stated this was an infection control issue and the bag should have been attached securely to his chair. He stated he had been trained in infection control practices by the DON. He stated the consequences of having a bag on the floor were infection to the residents. During an interview on 07/01/2026 at 9:23 am the DON stated she expected staff to follow best practices and expected catheter bags to be secured and not dragging on the floor. She stated she tried to work with the staff to ensure they do what needed to be done. She stated the consequences of the bag dragging on the floor were infection control issues and created unsanitary conditions. She stated she had trained the staff in infection control practices, and she had also been trained in infection control practices by the former DON. Resident #2 Record review of Resident #2's face sheet printed on 07/01/2026, revealed a [AGE] year-old female that admitted to the facility on [DATE] with a readmission on [DATE] with the following diagnosis: heart failure (heart muscle too weak or stiff to pump enough blood to meet your body's needs), hypertension (the force of blood against your artery walls is consistently too high), dysphagia (language disorder caused by brain damage that impairs a person's ability to speak, understand, read, or write), Parkinson's disease with dyskinesia (progressive neurological disorder that damages dopamine-producing brain cells- involuntary muscle movement) , and dementia (decline in mental ability). Record review of Resident #2's Quarterly MDS dated [DATE], revealed a BIMS of 2 out of 15 indicating a severe cognitive impairment. Resident #2 requires substantial/maximal too dependent physical assistance for functional abilities. Resident #2 is dependent for toileting hygiene. Resident #2 was always incontinent of bladder and bowel. Record review of Resident #2's Care Plan dated 05/06/2026 revealed Resident #2 required total assistance of one staff for toileting. Resident #2 has bowel and bladder incontinence related to her cognition decline and forgetfulness. Record review of Resident #2's physician's orders as of 07/01/2026 revealed Resident #2 is incontinent of bowel and bladder and wears brief/pullup. During an incontinence care observation on 06/30/2026 at 11:01 am, for Resident #2. Revealed C.N.A. G washed his hands and put on gloves. C.N.A. G raised bed to working height, removed Resident #2's blanket and undid Resident #2's brief. C.N.A. G proceeded with pericare without changing his gloves. During an interview with the DON on 06/30/2026 at 1:27 pm she reported that she used a skills checklist for peri-care; that they do upon hire and annually. The DON stated that she expected her staff to follow infection control procedures. The DON voiced that staff should remove their gloves and perform hand hygiene after touching resident's bedding, prior to starting peri-care. The DON stated that staff should be cleaning multiuse equipment, including the wrist blood pressure cuffs, with alcohol or the Sani-wipes. The DON stated that a negative outcome of not following the infection control guidelines could result in cross-contamination or infections. The DON presented a copy of her checklist that she used. The DON reviewed the checklist and stated a step was missed between getting the resident ready and starting peri-care. The DON voiced that she would update the checklist and put the step in to remove gloves and utilize hand hygiene after preparing the resident for care. The DON stated staff should put on a clean pair of gloves prior to starting peri-care. The DON stated that she just went over the checklist with the staff, and if she had not, they probably would not have missed that step. During an interview with C.N.A. G on 06/30/2026 at 2:30 p.m. regarding the observation of peri-care for Resident #2 revealed that C.N.G. did not agree with the observation. C.N.A. G voiced that he followed the checklist and he had just changed the resident's bedding that morning. C.N.A. G voiced that all he could say was, Ok. During an interview with the DON on 07/01/2026 at 8:53 am revealed that she had talked to C.N.A. G the day before regarding pericare. The DON reported that C.N.A. G did understand that raising the bed and removing the blanket and brief contaminated his gloves, and that he should utilize hand hygiene and put on a clean pair of gloves. During an interview with the ADM on 07/01/2026 at 9:50 am regarding the infection control issues identified during survey revealed the ADM shook her head no, and stated that staff needed to change their gloves after preparing the resident for care. The ADM also stated that all multi-use equipment should be cleaned after each resident to prevent cross contamination and potentially an infection. Record review of the facility policy titled Policies and Practice- Infection Control dated October 2018, revealed the facility infection control policies and practices apply to all personnel, consultants, residents , visitors and the general public. The objectives of our infection control policies and practices are to maintain a safe sanitary comfortable environment. Record review of the facility policy titled, Standard Precautions, revised September 2022: Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 2. Gloves d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. f. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). h. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Record review of the facility policy titled, Catheter Care, Urinary revised August 2022: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. General Guidelines: Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1 c. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bed pans, blood pressure cuffs, crutches, and computers. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturer's instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. Record review of the Staff Education/Orientation Policies and Procedures checklist- Discipline: Nursing. Competency: Peri-Care. Revision 07/01/2013. Performance Criteria: 4. Washes hands, applies disposable gloves and PPE as indicated. 5. Assembles supplies at bedside. 6. Raise head of bed to comfortable working height; assists the patient/resident to a supine position. FEMALE 7. Positions waterproof pad under buttocks or places bedpan under buttocks. 8. Helps to flex knees and spread legs apart. Notes limitation in positioning. 9. Cleans the upper thighs. All personnel will be trained on infection control policies and practices upon hire and periodically thereafter.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included: Observation of the prep area in the kitchen on 06/29/26 at 9:25 AM revealed the following:1. (3) clear bins containing individual cereal bowls were not labeled or dated. Observation of the walk-in refrigerator on 06/29/26 at 9:27 AM revealed the following:1. (1) box of vegetables, no label or date. 2. (1) bag that contained half of a cut lemon in a foam bowl, no label or date.3. (4) bags of fresh grapes, open to air, and 1 bag contained moldy grapes.4. (1) tray of fruit cups, covered, no label, and the date was unreadable.5. (1) box of cupcakes, not sealed, no label or date. 6. (1) box containing tortillas, no label or date. Observation of the freezer on 06/29/26 at 9:33 AM revealed the following:1. (4) large trays with individual foam bowls containing what looked to be ice cream, all open to air, not labeled or dated.2. (1) bag of patties, no label or date.3. (1) bag of chicken patties, open to air.4. (1) bag of meat, label unreadable, dated. Observation of the pantry on 06/29/26 at 9:37 AM revealed the following:1. (1) powdered Kool-Aid package, open to air, dated and labeled.2. (1) large clear container of rice, lid was not on, and rice was open to air.During an interview on 06/29/26 at 9:48 AM, the DM stated it was everyone's responsibility to label and date food and if that did not happen, they could serve outdated food to residents and they could get sick. During an interview on 06/29/26 at 9:51 AM, [NAME] A stated she had worked at the facility for 9 years and everyone who worked in the kitchen was responsible for labeling and dating food. She stated if that did not happen, residents could become sick from eating bad food. During an interview on 06/29/26 at 10:01 AM, [NAME] B stated it was everyone's responsibility to label and date food and if that was not happening, the kitchen could serve bad food which could make residents sick.In an interview on 06/10/26 at 10:40 AM, [NAME] C stated he had worked at the facility for 5 years and that it was everyone's responsibility to label and date food and that if it was not done, kitchen staff would not know if food was outdated and it could put residents at risk of getting sick. Record review of facility policy, titled Nutrition Policies and Procedures, Subject: Safe Food Handling dated October 2009, revealed the following information in part.3. All foods are stored in a closed container or tightly wrapped package and labeled with the common name of the item and dated. 5. Leftover foods are properly covered, labeled and dated.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that meet professional standards of quality and that included measurable objectives and time frames for 1 of 11 (Residents #3) Residents reviewed for care plans.A. The facility failed to ensure Resident #3's daily use of compression socks had been care planned. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need.This failure to accurately develop and implement a care plan could result in staff not being aware of critical treatment-related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services. Findings include:Record review of Resident #3 's face sheet printed 06/29/2026 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of embolism ( a traveling mass of undissolved matter such as a blood clot ) deep vein thrombosis of lower extremities bilateral (blood clot in deep vein of legs), fluid overload (when body retains too much fluids), acute on chronic diastolic congestive heart failure (decompensation that causes fluid to quickly back up to the lungs), difficulty walking, and muscle weakness. Record review of Resident # 3's Quarterly MDS, dated [DATE] revealed a BIMS of 13 out of 15 indicating no cognitive impairment. The MDS revealed he required substantial/maximal assistance to complete toileting and transfers. Resident # 3 was totally dependent on staff for putting on and taking off footwear. Record review of the Care Plan dated 3/24/26 documented Resident # 3 was totally dependent on staff for transfers, toileting, dressing and bathing. The Care plan documented Resident #3 was on diuretic therapy related to edema. The Goal listed revealed Resident will be free of discomfort or side effects of diuretic therapy through the review date. Interventions include administering diuretic medications as ordered. Monitor for side effects. There was no mention of the compression socks listed in the care plan for any task.Record review of Resident # 3's physician's orders dated 6/29/26, documented Wear BLE (Bilateral Lower Extremities) above the knee compression stockings while awake every dayshift for edema. Order start date was 05/15/25 with no discontinue date.Record review of Treatment Administration Record on 7/1/26 revealed compression socks were documented as being placed on Resident # 3 on 6/29/26, 6/30/26 and 7/1/26 in the am when observations and interviews stated otherwise.In an Observation and Interview on 6/29/26 at 9:30 am revealed Resident # 3 was sitting in his recliner in his room, and there were no compression socks observed on his legs. Resident #3 stated, I am supposed to have compression socks on. I usually have to tell the staff to put them on. I usually tell them around 10:30 am because I know they are busy and they had not put them on yet. I need to wear them. I am at risk of getting blood clots if I do not have them on when I am up. Resident #3 stated he was usually up by 6 am and sitting in his wheelchair to go eat breakfast in the dining room. He stated after breakfast he liked to sit in his recliner in his room. He stated he liked to go to bed at 8 pm. He stated he was dependent on staff for catheter care, transferring to chair from his bed and getting the compression hose on. He stated he could not put the compression socks on his legs without staff assistance. He stated the staff rarely put the compression socks on first thing when he gets up and he knows they are busy, so he waits. He stated by around 10 :00 am, if the staff still had not put the compression socks on he will tell the staff he needs the socks on his legs. He stated he was supposed to have them put on when he got up at 6 am and into his chair. He stated he could not get up from his chair to the bed without staff assistance. In an Observation on 6/29/26 at 11:25 am revealed Resident # 3 was sitting in his wheelchair in the dining room waiting for the lunch meal. Resident #3 had no compression socks on his legs. In an Observation and Interview on 6/29/26 at 2:00 pm revealed Resident # 3 was sitting in his wheelchair in his room, and there were no compression socks on his legs. He stated he had not told the staff he needed the socks to be put on. He stated he thought the staff would have put the socks on by now. In an interview on 6/29/26 at 3:30 pm Resident #3 stated the staff put the compression socks on his legs around 2:30 pm.In an observation on 6/30/26 at 7:05 am Resident #3 was in his wheelchair in the dining room waiting for breakfast. Resident #3 had no compression socks on his legs. In an observation on 6/30/26 at 7: 50 am Resident #3 was in his wheelchair in the dining room. Resident #3 had no compression socks on his legs. In an observation on 6/30/26 from 11:40 am to 12:45 pm, Resident #3 was in his wheelchair in the dining room. Resident #3 had no compression socks on his legs. In an observation on 7/1/26 at 7:55 am Resident #3 was observed in the dining room with no compression socks on his legs. In an observation and interview on 7/1/26 at 8:20 am Resident #3 was observed in his room in his with no compression socks on his legs. Resident #3 stated he had been up in his wheelchair since 6 am. In an Interview on 7/1/26 at 8:40 am, CNA H stated she was aware Resident #3 had compression socks and that he needed to wear them daily. She stated Resident #3 did not like to wear compression socks and also stated Resident #3 usually called staff to put them on around 10:00 am. She stated the staff waited to put the compression socks on until the resident called for them. When asked what the care plan and physician orders said she stated she did not know because she did not look at the orders or the care plan. She stated the consequences for not putting the compression socks on for the resident would be swelling in his legs and he retained a lot of water. She stated she had been trained for her job by a lot of different people. In an interview on 7/1/26 at 9:05 am, LVN I stated he had been aware Resident #3 had an order for compression socks to be on in the day and off at night. He stated he was not aware Resident #3 had not had the socks put on until late in the afternoon. He stated the CNAs usually put the compression socks on and he did not know why they had not done that when the resident had gotten up in the morning. He stated when the physician order says during the day that meant when the resident gets up at 6 am, the CNAs should put the hose on Resident #3. He stated he monitors the CNAs work to make sure the CNAs are providing adequate care. LVN I stated the compression socks should have been in the care plan and he was not sure if the socks had been care planned. He stated the consequences of not having the socks care planned would be poor treatment and care. He stated the consequences of Resident #3 not wearing compression socks would be swelling, edema or blood clots. In an Interview on 7/1/26 at 9:30 am, the DON stated she expected all staff to follow the physicians' orders. She stated that an order would be put into the charting system after it is written by a physician and would be listed on the Treatment Administration Record. She stated the staff were supposed to record the treatment activities as they had occurred. The DON stated she was not aware Resident # 3 had not had his compression socks on in the mornings. She stated she had trained the nursing staff to do their jobs and expected physicians' orders were followed 100 percent for all orders and all residents. The DON stated she expected the compression socks to be listed in the care plan. She stated the consequences of not wearing the compression socks for a resident would be blood clots and circulation issues. She stated the consequences of not having the compression socks care planned would be treatments not being done. In an Interview on 7/1/26 at 9:40 am, CNA J stated she was aware Resident #3 had compression socks and that he needed to wear them daily. She stated the CNAs usually put the compression socks on him around 10:00 am if he wanted them on. When she was asked what the physician order, care plan or the TAR said about the socks, she did not know. When asked what wear socks while awake meant, she said she thought it meant put the socks on before 10:00 am and taking them off before bed. She stated the consequences for not putting the compression socks on for the resident would be swelling in his legs. Record Review of the facility policy dated March 2022 titled Care Plans, Comprehensive - Person Centered revealed: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet resident needs is developed and implemented for each resident. The care plan interventions from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 11 residents (Resident #3) reviewed for physician orders for treatments. The facility failed to follow physician orders and apply Compression socks as ordered for Resident # 3. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include:Record review of Resident #3 's face sheet printed 06/29/2026 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of embolism ( a traveling mass of undissolved matter such as a blood clot ) deep vein thrombosis of lower extremities bilateral (blood clot in deep vein of legs), fluid overload (when body retains too much fluids), acute on chronic diastolic congestive heart failure (decompensation that causes fluid to quickly back up to the lungs), difficulty walking, and muscle weakness. Resident # 3's Quarterly MDS, dated [DATE] revealed a BIMS of 13 out of 15 indicating no cognitive impairment. The MDS revealed he required substantial/maximal assistance to complete toileting and transfers. Resident # 3 was totally dependent on staff for putting on and taking off footwear. Record review of Resident #3's Care Plan dated 3/24/26 documented Resident # 3 was totally dependent on staff for transfers, toileting, dressing and bathing. Record review of Resident # 3's physician's orders dated 6/29/26, documented Wear BLE (Bilateral Lower Extremities) above the knee compression stockings while awake every dayshift for edema. Order start date was 05/ 15/25 with no discontinue date. Record review of Treatment Administration Record on 7/1/26 revealed compression socks were documented as being placed on Resident # 3 on 6/29/26, 6/30/26 and 7/1/26 in the mornings when observations and interview stated otherwise. In an Observation and Interview on 6/29/26 at 9:30 am revealed Resident # 3 was sitting in his recliner in his room, and there were no compression socks observed on his legs. Resident #3 stated, I am supposed to have compression socks on. I usually have to tell the staff to put them on. I usually tell them around 10:30 am to put the socks on because I know they are busy in the mornings. I need to wear them. I am at risk of getting blood clots if I do not have them on when I am up. Resident #3 stated he was usually up by 6 am and sitting in his wheelchair to go eat breakfast in the dining room. He stated after breakfast he liked to sit in his recliner in his room. He stated he liked to go to bed at 8 pm. He stated he was dependent on staff for catheter care, transferring to chair from his bed and getting the compression hose on. He stated he could not put the compression socks on his legs without staff assistance. He stated the staff rarely put the compression socks on first thing when he gets up and he knows they are busy, so he waits. He stated by around 10:00 am the staff still have not put the compression socks on he will tell them. He stated he was supposed to have them put on when he got up at 6 am and into his chair. He stated he could not get up from his chair to the bed without staff assistance. In an Observation on 6/29/26 at 11:25 am revealed Resident # 3 was sitting in his wheelchair in the dining room waiting for the lunch meal. Resident #3 had no compression socks on his legs. In an Observation on 6/29/26 at 2:00 pm revealed Resident # 3 was sitting in his wheelchair in his room, and there were no compression socks on his legs. In an interview on 6/29/26 at 3:30 pm Resident #3 stated the staff put the compression socks on his legs at 2:00 pm. He stated the compression hose were put on his legs on 6/28/29 around 2:30 pm. In an observation on 6/30/26 at 7:05 am Resident #3 was in his wheelchair in the dining room waiting for breakfast. Resident #3 had no compression socks on his legs. In an observation on 6/30/26 at 7: 50 am, Resident #3 was in his wheelchair in the dining room. Resident #3 had no compression socks on his legs. In an observation on 6/30/26 at 11:40 am to 12:45 pm, Resident #3 was in his wheelchair in the dining room. Resident #3 had no compression socks on his legs. In an observation on 7/1/26 at 7:55 am Resident #3 was observed in the dining room with no compression socks on his legs. In an observation and interview on 7/1/26 at 8:20 am Resident #3 was observed in his room in his with no compression socks on his legs. Resident #3 stated he had been up in his wheelchair since 6 am. In an Interview on 7/1/26 at 8:40 am, CNA H stated she was aware Resident #3 had compression socks and that he needed to wear them daily. She stated Resident #3 did not like to wear compression socks and also stated Resident #3 usually called staff to put them on around 10:00 am. She stated the staff waited to put the compression socks on until the resident called for them. When asked what the care plan and physician orders said she stated she did not know because she did not look at the orders or the care plan. She stated the consequences for not putting the compression socks on for the resident would be swelling in his legs and he retained a lot of water. She stated she had been trained for her job by a lot of different people. In an interview on 7/1/26 at 9:05 am, LVN I stated he had been aware Resident #3 had an order for compression socks to be on in the day and off at night. He stated he was not aware Resident #3 had not had the socks put on until late in the afternoon. He stated the CNAs usually put the compression socks on and he did not know why they had not done that when the resident had gotten up in the morning. He stated when the physician order says during the day that meant when the resident gets up at 6 am the CNAs should put the hose on Resident #3. He stated he monitors the CNAs work to make sure the CNAs are providing adequate care. He stated the consequences of Resident #3 not wearing compression socks would be swelling, edema or blood clots. In an Interview on 7/1/26 at 9:30 am, the DON stated she expected all staff to follow the physicians' orders. She stated that an order would be put into the charting system after it is written by a physician and would be listed on the Treatment Administration Record. She stated the staff were supposed to record the treatment activities as they had occurred. The DON stated she was not aware Resident # 3 had not had his compression socks on in the mornings. She stated she had trained the nurses to do their jobs and expected all staff to follow physicians' orders 100 percent for all orders and all residents. The DON stated she expected the compression socks to be listed in the care plan. She stated the consequences of not wearing the compression socks for a resident would be blood clots and circulation issues. She stated the consequences of not having the compression socks care planned would be treatments not being done. In an Interview on 7/1/26 at 9:40 am, CNA J stated she was aware Resident #3 had compression socks and that he needed to wear them daily. She stated the CNAs usually put the compression socks on him around 10:00 am if he wanted them on. When she was asked what the physician order, care plan or the TAR said about the socks, she did not know. When asked what wear socks while awake meant, she said she thought it meant put the socks on before 10:00 am and taking off before bed. She stated the consequences for not putting the compression socks on for the resident would be swelling in his legs. Record Review of the facility policy titled Medications and Treatment Orders dated July 2016, revealed the facility orders for medication and treatments will be consistent with principles of safe and effective order writing. Orders must be recorded on the physician's order sheet in the resident chart.

Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed. The Facility Assessment had not been updated since January 2025. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.The findings included: Record review of the Facility Assessment revealed the last documented review and update occurred in January 2025. During an interview on 06/30/26 at 1:59 PM, the AIT stated she had served in that role since July 2025. She stated she had not reviewed the Facility Assessment since assuming the position because she had not had time but stated it had been updated before the previous survey. The AIT stated it was her responsibility along with the ADM to update the Facility Assessment and acknowledged it should be reviewed and updated annually or whenever significant changes occurred. The AIT stated the only changes since the last update had been administrative leadership changes and indicated she would update the assessment that day with assistance from the Interim ADM. During an interview on 06/30/26 at 2:55 PM, the Interim ADM stated that she had been employed at the facility since February 2026. She stated she had not reviewed the Facility Assessment upon assuming her position and was unsure when it had last been updated. The Interim ADM stated she believed it was her responsibility to update the assessment annually or when changes occurred and thought it had already been updated during 2026. Record review of a facility policy titled Facility Assessment revised October 2018 revealed in part. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. 9. The facility assessment is reviewed and updated annually, and as needed .

Based on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who was licensed by the state, was responsible for the management of the facility, and was accountable the to the governing body for 1 of 1 facility reviewed for administration. The facility had not had an administrator from 07/16/2025 to 01/07/2026 This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care.The findings included: Record review of the former Administrator's employee record titled Profiles dated 11/20/2025 revealed he was hired on 02/01/2018 with a termination date of 07/16/2025. During an interview on 1/07/2026 at 05:56 AM the AIT reported she (AIT) had completed her administrator training and tested but she did not pass the test the first time. She (AIT) was planning on retesting. The AIT reported that the facility was actively looking for an interim administrator and has had several applications. The facility has one current applicant that was considering an interim position but has not given the facility a definite answer. The AIT stated the facility did not have a current administrator and had not had an administrator since the former administrator left in July of 2025. During an interview on 1/07/2026 at 08:10 AM the AIT reported the last time they had an administrator was July of 2025. The AIT reported they advertised several times and were currently advertising for a full-time or interim administrator with no applicants that have qualified. During an interview on 1/07/2026 at 08:46 AM the AIT reported she was the regional BOM for the facility since 2012 and would be the administrator when she passed her test. The AIT reported not having an administrator could result in the facility not following regulation and rules, the residents would not feel safe, the families would not feel comfortable, and they could have bad outcomes with resident's care. Record review of the facility provided policy titled, Administrator revised March 2023, revealed the following: Policy Statement: A licensed administrator is responsible for the day-to-day function of the facility.Policy Interpretation and Implementation:The governing body of the facility has appointed an administrator who is duly licensed in accordance with current federal and state requirements. Maintaining his/her license on a current status as required by law, and maintaining a copy of such license or registration on premises.

Based on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care for all 50 residents at the facility. The findings included: Record review of the former Administrator's employee record titled Profiles dated 11/20/2025 revealed he was hired on 02/01/2018 with a termination date of 07/16/2025. During an interview on 11/20/25 at 6:48 AM, an entrance conference was conducted with the AIT who stated she took the test and failed and the facility, at this time, did not have a licensed ADM. She stated the former ADM had been terminated on 07/16/25. The AIT stated that corporate wanted her to take the position of ADM as soon as she passed the ADM exam. During an interview on 11/20/25 at 5:31 AM, the Interim DON stated that the facility did not have a full-time administrator. She stated that the AIT failed the ADM exam and was going to take it again but was not sure when. The Interim DON stated that she could not think of a negative outcome for not having a licensed ADM because the situation was working and there had been no negative impacts. During an interview on 11/20/25 at 7:35 AM, the HRP Dir stated that she had worked at the facility for 11 years and the facility currently did not have a full-time licensed ADM. She stated that the AIT was acting in that role as the ADM, but she was not licensed. The HRP Dir stated that the facility had not had a licensed full time ADM since Mid-July, 2025. She stated a possible negative outcome for not having a licensed ADM could be that they would get a tag from state. During an interview on 11/20/25 at 8:49 AM, the CRCD stated she had worked at the facility for 4 years as the DON prior to taking the role as corporate regional director. She had been in her current role for 6 years. The CRCD stated that that they did not currently have a full-time administrator because he was fired in July, 2025. She stated they were actively looking for an ADM and they wanted to offer the job to the AIT once she passed her test. In the meantime, corporate was going to hire an Interim ADM so the AIT could have time to study for the test. The CRCD stated that a possible negative outcome for not having a licensed ADM could be that staff may not follow facility policies/rules because there was not a licensed ADM which could affect resident care. Record review of a facility policy titled Administrator with revised date of March 2021 revealed the following, in part. A licensed Administrator is responsible for the day-to-day functions of the facility.1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirementsi. Maintaining his/her license on a current status as required by law, and maintaining a copy of such license or registration on premises.

Based on interview and record review the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care. The findings included: During an interview on 09/04/2025 at 9:32 AM, an entrance conference was conducted with the BOM who stated she was the AIT and acting as ADM for the facility. She stated that the former ADM had been terminated. During an interview on 09/04/2025 at 2:04 PM, the DON stated that the facility did not have a full-time administrator. She stated that she was not exactly sure when the last administrator was terminated, but she thought around the 20th of July. The DON stated the AIT took the administrator role, but she was not licensed and still in training. During a follow-up interview on 09/04/2025 at 3:32 PM, the AIT said the previous Administrator was terminated on 7/16/2025. She stated the facility currently did not have an administrator. The AIT stated she had not gotten a formal offer for the administrator position but that she will submit her hours in 9 days to the licensing department and then she can apply to take the test. During an interview on 09/04/2025 at 3:40 PM, the MP Dir stated she had worked at the facility for 11 years. She stated that that they do not have a full-time administrator at this time, but the AIT is acting in that role and that the former ADM was fired but not sure when his last day was. The MP Dir stated they are actively looking for an Administrator. Record review of former Administrators employee record titled Profiles dated 09/04/2025 which showed he was hired on 02/01/2018 with a termination date of 07/16/2025. Record review of a facility policy titled Administrator with revised date of April 2007 revealed the following, in part. A licensed Administrator is responsible for the day-to-day functions of the facility.1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirementsi. Maintaining his/her license on a current status as required by law, and maintaining a copy of such license or registration on premises.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: Observation of the kitchen food prep activities on 4/30/25 from 11:15 a.m. to 12:35 p.m. revealed the following: In an observation and interview on 4/30/25 at 11:40 a.m., [NAME] I was observed in the kitchen with gloved hands, chopping meat for lunch using a spoon to chop the meat. [NAME] I pushed meat off the bowl of the spoon with her gloved hands. [NAME] I did not wash her hands. [NAME] I took off her gloves and applied new gloves from her pocket. [NAME] I began touching the meat with her gloved hand, picked up the meat and put the chopped meat in the metal container. [NAME] I was asked if she realized she had not washed her hands and had touched other surfaces then touched the meat with her gloved hands. [NAME] I just smiled and said she did not speak English. The DM was present and stated to [NAME] I in Spanish, she needed to wash hands and change gloves between tasks. The DM stated she expected [NAME] I to wash her hands, and change her gloves between tasks before putting on new gloves. In an observation and interview on 4/30/25 at 11:50 am [NAME] J was observed carrying a tray of glasses to the serving counter with gloved hands. [NAME] J set the tray on the counter and began turning the glasses right side up. [NAME] J picked up a glass with one gloved hand and grabbed a handful of ice with his other gloved hand. [NAME] J filled the glass with ice. [NAME] J then put the glass down and picked up another glass. [NAME] J then filled another glass of ice using his gloved hand and set the glass down. [NAME] J touched other kitchen surfaces in the kitchen then filled another glass with ice using his gloved hand. [NAME] J did not wash his hands or change his gloves. [NAME] J was asked if he realized he had touched the ice after touching other kitchen surfaces. [NAME] J stated No, I did not. [NAME] J refused to speak to this writer the rest of the observation. In an observation and interview on 4/30/25 at 11: 55 am, [NAME] I was observed with gloved hands to touch food trays, picked up the serving utensils, put the serving utensils down on the counter, removed the lids off the food on the tray line, picked up the serving utensils and placed them into the food items, picked up tray tickets and put them down, picked up a plate, put the plate down, picked up tray tickets again and then picked up a plate. [NAME] I began plating the food. [NAME] I picked up a roll with her gloved hands and placed it on the plate. [NAME] I picked up another plate, plated the food and picked up another roll with her gloved hand and placed the roll on the plate. [NAME] I was asked if she realized she had touched various surfaces in the kitchen and then used her hand to pick up the roll. [NAME] I smiled and said No English and continued to plate the food. [NAME] I did not change her gloves. The DM was present and spoke to [NAME] I. [NAME] I used tongs to place the roll on the plates for the next few plated meals. In an observation and interview on 4/30/25 at 12:20 pm, [NAME] I was observed from the kitchen/ dining room window picking up utensils, plates, touching the serving cart and then plating food. [NAME] I was seen picking up a roll with her gloved hands and placing the roll on the plate. [NAME] I then picked up another plate, plated the food and placed a roll on the next plate. [NAME] I did not change her gloves or wash her hands. In an interview on 5/1/25 at 10:00 am, the DM was asked about handwashing. The DM stated They shouldn't be touching the food. FSS further stated, Tongs should be used to serve rolls. The DM stated the staff were just nervous. She stated both [NAME] I and [NAME] J came to her and stated they were nervous and just forgot to wash and change gloves. The DM stated she was trained by the Dietician for her job duties. The DM stated she trained the staff on handwashing and glove use and had just in serviced the staff that week. The DM stated the consequences of not washing hands and changing gloves was cross contamination. Record Review of the facility's policies titled Indications for Glove Use with a date of 2009, documented: ' Food service employees may not contact exposed ready to eat food or food that will be cooked with their bare hands and shall use suitable utensils . Change gloves when an unsensitized surface is touched. Change gloves when beginning a different task . Record Review of the facility's policies titled Safe Food Preparation with a date of 2009, documented: ' Prepare foods in a sanitary manner with minimal handling Hands do not touch areas of utensils, dishware or silverware where the food or mouth is placed. Avoid touching foods with bare hands. Use tongs instead. Record Review of the facility's policies titled Safe Food Handling with a date of 2009, documented: ' Follow all local, State and Federal regulations when handling food. Food is served with clean sanitized utensils.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 3 of 3 medication carts (NE Hall, NW Hall, and South side Hall) and 1 of 12 residents (Resident #15) reviewed for medication storage. -Medication cart for NW Hall revealed Fluticasone Propionate nasal spray 50mcg with no open date on the bottle or resident identifying information. -Breo Ellipta had a date of 06/11/2025, with no resident identifying information. -Medication cart for NE Hall had a pill in a medication cup in the top draw of the medication cart. -Medication cart for NE hall had 1 unidentified pill loose in the bottom of the medication cart drawers. -Medication cart for NE hall had 1 loose Protonix pill in the bottom of the medication cart drawers. -Medication cart for NE hall had Fluticasone Propionate nasal spray 50mcg, for Resident # 15, bottle did not have an open date on it. -Medication cart for South side had Fluticasone Nasal spray 50mcg with no name and no open date on the bottle. -Medication cart for South side had 2 loose pills in the bottom of the medication cart drawers. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation and interview on 04/30/25 at 10:15 AM the medication cart for NW hall revealed Fluticasone propionate 50mcg nasal spray for Resident #8 had a date on the box of 04/23. LVN A was unsure if that was the open date or date of expiration. Fluticasone Propionate nasal spray 50mcg had no open date on the bottle or any resident information. Breo Ellipta had a date of 06/11/2025, no resident information on the medication. LVN A was unsure if this was an open date or an expiration date. LVN A stated a negative outcome for having expired medications was that the meds would be effective due to not knowing if the medication was still good or not. During an observation and interview on 04/30/25 at 10:37 AM the medication cart for NE Hall revealed a loose pill in a medication cup in the top drawer of the medication cart. LVN B stated it was a probiotic for Resident # 1. LVN B stated she pulled the probiotic out early and the medication was to be given to Resident #1 at 8am, but the resident refused it. 2 unidentified pills were found loose in in the bottom of the medication cart drawers. One pill was an Oval yellowish/cream in color pill that was identified as a Protonix. Fluticasone Propionate nasal spray 50mcg, for Resident # 15 nasal spray bottle did not have an open date on it. LVN B stated a negative outcome for having medications without expiration dates could lead to a medication not being effective. LVN B stated the negative outcome for having loose pills was staff would not know what they (the pills) would be. During an observation on 04/30/25 at 01:50 PM the medication cart for the South side revealed Fluticasone Nasal spray 50mcg with no name and no open date on the bottle of nasal spray. 2 loose pills were found in the bottom of the medication cart drawers 1 was identified as Lisinopril and the 2nd pill was identified as omeprazole by LVN E. During an interview on 04/30/25 at 02:01 PM LVN E stated the negative outcome for having loose pills in the medication cart was it could lead to the resident being short on medication at the end of the month. LVN E stated the negative outcome for not having the open date on medications that required them, would be the medication could be expired and not as effective for the resident. During an interview on 05/02/2025 at 01:32 PM DON stated the negative outcome for having loose pills in the medication carts would be that the staff don't know what the medications are. DON stated having expired medications in the cart would be the medication was not as effective as it should be. DON stated the negative outcome for not writing the open date on a medication that needs one was that the medication could be expired and then not effective and not having the name on the medication we don't know who the medication belongs to. Record review of the facility provided policy titled, Administering Medications, Revised April 2019, revealed the following: .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. No other policy provided by the facility.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (Resident #15, #24, #26, #27, #31, and Resident #36) reviewed for infection control. The facility failed to ensure that facility staff performed hand hygiene appropriately during medication preparation, medication administration and incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings included: During an observation on 04/30/25 at 11:00 AM Resident #27 was being assisted to the restroom by CNA F who did not don any PPE. Resident #27 was on EBP due to having a wound. During an interview on 04/30/25 at 11:08 AM CNA F, stated he didn't know if Resident # 27 was on EBP precautions. CNA F went to the door of the residents room and turned to the state investigator and stated yep, he sure is. CNA F stated a negative outcome was the possibility of spreading infection to other residents. During an observation on 04/30/25 at 12:23 PM CNA C was assisting 2 unidentified residents with eating and used her right hand for both residents without performing hand hygiene in between residents. During an observation on 04/30/25 at 02:14 PM CNA C stated a negative outcome for not washing hands when assisting residents to eat was that it could lead to cross contamination. During an observation on 05/01/25 at 06:31 AM LVN B administered medication to Resident #15 who was on EBP and did not don PPE to perform a glucose check or to administer insulin to Resident #15. LVN B did not perform hand hygiene before administering insulin and did not perform a glove change after preparing medication and then entering the resident's room. During an observation on 05/01/25 at 06:34 AM LVN B administered insulin to Resident #24, LVN B did not clean glucometer before performing the glucose check and did not perform hand hygiene before donning gloves to perform the glucose check. LVN B used the same gloves she prepared medications with and administered insulin to Resident #24 without performing HH or a glove change. During an interview on 05/01/25 at 06:45 AM LVN B stated the negative outcome for not performing HH and not donning PPE for a resident on EBP was it could lead to the passing of bacteria on to another resident. During an observation on 05/01/25 at 06:48 AM LVN A who was preparing medicated eye gtts for Resident #31, did not perform HH before donning gloves to administer eye gtts. LVN A did not perform HH after removing gloves. During an observation on 05/01/25 at 06:56 AM LVN A donned gloves at her medication cart which was located midway down the NE hall and walked to the end of the hallway were Resident #36's room was, Resident #36's roommate was on contact precautions for ending stages of shingles. LVN A left room with the gloves on that she checked Resident #36's blood sugar with and walked down the hall with dirty gloves on and touched her medication cart. LVN A removed gloves and did not perform HH. During an observation on 05/01/25 at 07:07 AM LVN A did not perform HH and did not don gloves to administer insulin to Resident #23 and did not perform HH after the administration of medication. During an observation on 05/01/25 at 07:18 AM LVN A did not perform HH before donning gloves for insulin injection of Resident #35. During an interview on 05/01/25 at 07:28 AM LVN A stated by not performing HH or donning/doffing gloves at the appropriate times could lead to cross contamination and the spread of germs. During an observation on 05/01/25 at 12:27 PM CNA D was assisting the wound doctor and LVN M with incontinent care and wound care for Resident #26. CNA D walked into the room and did not don PPE since Resident #26 was on EBP for a wound and Foley catheter. CNA D did not wash hands before donning gloves and took over the incontinent care for LVN M who was washing hands and donning new gloves so she could start wound care for Resident #26. CNA D did not perform HH after performing care and doffed and donned new gloves with no HH performed in between glove change. Before wound care was started she donned a gown. At the end of assisting LVN M with wound care CNA D did not perform HH. During an interview on 05/01/25 at 12:51 PM CNA D stated the negative outcome would be that other residents could get an infection. During an interview on 05/02/25 at 01:32 PM DON stated a negative outcome for not performing HH could lead to the transmission of microbes to everywhere and everyone. DON stated the negative outcome for not donning gloves to perform an injection could lead to a potential a stick and it isn't safe. DON stated a negative outcome for not donning PPE for residents on EBP was the potential to transmit bacteria via clothing. Record review of facility provided policy titled, Administering Medications, revised April 2019, revealed the following: .25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility provided policy titled, Insulin Administration, revised September 2014, revealed the following: .Steps in the procedure (Insulin Injections via Syringe) 1. Wash Hands . 21. Wash hands. Record review of facility provided policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. .7. .c. Before preparing or handling medications. .e. Before and after handling an invasive device (e.g., urinary catheters, .) . .H. before moving from a contaminated body site to a clean body site during resident care; . .m. after removing gloves; n. Before and after entering isolation precautions settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; . .8. Hand hygiene is the final step after removing and disposing of person protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 48161

Based on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #43) of 12 residents reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #43. This failure could affect all residents on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings included: Record review of Resident #43's face sheet, dated 05/02/2025, revealed Resident #43 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus without complications (a condition where blood sugar levels are persistently high due to either the body's inability to use insulin effectively (insulin resistance) or the pancreas doesn't produce enough insulin, or both), pulmonary hypertension (a condition characterized by high blood pressure in the arteries of the lungs), dorsopathy (any disease or condition of the spine and related structures, often causing back pain), and essential hypertension (a condition in which the force of blood against the walls of the arteries is consistently elevated above normal levels). Photo of Resident #43 on face sheet revealed the resident with NC on in the photo. Record review of Resident #43's last quarterly MDS, dated [DATE], revealed that Resident #43 was not receiving oxygen therapy. The ARD date for MDS was 02/17/2025. The MDS did reveal that Resident #43 had a BIMS score of 09, which indicated Resident #43 did have moderate cognitive impairment. Resident #43 required total assistance with putting on/taking off footwear, maximal assistance was required for lower and upper body dressing, showering/bathing, and toileting hygiene. Moderate assistance was required for Resident #43 with oral and personal hygiene, and setup assistance was required for eating. Record review of Resident #43's active medication orders, dated 05/02/202, revealed Resident #43 had an oxygen order that stated: May use oxygen @ 2 L per NC to maintain sats @ =/> 90% and/or SOB. every shift for SOB Verbal Active 09/17/2024 09/17/2024 Record review of Resident #43's care plan, dated 03/26/2025, revealed the following: Focus o [Resident #43 name] has a terminal prognosis r/t respiratory failure -[Hospice name] hospice -continuous O2 via NC Date Initiated: 10/09/2024 Revision on: 04/10/2025 Goals o [Resident #43 name]'s comfort will be maintained through the review date. Date Initiated: 10/09/2024 Revision on: 03/26/2025 Target Date: 03/30/2025 o [Resident #43 name]'s dignity and autonomy will be maintained at highest level through the review date. Date Initiated: 10/09/2024 Revision on: 03/26/2025 Target Date: 03/30/2025 During an observation on 04/30/25 at 11:38 AM Resident #43 had a NC on and oxygen concentrator was delivering oxygen on 4L/min. to Resident #43. During an observation on 05/01/25 at 01:32 PM revealed Resident #43's oxygen concentrator set at 4L/min and Resident #43 had NC on and receiving oxygen at time of observation. During an observation and interview on 05/02/25 at 09:56 AM revealed Resident #43's oxygen concentrator set at 4L/min and running, but Resident #43 couldn't find her NC to put it on. Resident #43 stated she wore her oxygen all of the time, and that the machine was so loud. During a record review of Resident #43's oxygen saturation log, saturation level's had not been checked since 02/11/2025. During an interview on 05/02/25 at 10:04 AM LVN K stated a negative outcome for not following physician orders, the resident wouldn't get the medication that they need. During an interview on 05/02/25 at 01:32 PM DON stated a negative outcome for not following physician orders would be that the resident would not get the correct dose of medication and it could have a negative outcome for the resident. Record review of the facility provided policy titled, Oxygen Administration, revised October 2010, revealed the following: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. Record review of facility provided policy titled, Administrating Medications, revised April 2019, revealed the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame.

48161 Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest t practicable physical, mental, and psychosocial well-being for 1 (Resident #37) of 16 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan that accurately addressed Resident #37's oxygen therapy. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings included: Record review of Resident #37's admission record dated 05/02/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified diastolic congestive heart failure, acute respiratory failure with hypoxia, and hypokalemia (low potassium). Record review of Resident #37's quarterly MDS completed on 04/03/2025 revealed a BIMS score of 12 out of 15 indicating moderate cognition impairment. Section J Shortness of Breath (dyspnea) revealed no shortness of breath during exertion, sitting at rest, or lying flat. Record review of Resident #37's care plan latest revision on 04/22/2025 had a focus for Resident #37's congestive heart failure with interventions for oxygen settings: oxygen via NC/ 2-3 L continuous. Record review of Resident #37's active physician orders dated 02/22/2024 revealed the following: May use oxygen at 2 L per NC to maintain sats at or above 90 and/or SOB as needed. During an observation on 04/30/2025 at 10:08 AM, Resident #37 was in his room sitting in his recliner, the oxygen tank was located near his bed. Resident #37 was not utilizing oxygen therapy. During an observation on 04/30/2025 at 12:00 PM Resident #37 was in the dining room for lunch, he was sitting at a table alone, he was not utilizing oxygen therapy. During an observation on 05/02/2025 at 8:02 AM, Resident #37 was in the dining room for breakfast, he was sitting at a table alone, he was not utilizing oxygen therapy. During an observation and interview on 05/02/2025 at 10:23 AM, Resident #37 was in his room sitting in his recliner, he was utilizing oxygen therapy at 2LPM Resident #37 stated he did not utilize oxygen all the time, he mostly used it in his room., He stated he never used it out in the dining room. Resident #37 stated he was unsure what his orders were related to his oxygen. During an interview on 05/02/2025 at 10:38 AM, the DON stated she was responsible for ensuring care plans were done correctly and updating them as needed. The DON stated oxygen therapy should be in the care plan and it's interventions . During an interview on 05/02/2025 at 10:50 AM, the BD stated every morning during staff meetings, the staff discuss resident care and care plans. The BD stated the DON was responsible for ensuring care plans were accurate and reflected doctor orders. The BD stated if the care plan did not reflect the doctor's orders, then the resident would not get the care he or she needed. During an interview on 05/02/2025at 11:00 AM, LVN K stated the DON was responsible to ensure the care plans were accurate and that the care plan should match what the doctor ordered. LVN K stated if a doctor ordered prn oxygen, then it should reflect prn in the care plan. The negative outcome for not having an accurate care plan would be a resident would not get the services they needed. During an interview on 05/02/2025 at 11:11 AM, the MDS Coordinator stated Resident #37 did not utilize oxygen continuously and said if the care plan stated his oxygen therapy was continuous then the care plan was inaccurate. The MDS Coordinator stated she and the DON were responsible for updating residents care plans and the care plan should reflect what the physician ordered. The MDS Coordinator stated there would be no negative outcome for having an inaccurate care plan. Record review of the facility policy titled 'Care Plan, Comprehensive Person-Centered ' no date: The comprehensive, person-centered care plan: Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making.

Based on observations, interviews and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 12 residents (Resident #43) reviewed for accuracy of MDS assessments. -The facility did not correctly identify oxygen therapy for Resident #43 on her MDS assessment. This failure to ensure accurate assessments could affect all the residents by placing them at risk for inaccurate and incomplete MDS assessment, which could result in the residents not receiving correct care and services. Finding included: Record review of Resident #43's face sheet, dated 05/02/2025, revealed Resident #43 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus without complications (a condition where blood sugar levels are persistently high due to either the body's inability to use insulin effectively (insulin resistance) or the pancreas doesn't produce enough insulin, or both), pulmonary hypertension (a condition characterized by high blood pressure in the arteries of the lungs), dorsopathy (any disease or condition of the spine and related structures, often causing back pain), and essential hypertension (a condition in which the force of blood against the walls of the arteries is consistently elevated above normal levels). Photo of Resident #43 on face sheet revealed resident with NC on in the photo. Record review of Resident #43's active medication orders, dated 05/02/202, revealed that Resident #43 had an oxygen order that stated: May use oxygen @ 2 L per NC to maintain sats @ =/> 90% and/or SOB. every shift for SOB. Verbal Active 09/17/2024 09/17/2024 Record review of Resident #43's MAR's (medication administration record), dated 02/01/2025-02/28/2025, revealed that Resident #43 received oxygen every day for the month of February. MAR for the month of March, dated 03/01/2025-03/31/2025 revealed that Resident #43 received oxygen every day of the month. MAR for the month of April, dated 04/01/2025-04/30/2025 revealed that Resident #43 received oxygen every day of the month. Record review of Resident #43's last quarterly MDS, dated [DATE], revealed Resident #43 was not receiving oxygen therapy. The ARD date for the MDS was 02/17/2025. The MDS did reveal Resident #43 had a BIMS score of 09, which indicated Resident #43 did have moderate cognitive impairment. Resident #43 required total assistance with putting on/taking off footwear, maximal assistance was required for lower and upper body dressing, showering/bathing, and toileting hygiene. Moderate assistance was required for Resident #43 with oral and personal hygiene, and setup assistance was required for eating. During an observation on 04/30/25 at 11:38 AM Resident #43 had a NC on and oxygen concentrator was delivering oxygen on 4L/min. to Resident #43. During an observation on 05/01/25 at 01:32 PM revealed Resident #43's oxygen concentrator set at 4L/min and Resident #43 had a NC on and receiving oxygen at the time of the observation. During an observation and interview on 05/02/25 at 09:56 AM revealed Resident #43's oxygen concentrator set at 4L/min and running, but Resident #43 couldn't find her NC to put it on. Resident #43 stated she wore her oxygen all of the time, and the machine was so loud. During a record review of Resident #43's oxygen saturation log, saturation level's had not been checked since 02/11/2025. During an interview on 05/01/25 at 10:50 AM MDS nurse stated she did not put the resident would need oxygen therapy due to the resident does not need oxygen from the documentation that she needed to perform the assessment. During an interview on 05/02/25 at 01:28 PM MDS nurse stated she did not assess the resident directly she looked at the documentation she received from the floor nurses. MDS nurse stated the accuracy of her assessment was only done by reviewing the documentation she was provided. MDS nurse stated the floor nurses were supposed document accurately, and the MDS nurse stated she was unaware if the documentation was accurate or not. MDS nurse stated the DON and the Regional MDS Coordinator were responsible for checking her work. MDS Nurse stated to check the accuracy of the information she was provided she just checked orders. MDS nurse stated the negative outcome for not having an accurate assessment would be We won't get reimbursement. During an interview on 05/02/2025 at 1:32 PM DON stated the negative outcome for not performing an accurate assessment would be you don't really know what the care the resident will need, and I do sign off on them, but I should be looking at them more closely because I don't really read them. the Regional MDS should be looking at them too. Record review of the facility provided policy titled, Electronic Transmission of the MDS, revised November 2019, revealed the following: 1. All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual, before being permitted to use the MDS information system. A copy of the MDS Rai Instruction Manual is maintained by resident assessment coordinator. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: Section O - Special Treatments, Procedures, and Programs Respiratory Treatments: C1. Oxygen Therapy a. On Admission b. While a Resident c. At Discharge Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days.

Based on observation, interviews, and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 2 of 5 residents (Residents #1 and #2) reviewed for Quality of Care. The facility failed to ensure Resident #1's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. Resident #1 had a post-surgery check up on 9/3/24, 18 days after admission and the bulky wound dressing from the surgery was still covering the wound and was dried to his leg but the incision was not infected. The facility failed to ensure Resident #2's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. Resident #2 had a post-surgery check up on 9/3/24, 13 days after admission and the bulky wound dressing from the surgery was still covering the wound and was soaking wet. No infection was present at this time, but the surrounding tissue was excoriated. An Immediate Jeopardy (IJ) was identified on 9/18/24 at 4:15 p.m. While the IJ was removed on 9/20/24 at 2:15 p.m., the facility remained out of compliance at a scope of Isolated with the potential for harm because the facility's need to implement and monitor the effectiveness of its corrective systems. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, the need for hospitalization or death. Findings include: Resident #1 Record review of Resident #1's clinical record revealed he admitted to the facility on [DATE], was [AGE] years of age with the following diagnoses: orthopedic aftercare of fracture of right femur (broken thigh bone), history of falling, muscle weakness, unsteadiness on feet, malignant neoplasm of prostate (a disease that occurs when malignant cells form in the prostate gland), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hyperlipidemia (too high fat levels in the blood), Idiopathic Peripheral Autonomic Neuropathy (a condition that causes damage to the peripheral nerves without a known cause with symptoms that often affect the feet), hypertension (high blood pressure), Atherosclerotic heart disease of native coronary artery (a common heart condition that occurs when plaque builds up in the coronary arteries) and angina pectoris (chest pain) Record review of a Medicare 5-day MDS resident assessment, dated 8/22/24, documented Resident #1 scored 14 of 15 on a mini-mental exam for cognitive awareness and was interviewable, had a surgical wound with no dressing changes. Record review of Physician Orders, dated 8/16/24, revealed there were no wound care orders for Resident #1. Record review of nurses notes, dated 8/16/24 through 9/4/24, during Resident #1's stay at the nursing home, did not document any wound assessments. Record review of an Admission Data Collection form, dated 8/16/24, did not document any skin issues for Resident #1. Record review of a Head to Toe Skin Checks form, dated 8/19/24, documented Resident #1 had existing bruises to right forearm, multiple small scabs to right shin and had a dressing to right hip. Record review of a Head to Toe Skin Checks form, dated 8/26/24, documented Resident #1 had existing bruises to right forearm, multiple small scabs to right shin - no dressing to right hip documented on this skin check. Resident #2 Record review of Resident #2's clinical record revealed she admitted to the facility on [DATE], was [AGE] years of age with the following diagnoses: intertrochanteric fracture of left femur (a type of fracture that occurs in the upper part of the thigh bone between the greater and lesser trochanters - most common hip fracture in the elderly), hyperlipidemia (too high fat levels in the blood), essential tremor (a nervous system disorder that causes rhythmic shaking), hypertension (high blood pressure), muscle weakness, chronic kidney disease - stage 3 (a midpoint on the CKD spectrum, where kidneys have mild to moderate damage and are less able to filter waste from the blood), abnormal gait and mobility (abnormal walking pattern) and lack of coordination. Record review of a Medicare 5-day MDS resident assessment, dated 8/27/24, documented Resident #2 scored 12 of 15 on a mini-metal exam for cognitive awareness and was interviewable, had surgical wound with dressing orders. Record review of Physician Orders for Wound Care for Resident #2: Do not remove Dermabond tape on incision: okay to shower. Record review of nurses notes, from 8/21/24 to 9/3/24, did not document any wound assessments. During an interview on 9/10/24 at 4:25 p.m., a confidential complainant #1 stated both Resident #1 and #2 had orders, when they admitted , to remove the bulky dressing which covered the Dermabond, after three days and leave the Dermabond on the surgical wounds so the site could be assessed. (Dermabond is a skin closure like superglue for the skin). The confidential complainant #1 stated on their post-surgical visits, the bulky dressings were present - Resident #1's bulky dressing was dried up and Resident #2's bulky dressing was soaking wet and her skin around the surgical incision was excoriated. The confidential complainant #1 stated the bulky dressings on Residents #1 and #2 were not removed and staff at the nursing home were giving Resident #2 a shower with the bulky dressing still intact. The confidential complainant #1 stated Resident #1 has his bulky dressing on for 18 days and Resident #2 had the bulky dressing on for 13 days. The confidential complainant #1 stated the surgical incision was covered by the Dermabond and the wounds were not infected but the physician orders were not followed. During an interview on 9/11/24 at 9:25 a.m., the MDS Coordinator A stated they do not have a wound care nurse, each nurse does dressing changes for the residents in their care. MDS Coordinator A stated on the weekends, they have an RN who oversees all the dressing changes and care issues. During an interview on 9/11/24 at 9:45 a.m., LVN A stated he does his own dressing changes, and he did not have any surgical dressing changes at this time. During an interview on 9/11/24 at 10:20 a.m., LVN B stated she does wound care on the residents on her hallway. LVN B stated she did not have any surgical wounds on her side of the building at this time. During an interview on 9/11/24 at 11:45 a.m., the DON stated she had never had any complaints about wound care. The DON stated she remembered Resident #1 had a seven-day dressing on and that was left until the resident went back to the surgeon. The DON stated when Resident #1's dressing was taken off at the doctor, the wound was irritated around the wound from the tape. The DON stated they did not have any wound care orders for Resident #1. The DON stated sometimes a resident comes with wound care orders and sometimes they don't. The DON stated if a resident with a surgical wound was admitted to the facility, she would expect the nurse to call the doctor and get orders for wound care. The DON stated Resident #2 had hip surgery also and was admitted with wound care orders, but the order was just to not remove the Dermabond. The DON stated the nurse on duty does the admission assessment and would document any skin issues. The DON stated LVN A was the nurse that did Resident #2's initial assessment and he would know more about the wound care orders. During a follow-up interview on 9/11/24 at 12:15 p.m., LVN A stated Resident #2 had a dressing on her hip when she admitted but there were no orders to take the dressing off. LVN A stated the doctor usually does not take anything (dressings) off until after the first visit back to the doctor. LVN A stated when a resident admits with a wound, the nurse needs to call the doctor for orders because PT does the wound care at the hospital. LVN A stated they typically do not take off any surgical wound dressings until the resident has seen the surgeon. LVN A stated he should have called the physician and double checked the wound care orders for Resident #2. During a confidential interview #2 on 9/11/24 at 1:50 p.m., it was said the Resident #2's physician was very upset because when Resident #2 went for her initial checkup after surgery, the dressing on the wound was sopping wet and had never been taken off. The confidential interview #2 stated staff were giving Resident #2 a shower and never covered the dressing up. The confidential interview #2 stated the Nurse Practitioner said Resident #2 had a severe case of diaper rash on her hip but Resident #2's wound was not infected, and Resident #2 was very fortunate the wound was not infected. The confidential interview #2 stated staff never removed the covering over the surgical incision like they should have. During a telephone interview on 9/11/24 at 2:30 p.m., Resident #1 stated the dressing on his leg was never changed during his stay at the facility. Resident #1 stated the Nurse Practitioner told him that the outer dressing should have been removed after three days and that was not done. Resident #1 stated his hip wound was not infected and everything was fine, but it could have been worse, at his age (95), it could have been very bad. During an interview on 9/12/24 at 11:30 a.m., the Administrator stated staff should have called for wound care orders for Residents #1 and #2 when they were admitted if they did not have orders with them. The Administrator stated staff did not call to get wound care orders for either resident, but they should have. An observation on 9/12/24 at 12:00 p.m., of Resident #2's surgical incision on her hip revealed the incision was across her lower left buttock, was healing and was pink around the edges. The pink color went around the edges of the incision site for about 3 to 4 inches. During a follow-up interview on 9/17/24 at 9:05 a.m., the confidential complainant #1 was informed that the facility did not receive wound care orders when Resident #1 and #2 admitted to the facility. The confidential complainant #1 stated the orders were written and given to the van driver who picked up the residents at the hospital. The confidential complainant #1 stated if a resident admitted with no orders for wound care, it would be nursing 101 for the nurse on duty to call the physician or nurse practitioner for wound care orders at that time. During an interview on 9/18/24 at 10:55 a.m., RN C stated she works every weekend and does wound care for residents with orders. RN C stated Resident #1 and Resident #2 did not have any wound care or dressing changes ordered so there was no wound care completed for those two residents. RN C stated she did check both resident's dressings to make sure they were clean, but she never removed any dressings because there were no orders for removing a dressing or changing a dressing. RN C stated she felt she was the only nurse in the facility that looked at any wounds because the DON doesn't do it. RN C checked PCC for any documentation or assessments in the computer and there was not any documentation for Resident #1 or Resident #1. RN C stated she was thinking about leaving the facility due to the lack of leadership. Record review of a policy titled, Admission Assessment and Follow up: Role of the Nurse revealed the following: Purpose: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. 8. Conduct a physical assessment, including the following systems: j. skin: 1. All wounds or surgical incisions should be looked at and documented. Nurse must ensure that there are any wound care orders, and if not, then MD or physician that completed the surgery must be contacted for any wound care orders day of admission and documentation should be charted on who was contacted and the orders given. 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The facility was notified an Immediate Jeopardy was identified on 9/18/24 at 4:15 p.m. and the Immediate Jeopardy templates were provided to the Facility's Administrator and a Plan of Removal was requested. The following Plan of Removal was submitted on 9/19/24 at 3:10 p.m. and accepted on 9/19/24 at 3:20 p.m. Plan of Removal for F 684 A. This deficient practice will be corrected. Chart reviews have been completed for all residents that have wounds to ensure that they have orders. Dressing changes and assessments have been documented in the resident's clinical record. Wound care has been completed and wound care orders for the residents were followed per the physician orders. Nursing staff has been re-educated and in-serviced on ensuring residents have wound orders for surgical wounds on admission, assessment, and documentation of wound/skin in PCC every shift, informing the physician of any changes as needed. B. This deficient practice has the potential to affect all residents. C. IDT/Nursing staff has been re-educated and in-serviced on ensuring residents have wound orders for surgical wounds on admission, assessment, and documentation of wound/skin in PCC every shift, informing physician of any changes as needed. D. DON/Designee will monitor assessment of skin documentation and assist in physician notification of any changes and to ensure orders are obtained for any wounds. Administrator will have oversight. QAPI committee will monitor monthly until compliance is assured. Will be done by 9/19/24. On 9/20/24 at 8:00 a.m., the surveyor confirmed the Plan of Removal was sufficiently implemented by: 1. During the interviews that occurred on 9/20/24 starting at 10:20 a.m. and ending at 2:00 p.m., nursing staff were able to describe what steps to follow when a resident was admitted with a wound dressing and no orders. On admission to the facility, every resident's skin will be assessed from head to toe for any kind of skin issues or surgical incisions. If a resident was admitted to the facility with any kind of a wound and had no orders for care and dressing changes (if needed), the physician or nurse practitioner would be contacted to obtain orders. Wound care orders would be placed on the TAR and immediately implemented. Documentation should be charted in the clinical record who was contacted for orders and the orders given. The wounds would be assessed every shift for any changes of the wound and the physician or nurse practitioner would be informed of changes. 2. Interviews conducted with nursing staff working at the facility on 9/20/24: Administrator, DON, LVN A. RN C, LVN D, LVN E, MDS Coordinator B. Telephone interviews with staff on 9/20/24: MDS Coordinator A and LVN F, G, H, I J, and K. All staff were interviewed on all shifts. (NOTE: During a follow-up interview on 9/20/24 at 2:00 p.m., the DON stated LVN B was let go earlier this week and RN C just gave her resignation so as of today, she was the only RN left working in the facility. The DON stated the facility has 7 full times nurses, 3 PRN nurses and agency staff were always in the facility. The DON stated they advertise for nurses all the time, but no one wants to work. 3. Record review of the in-service sheets reflected all nursing staff had been trained on the facility's Daily Documentation Guidelines - when a resident is skilled, please document on the topics as listed below every shift, and Wound Assessment and Documentation. An Immediate Jeopardy (IJ) was identified on 9/18/24 at 4:15 p.m. While the IJ was removed on 9/20/24 at 2:15 p.m., the facility remained out of compliance at a scope of Isolated with the potential for harm because the facility's need to implement and monitor the effectiveness of its corrective systems.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to obtain or maintain the resident's highest practicable physical, metal, and psychosocial well-being for 1 of 5 residents (Resident #2) whose comprehensive care plans were reviewed. The facility failed to develop a comprehensive care plan for Resident #2 that included dressing changes, assessing the wound for any changes and documenting in the clinical record what was found. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as a serious wound infection, wound deterioration, sepsis, or death. Findings include: Record review of Resident #2's clinical record revealed she admitted to the facility on [DATE], was [AGE] years of age with the following diagnoses: intertrochanteric fracture of left femur (a type of fracture that occurs in the upper part of the thigh bone between the greater and lesser trochanters - most common hip fracture in the elderly), hyperlipidemia (too high fat levels in the blood), essential tremor (a nervous system disorder that causes rhythmic shaking), hypertension (high blood pressure), muscle weakness, chronic kidney disease - stage 3 (a midpoint on the CKD spectrum, where kidneys have mild to moderate damage and are less able to filter waste from the blood), abnormal gait and mobility (abnormal walking pattern) and lack of coordination. Record review of a Medicare 5-day MDS resident assessment, dated 8/27/24, documented Resident #2 scored 12 of 15 on a mini-metal exam for cognitive awareness and was interviewable, had surgical wound with dressing orders. Record review of Physician Orders for Resident #2 indicated Wound Care: Do not remove Dermabond tape on incision: okay to shower. Record review of nurses' notes, from 8/21/24 to 9/3/24, did not document any wound care or assessments for Resident #2. Record review of Resident #2's comprehensive care plan, dated 9/11/24, revealed the document did not contain any information about the resident's primary reason for receiving skilled services, which was after care for hip surgery - dressing changes, assessing the wound for any changes and documenting in the clinical record what was found. During an interview on 9/18/24 at 1:20 p.m., the DON stated the comprehensive care plan should include wound care orders and assessments of those wounds but Resident #2 did not have them in the comprehensive care plan. During a confidential interview #1 on 9/10/24 at 4:25 p.m., it was said Resident #2 had orders, when she admitted , to remove the bulky dressing which covered the Dermabond, after three days and leave the Dermabond on the surgical wounds so the site could be assessed. (Dermabond is a skin closure like superglue for the skin). The confidential interview #1 stated on her post-surgical visit, the bulky dressing was present - Resident #2's bulky dressing was soaking wet and her skin around the surgical incision was excoriated like a bad diaper rash. The confidential interview #1 stated the bulky dressing on Residents #2 was not removed and staff at the nursing home were giving Resident #2 a shower with the bulky dressing still intact. The confidential interview #1 stated Resident #2 had the bulky dressing on for 13 days. The confidential interview #1 stated the surgical incision was covered by the Dermabond and the wounds were not infected but the physician orders were not followed and the possibility of Resident #2's surgical incision getting infected was elevated. During a confidential interview #2 on 9/11/24 at 1:50 p.m., it was said the Resident #2's physician was very upset because when Resident #2 went for her initial checkup after surgery, the dressing on the wound was sopping wet and had never been taken off. The confidential interview #2 stated staff were giving Resident #2 a shower and never covered the dressing up. The confidential interview #2 stated the Nurse Practitioner said Resident #2 had a severe case of diaper rash on her hip but Resident #2's wound was not infected, and Resident #2 was very fortunate the wound was not infected. The confidential interview #2 stated staff never removed the covering over the surgical incision like they should have. Record review of a policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Includes the resident's stated goals upon admission and desired outcomes. d. builds on the resident's strength; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care for one of 5 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #1 that included assessment and dressing changes for a surgical wound. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as a serious wound infection, wound deterioration, sepsis, or death. Findings include: Record review of Resident #1's clinical record revealed he admitted to the facility on [DATE], was [AGE] years of age with the following diagnoses: orthopedic aftercare of fracture of right femur (broken thigh bone), history of falling, muscle weakness, unsteadiness on feet, malignant neoplasm of prostate (a disease that occurs when malignant cells form in the prostate gland), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hyperlipidemia (too high fat levels in the blood), Idiopathic Peripheral Autonomic Neuropathy (a condition that causes damage to the peripheral nerves without a known cause with symptoms that often affect the feet), hypertension (high blood pressure), Atherosclerotic heart disease of native coronary artery (a common heart condition that occurs when plaque builds up in the coronary arteries) and angina pectoris (chest pain) Record review of a Medicare 5-day MDS resident assessment, dated 8/22/24, documented the resident scored 14 of 15 on a mini-mental exam for cognitive awareness which indicated the resident was interviewable, had a surgical wound with no dressing changes. Record review of Physician Orders, dated 8/16/24, revealed there were no wound care orders for Resident #1. Record review of nurses notes, dated 8/16/24 through 9/4/24, during Resident #1's stay at the nursing home, did not document any wound assessments. Record review of an Admission Data Collection form, dated 8/16/24, did not document any skin issues for Resident #1. Record review of a Head to Toe Skin Checks form, dated 8/19/24, documented Resident #1 had existing bruises to right forearm, multiple small scabs to right shin and had a dressing to right hip. Record review of a Head to Toe Skin Checks from, dated 8/26/24, documented Resident #1 had existing bruises to right forearm, multiple small scabs to right shin - no dressing to right hip documented on this skin check. Record review of Resident #1's baseline care plan, dated 8/18/24, revealed the document did not contain any information about the resident's primary reason for receiving skilled services, which was after care for hip surgery - dressing changes, assessing the wound for any changes and documenting in the clinical record what was found. During an interview on 9/18/24 at 1:20 p.m., the DON stated the baseline care plan should include wound care orders and assessments of those wounds but Resident #1 did not have them in the baseline care plan. During a confidential interview #1 on 9/10/24 at 4:25 p.m., it was stated Resident #1 had orders, when he admitted , to remove the bulky dressing which covered the Dermabond, after three days and leave the Dermabond on the surgical wounds so the site could be assessed. (Dermabond is a skin closure like superglue for the skin). The confidential interview #1 stated on his post-surgical visit, the bulky dressings were present - Resident #1's bulky dressing was dried up and stuck to his buttocks. The confidential interview #1 stated the bulky dressing on Residents #1 was not removed. The confidential interview #1 stated Resident #1 has his bulky dressing on for 18 days. The confidential interview #1 stated the surgical incision was covered by the Dermabond and the wounds were not infected but the physician orders were not followed and the possibility of Resident #1's surgical incision getting infected was elevated. During a telephone interview on 9/11/24 at 2:30 p.m., Resident #1 stated the dressing on his leg was never changed during his stay at the facility. Resident #1 stated the Nurse Practitioner told him that the outer dressing should have been removed after three days and that was not done. Resident #1 stated his hip wound was not infected and everything was fine, but it could have been worse, at his age (95), it could have been very bad. Record review of the policy titled, Care Plans -Baseline, revised 3/2022, revealed the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for reach resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident /representative. b. Physician orders. c. Dietary orders. d. Therapy services. e. Social Services; and f. PASARR recommendation, if applicable.

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 to help prevent the development and transmission of communication diseases and infections for 1 (Resident #2) of 5 Residents in that: - The facility failed to ensure CNA performed hand hygiene during foley catheter care for Resident #2. -The facility failed to ensure CNA and HA donned PPE before entering Resident #2's room who was on EBP's. (Enhanced Barrier Precautions). -The facility failed to provide staff with adequate PPE. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/08/2024 at 10:03am revealed foley catheter care for Resident #2. Care was provided by CNA and HA. CNA and HA performed HH at the beginning of care. CNA started to clean Resident #2's penis, the foley was secured by CNA so that no pulling took place. The meatus of penis was cleaned, and foreskin was retracked with no discomfort for resident. Once shaft of penis was cleaned the foley catheter was cleaned starting at the meatus and down towards the bag of the catheter. This action was done 3 times with clean wipes every time. CNA did not remove gloves or perform HH before placing a brief back on the resident or pulling up his short. CNA then pulled blankets back up on top of resident with the same gloves that she performed foley catheter care with. Resident #2 was left in a comfortable position and HH was performed by HA and CNA before leaving the room. During an interview on 05/08/2024 at 10:11am with CNA when asked about HH, CNA stated, Oh, my goodness, I didn't did I? CNA stated that the negative outcome of not performing HH and a glove change would lead to an increased risk for an infection for the resident. Record review revealed an in-service for Enhanced Barrier Precautions (EBP), CNA had not had this training. Training was dated 04/16/2024. HA had signed the in-service. During an interview on 05/08/2024 at 1:04pm DON stated that the EBP protocol was supposed to go into effect on 04/16/2024. DON stated that if the staff member hadn't signed the document then the staff had not read the policy. DON stated that a negative outcome for not performing HH or glove changes in between dirty and clean aspects of incontinent care could lead to the spread of infection. During an interview on 05/08/2024 at 1:24pm HA was asked if she knew what the in-service was for, she stated that it was for residents that have foley catheters that we are supposed to wear gowns and gloves when care was performed for them. CNA was asked why PPE was not worn during catheter care for Resident #2. CNA stated she just forgot. CNA stated that a negative outcome for not wearing PPE for this type of care was the increased risk for infection. During an interview on 05/08/2024 at 1:31pm CNA was asked about the in-service for EBP. When the CNA was asked what the document was she stated, it looks like the schedule. CNA was asked to look at the document. CNA stated, I don't know what that is. CNA stated, I didn't know anything about having to wear PPE until after catheter care was performed for [Resident #2]. CNA was asked what a negative outcome would be for not having PPE during this type of care, she stated it could make them sick. During an interview on 05/08/2024 at 1:55pm DON was asked why there was not any PPE available outside of Resident #2's room for catheter care. DON stated that the staff that is responsible for ordering PPE has told her that there is an issue with supply for PPE items. DON was asked what a negative outcome would be for not having the appropriate PPE for individuals with precautionary measures in place. DON stated, increased risk for the spread of infections. During an interview on 05/08/2024 at 2:00pm RRN was not aware that there was a shortage or issue getting PPE supplies. RRN was asked what a negative outcome with no having the appropriate PPE and not performing HH and glove changes during foley care. RRN stated there was a potential risk for an increased risk for infection. During an interview on 05/08/2024 at 2:21pm RN stated that the facility was very limited on gowns however there were some in the facility. RN stated that a negative outcome for not having the appropriate PPE was that staff could not follow protocol. Record review of facility provided policy titled Handwashing/Hand Hygiene revealed the following: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . .e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); . .h. Before moving from a contaminated body site to a clean body site during resident care; . Record review of facility provided policy titled, Catheter Care, Urinary, revised August 2022, revealed the following: .18. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of CMS from the Quality, safety, and oversight group, dated 03/20/2024, revealed the following: EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact residents care activities regardless of their multidrug-resistant organism status. The approach recommended gown and glove use for residents during specific high-contact resident care activities .EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .

Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. The facility failed to follow physician's orders in that Resident #1 was given 100 mg of Amitriptyline (an antidepressant medication) rather than the 25 mg the physician ordered. This failure could place residents at risk for oversedation such as dizziness, drowsiness and fatigue. Findings Included: Record review of Resident #1's admission record dated 05/08/24 revealed a [AGE] year-old male admitted for a short term to the facility on [DATE] with diagnoses that included, but were not limited to, aftercare following joint replacement surgery, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), fracture of base of neck of right femur (break in the neck of the big bone of the right leg near where the ball goes into the hip socket), volume depletion (abnormally low extracellular fluid in the body due to decrease in salt and water or decrease in blood volume), hypo-osmolality (decrease in the levels of electrolytes, chemicals, and other fluids in the blood) and hyponatremia (sodium levels in the blood are extremely low can cause nausea, headache, fatigue, or confusion), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and heart failure (heart muscle fails to pump blood as it should). Resident #1 was discharged from the facility to a hospital on 05/04/24. Record review of Resident #1's MDS front sheet in the EHR revealed his Admission MDS was in progress. Record review of Resident #1's Admission MDS which was in progress revealed Section C had been completed and Resident #1 had a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #1's baseline care plan completed by DON on 05/03/24 revealed he was able to communicate easily with staff. Resident #1's goals were to remain safe and get stronger to return to the community. Resident #1 needed one-person physical assist across his ADL's except for eating where he only needed set up assistance. Resident #1 was cognitively alert and intact. Resident #1 was receiving psychotropic medication. His medication list was provided to him and reconciled by him. Record Review of Resident #1's Order Summary Report dated 05/08/24 revealed an order for Amitriptyline Tablet 100 MG each day at bedtime for depression. Record review of Resident #1's Progress Notes revealed the following: A note dated 05/05/24 at 04:02 PM written by DON which read, Md was going through dc (discontinued) medication list and caught that amitriptylline [sic] was put in at 100 mg qhs instead of 25 mg. The note was labelled LATE ENTRY. A note dated 05/01/24 at 01:03 PM written by LVN for Amitriptyline Tablet 100 MG by mouth at bedtime for depression Severity: Moderate. Record review of Resident #1's Medication Administration Record dated 05/08/24 revealed he received 100 mg of Amitriptyline at bedtime on 05/01/24, 05/02/24, and 05/03/24. Record review of Resident #1's discharge record revealed he was discharged due to being unresponsive on 05/04/24 at 12:16 PM. Record review of Resident #1's hospital records from his stay 04/27/24 to 05/01/24 revealed he was taking Amitriptyline 25 mg per day at home prior to his admission to the hospital. The records further revealed he had an elevation in his white blood cells which indicated an infection of some kind on the two days before he was released to the facility (04/30/24 and 05/01/24). Record review of Resident #1's hospital records from his stay 05/04/24 to 05/08/24 revealed he was admitted to the hospital with elevated white blood cell count, diagnosis of a UTI (urinary tract infection), and elevated his troponin levels (an indicator in blood that can indicate a cardiac event). During an interview on 05/07/24 at 03:00 PM Resident #1's FM A stated Resident #1 was living on his own and in his right mind prior to his hip surgery. She stated he was the treasurer for his local club. FM stated Resident #1 had a history of becoming dehydrated and she, FM B, and FM C could recognize the signs. She stated when she and FM C visited Resident #1 on 05/03/24 he was showing the signs which included being sleepy and confused. During an observation and interview on 05/07/24 at 04:56 PM Resident #1 was sitting in a chair next to his bed in the local hospital with a bedside table in front of him. FM B was standing in front of Resident #1 who was eating his dinner from the bedside table. He appeared to be feeding himself easily and was observed drinking from his cup with no assistance. Resident #1 stated he did not remember much about his stay in the facility. He stated he remembered being admitted on [DATE] and put in a wheelchair. When asked if he had a history of getting dehydrated, he said he did but not of passing out from dehydration. FM B stated when he left Resident #1 in the facility on 05/01/24 Resident #1 was doing well and thinking clearly. He stated Resident #1 was living in an assisted living facility prior to his hip surgery and subsequent admission to the facility. He stated Resident #1 had never had issues with confusion prior to his admission to the facility. During an interview on 05/08/24 at 08:31 AM HRN stated Resident #1 was admitted to the hospital's ICU floor under her care on 05/04/24. She said at the time he was admitted he was slurring his speech, could not maintain O2 saturation without supplemental O2 at 2 lpm, was pale in color, had very low blood pressure, and very little urine output. She said he would attempt to say a word on occasion and his speech was incomprehensible. HRN stated she did not work on 05/05/24 and when she returned to work on 05/06/24 Resident #1 was completely different. She stated, Oh my goodness! It was a 360 turn. HRN said Resident #1 no longer needed supplemental O2, his blood pressure was better, his urine output was normal, his color was normal, and he was joking and have full conversations with staff. During an observation and interview on 05/08/24 at 08:36 AM Resident #1 was in his bed in the hospital on his back with HOB raised to sitting position and a tray table over the bed in front of him holding his breakfast. Resident #1 was feeding himself breakfast. FM B was seated next to the bed and FM C was standing in front of Resident #1. FM C stated when he was visiting Resident #1 in the facility on 05/03/24 Resident #1 was very confused and did not know where he was. He stated once Resident #1 drank some fluids he came around. FM C described Resident #1's condition when he was admitted to ICU on 05/04/24 as scary. During an interview on 05/08/24 at 10:57 AM FM A stated Resident #1 was not taking antidepressant medication prior to his stay in the facility, to her knowledge. She stated, I don't remember him taking antidepressants, he has never been depressed. During an interview on 05/08/24 at 01:21 PM MD stated Resident #1 taking four times the prescribed dose of Amitriptyline the three nights he was in the facility might have affected him going to the hospital. MD also stated due to the sudden nature of Resident #1's decline in condition it could also have been a cardiac event. He stated Amitriptyline was an antidepressant and had sedating qualities and could make you tired. He stated he spoke to LVN when he discovered the medication order had been entered incorrectly in the EHR. MD stated LVN told him he (LVN) made a mistake when he was entering the order into the EHR. During an interview on 05/08/24 at 02:03 PM DON stated the charge nurse on duty was responsible for entering orders into the EHR when a resident was admitted . She stated the next shift charge nurse was supposed to review the orders to ensure they were correct. She stated she had noticed that was not happening so recently she had a meeting with her nurses and told them after the second shift reviews the orders, they needed to give her a report so she could review them a second time and ensure they were correct. She stated the charge nurse admitting Resident #1 was LVN. She stated a possible negative outcome of receiving four times the prescribed amount of Amitriptyline was adverse side effects; increased sedation. During an interview on 05/21/24 at 10:22 AM LVN stated he made a mistake when he was entering Resident #1's order for Amitriptyline into the EHR. He stated on the morning of 05/01/24 Resident #1 was assessed and his blood pressure and oxygen saturation were within normal limits. He sated Resident #1 was alert and oriented at the time of the assessment. LVN stated Resident #1 ate 100% of his breakfast that morning and a CNA took him back to his room where he was talking with another resident. LVN stated there was a pretty sudden change in Resident #1's condition because when his family came to visit, they thought he was asleep and asked LVN to lay him down in his bed. LVN stated when he entered Resident #1's room to help lay him down Resident #1 was not responsive and LVN called the ambulance at that time. Record review of facility policy titled Admission Assessment and Follow Up: Role of the Nurse and dated September 2012 revealed the following: . 7. Conduct an admission assessment (history and physical), including: . d. Current medications and treatments. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Record review of facility policy titled Administering Medications and dated April 2019 revealed the following: . Medications are administered . as prescribed. 4. Medications are administered in accordance with prescriber orders, . Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following: . Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on record review and interview 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 eneds of each resident for 1 (Resident #1) of 5 residents reviewed for pharmaceutical services. The facility failed to transcribe Resident #1's order for Amitriptyline (an antidepressant medication) accurately. The dose was entered into the EHR as 100 mg per day rather than the ordered 25 mg per day. This failure could place residents at risk of receiving incorrect doses of medication resulting in overmedication. Findings Included: Record review of Resident #1's admission record dated 05/08/24 revealed a [AGE] year-old male admitted for a short term to the facility on [DATE] with diagnoses that included, but were not limited to, aftercare following joint replacement surgery, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), fracture of base of neck of right femur (break in the neck of the big bone of the right leg near where the ball goes into the hip socket), volume depletion (abnormally low extracellular fluid in the body due to decrease in salt and water or decrease in blood volume), hypo-osmolality (decrease in the levels of electrolytes, chemicals, and other fluids in the blood) and hyponatremia (sodium levels in the blood are extremely low can cause nausea, headache, fatigue, or confusion), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and heart failure (heart muscle fails to pump blood as it should). Resident #1 was discharged from the facility to a hospital on 05/04/24. Record review of Resident #1's MDS front sheet in the EHR revealed his Admission MDS was in progress. Record review of Resident #1's in progress Admission MDS revealed Section C had been completed and Resident #1 had a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #1's baseline care plan completed by DON on 05/03/24 revealed he was able to communicate easily with staff. Resident #1's goals were to remain safe and get stronger to return to the community. Resident #1 needed one-person physical assist across his ADL's except for eating where he only needed set up assistance. Resident #1 was cognitively alert and intact. Resident #1 was receiving psychotropic medication. His medication list was provided to him and reconciled by him. Record Review of Resident #1's Order Summary Report dated 05/08/24 revealed an order for Amitriptyline Tablet 100 MG each day at bedtime for depression. Record review of Resident #1's Progress Notes revealed the following: A note dated 05/05/24 at 04:02 PM written by DON which read, Md was going through dc (discontinued) medication list and caught that amitriptylline [sic] was put in at 100 mg qhs instead of 25 mg. The note was labelled LATE ENTRY. A note dated 05/01/24 at 01:03 PM written by LVN for Amitriptyline Tablet 100 MG by mouth at bedtime for depression Severity: Moderate. Record review of Resident #1's Medication Administration Record dated 05/08/24 revealed he received 100 mg of Amitriptyline at bedtime on 05/01/24, 05/02/24, and 05/03/24. Record review of Resident #1's hospital records from his stay 04/27/24 to 05/01/24 revealed he was taking Amitriptyline 25 mg per day at home prior to his admission to the hospital. During an interview on 05/08/24 at 01:21 PM MD stated after he discovered Resident #1 had been taking four times the prescribed dose of Amitriptyline during his stay in the facility he spoke to the admitting nurse, LVN. MD stated LVN said he (LVN) made a mistake when he was entering the order into the EHR. During an interview on 05/08/24 at 02:03 PM DON stated the charge nurse on duty was responsible for entering orders into the EHR when a resident was admitted . She stated the next shift charge nurse was supposed to review the orders to ensure they were correct. She stated she had noticed that was not happening so recently she had a meeting with her nurses and told them after the second shift reviews the orders, they need to give her a report so she can review them a second time and ensure they are correct. She stated the charge nurse admitting Resident #1 was LVN. She stated a possible negative outcome of receiving four times the prescribed amount of Amitriptyline was adverse side effects; increased sedation. During an interview on 05/08/24 at 03:30 PM RRN was asked for a policy addressing accuracy of medical records. During an interview on 05/08/24 at 03:40 PM RRN stated the facility did not have a policy that addressed accuracy of medical records. Attempts were made on 05/08/24 at 02:11 and 02:14 as well as 05/09/24 at 09:45 AM and 09:46 AM to reach LVN for interview. All attempts were unsuccessful. Record review of facility policy titled Admission Assessment and Follow Up: Role of the Nurse and dated September 2012 revealed the following: . 7. Conduct an admission assessment (history and physical), including: . d. Current medications and treatments. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Record review of facility policy titled Administering Medications and dated April 2019 revealed the following: . Medications are administered . as prescribed. 4. Medications are administered in accordance with prescriber orders, . Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following: . Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, interview and record review, the facility failed to ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, well-being of 1 of 12 sampled residents who had pressure sores (#2) in that: B)Resident #2 developed a stage 2 pressure sore to her right ear in which staff were not aware of, and which was preventable. c) The facility did not follow their Abuse Prohibition Policy related to Prevention due to staff (Administrator, DON and LVN #3) not providing or provided adequate supervision to ensure resident needs were not ignored and to provide effective ongoing assessment and monitoring of residents with special needs that lead to neglect related to pressure sores., and d) The facility did not follow their Abuse Prohibition Policy related to state-specific background screening related to initial and annual screening and facility screening of 6 of 17 employees (Staff A, B, C, D, E, F) (Nurse Aide Registry, Employee Misconduct Registry and reference checks). These problems resulted in the neglect of resident #2 and could further result in the neglect of other residents who were at risk for pressure sores. The practice of not providing occupational or restorative therapy to prevent further deterioration of a resident ' s condition could affect the 11 residents in the facility who have contractures. The failure to prevent deterioration of a condition causes the quality of life for the resident to diminish. The practice of not preventing pressure sores could affect the 48 residents in the facility who are either bedfast or in the chair most of the time. The failure to prevent pressure sores could cause worsening of the condition, including the development of infections. The findings include: ~ Pressure Sores (Resident #2): 1) Upon record review of the facility 2009 Pressure Ulcers policy, it was noted that the policy read " 2. Re-evaluate pressure ulcers at least weekly. If the patient condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. " 2) It was observed on 8/21/12 at 10:45 p.m. that resident #2 had a pressure sore to the right ear. 3) During an interview on 8/21/12 at 10:50 a.m., LVN #3 said that she was not aware of the pressure sore to resident #2 ' s right ear. She looked at the treatment sheets, and said that there were not treatment orders for the ear and that she would call Hospice and have them come assess the wound. 4) Upon record review of resident #2 ' s August Wound Treatment and Progress Record on 8/23/12, it was noted that there was still no treatment orders for resident #2 ' s right ear pressure sore. There were no physician orders found in the record for treatment of [REDACTED].#2 ' s right ear pressure sore. The last nurse ' s note found in resident #2 ' s record was for 7/12/12. 5) During interview on 8/24/24 at 12:15 p.m., the DON said that her nurse should have documented more in resident #2 ' s chart since 7/12/12. There had been 42 days without any documentation about resident#2 ' s care. 6) During an interview on 8/25/12 at 3:30, LVN #3 said " I didn ' t know about resident #2 ' s right ear wound because every time I see her, she is lying on her right side, so her ear was against the bed." LVN #3 said she did not turn the resident to look at the right side. I didn't know about the right ear on 8/21/12. I didn't document that there was an ear wound or that I called Hospice and talked to April. April told me that a nurse was supposed to come and look at it. I have not done a [MEDICATION NAME] dressing change to the ear; there were no orders for dressing changes, and no orders on the treatment record. I should have documented those things, 7) Upon record review of resident #2's August Weekly Skin Documentation Form, it was documented on 8/5/12. 8/12/12, and 8/19/12 that resident # 2 had a pressure area to her right ear. This was unknown by staff, and was left untreated. 8) During an interview on 8/22/12 at 11:25 a.m., the DON said that staff had tried to get resident #2 up, but she got uncomfortable. " Her husband is her responsible party, and we take direction from him. We have not tried putting her in the recliner. 9) During a confidential interview, family members A and B both stated that they wanted resident #2 to be out of bed more, and that she was comfortable sitting in the recliner at the bedside. 10) During an interview on 8/24/12 1t 12:05 p.m., the DON said that staff were not turning resident to her left side because of the fact that she had a pressure sore to her left side. This constant lying on the right side caused that rubbing of the right ear against the pillow, causing the pressure sore to the right ear. 11) It was observed throughout the survey between 8/20/12 and 8/26/12 that every time the surveyor went to see resident #2, she was lying on her right side with her ear rubbing on a pillow. Resident was seen once in the recliner, on 8/24/12 at 8:30 a.m. Resident #2 was positioned correctly, and was very comfortable. There was no grimacing on her face. Family members A and B were grateful, and said that resident #2 enjoyed being up in the recliner. Resident #2 was not seen in the recliner on 8/25/12 or 8/26/12. 12) Upon record review of resident #2 ' s Braden Scale, it was determined that she was rated as an "8," which puts her at a very high risk for skin breakdown. 13) During an interview on 8/24/12 at 11:30 a.m. the administrator brought up the fact that resident #2 ' s pressure sores were caused by low [MEDICATION NAME] levels. The last [MEDICATION NAME] level obtained for resident #2 was on 4/6/12. It was 3.0, with the normal range being 3.1-4.6. Resident #2 was just on the low side of being normal. 14) Upon record review of the facility 2009 Staging of Pressure Ulcers policy, it is noted that the policy reads, " A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ~ Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ... Procedures: ...Component III: Prevention ...5. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behavior, such as: ... C. Ignoring the patient ' s/residents needs ..., etc .... 6. Ongoing assessment, care planning, monitoring of those patients/residents with special needs that may lead to neglect, for example: ...E. Patient ' s/Resident ' s requiring excessive nursing care or staff attention ... " ~ Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ... Procedures: ...Component III: Prevention ...5. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behavior, such as: ... C. Ignoring the patient ' s/residents needs ..., etc .... 6. Ongoing assessment, care planning, monitoring of those patients/residents with special needs that may lead to neglect, for example: ...E. Patient ' s/Resident ' s requiring excessive nursing care or staff attention ... " ~ Abuse Prohibition Policy (Screening): 15) Review of the personnel files for 3 of 6 unlicensed employees employed more than one year (Staff B, C, and D) revealed that these employees had been employed in the facility more than one year and had not been screened through the Employee Misconduct Registry as required by the State Survey Agency (DADS). The date of hire for the employees were as follows: Staff B - 7-23-01 - no annual screening through the EMR present Staff C - 11-11-05 - no annual screening for EMR and NAR present Staff D - 2-22-11- no annual screening for EMR and NAR present None had been screened through the NAR and/or EMR on an annual basis. Review of the personnel files for 2 of 10 unlicensed employees (Staff A and E) employed less than one year revealed that these employees had been employed in the facility less than one year and had not been screened through the Employee Misconduct Registry and/or the NAR prior to hire as required by the State Survey Agency (DADS). Staff A had a date of hire of 7-17-12 and had not been screened through the EMR or NAR. Staff E had a date of hire 12-20-11 and had not been screened through the EMR prior to hire. Review of Staff F ' s personnel file revealed that no reference checks had been conducted for this employee. This staff member had a date of hire of 11-17-10.Interview with the ADON on 8-24-12 at 4:30 p.m. revealed that Staff F had been employed in the facility within the last " couple of weeks ... " Review of State regulation TAC 19.1921(l) revealed that all unlicensed employees must be screened through the NAR and EMR prior to hire. Review of State regulation TAC 19.1921(o) revealed that all unlicensed employees must be screened through the NAR and EMR on an annual basis. Interview with the Administrator on 8-29-12 at 10:50 a.m. revealed that the facility ' s employee screening procedures included obtaining 2 references from potential employees and contacting these references. Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... 5. The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ...Procedures: Component I: Screening...1. Pre-employment background screening is mandated for all employees of facility: A. Facility state-specific Background Investigation Policy is available through your HR representative. ... " Review of the Human Resources Policies and Procedures revised 1/2007 documented ... " Subject: Background Checks. HR Policy 3.2. Policy: We will verify and certify the accuracy of information provided by applicants, employees, and independent contractors in a resume or application ...A final offer of employment may not be made without completion of the background investigation ...Procedures: 1. Scope: Background investigations include an examination and verification of : A. References ... " Further review of Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... 5. The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ...Procedures: Component I: ... 2. The Facility Standard of Conduct...C. Section V, compliance With Laws and Regulations (2012) ...In General ... The Company and its Employees shall operate in accordance with all laws and regulations at all levels of government..." Review of the 3/2006 " Administrative Policies and Procedures: Leadership Framework. Subject: Administrator-Roles and Responsibilities. Policy: A full-time administrator appointed by the Governing Entity will be responsible for the facility's overall management. Procedures: responsibilities include but are not limited to: ... 1. Following the Facility Standards of Conduct. 2. Adopting and enforcing rules and regulations concerning patient/resident health care and safety... 9. Monitoring the overall management of the facility through a Performance Improvement program, consultant recommendations, and committee meetings... 17. Maintaining compliance by strict adherence to state and federal guidelines, and other regulatory bodies as indicated... "

Based on observation, interview and record review, the facility failed to effectively implement written policies and procedures that prohibit neglect of 1 of 13 sampled residents (#2) who had pressure sores , in that: a) Resident #2 developed a stage 2 pressure sore to her right ear in which staff were not aware of, and which was preventable. b) The facility did not follow their Abuse Prohibition Policy related to Prevention due to staff (Administrator, DON and LVN #3) not providing or provided adequate supervision to ensure resident needs were not ignored and to provide effective ongoing assessment and monitoring of residents with special needs that lead to neglect related to pressure sores., and c) The facility did not follow their Abuse Prohibition Policy related to state-specific background screening related to initial and annual screening and facility screening of 6 of 17 employees (Staff A, B, C, D, E, F) (Nurse Aide Registry, Employee Misconduct Registry and reference checks). These problems resulted in the neglect of 1 of 13 sampled residents (resident #2) and could further result in the neglect of other residents who were at risk for pressure sores. The practice of not preventing pressure sores had the potential to especially affect the 48 residents in the facility who are either bedfast or in the chair most of the time. The failure to prevent pressure sores could cause worsening of the condition, including the development of infections. The evidence is as follows: ~ Pressure Sores (Resident #2): 1) Upon record review of the facility 2009 Pressure Ulcers policy, it was noted that the policy read " 2. Re-evaluate pressure ulcers at least weekly. If the patient condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. " 2) It was observed on 8/21/12 at 10:45 p.m. that resident #2 had a pressure sore to the right ear. 3) During an interview on 8/21/12 at 10:50 a.m., LVN #3 said that she was not aware of the pressure sore to resident #2 ' s right ear. She looked at the treatment sheets, and said that there were not treatment orders for the ear and that she would call Hospice and have them come assess the wound. 4) Upon record review of resident #2 ' s August Wound Treatment and Progress Record on 8/23/12, it was noted that there was still no treatment orders for resident #2 ' s right ear pressure sore. There were no physician orders found in the record for treatment of [REDACTED].#2 ' s right ear pressure sore. The last nurse ' s note found in resident #2 ' s record was for 7/12/12. 5) During interview on 8/24/24 at 12:15 p.m., the DON said that her nurse should have documented more in resident #2 ' s chart since 7/12/12. There had been 42 days without any documentation about resident#2 ' s care. 6) During an interview on 8/25/12 at 3:30, LVN #3 said " I didn ' t know about resident #2 ' s right ear wound because every time I see her, she is lying on her right side, so her ear was against the bed." LVN #3 said she did not turn the resident to look at the right side. I didn't know about the right ear on 8/21/12. I didn't document that there was an ear wound or that I called Hospice and talked to April. April told me that a nurse was supposed to come and look at it. I have not done a [MEDICATION NAME] dressing change to the ear; there were no orders for dressing changes, and no orders on the treatment record. I should have documented those things, 7) Upon record review of resident #2's August Weekly Skin Documentation Form, it was documented on 8/5/12. 8/12/12, and 8/19/12 that resident # 2 had a pressure area to her right ear. This was unknown by staff, and was left untreated. 8) During an interview on 8/22/12 at 11:25 a.m., the DON said that staff had tried to get resident #2 up, but she got uncomfortable. " Her husband is her responsible party, and we take direction from him. We have not tried putting her in the recliner. 9) During a confidential interview, family members A and B both stated that they wanted resident #2 to be out of bed more, and that she was comfortable sitting in the recliner at the bedside. 10) During an interview on 8/24/12 1t 12:05 p.m., the DON said that staff were not turning resident to her left side because of the fact that she had a pressure sore to her left side. This constant lying on the right side caused that rubbing of the right ear against the pillow, causing the pressure sore to the right ear. 11) It was observed throughout the survey between 8/20/12 and 8/26/12 that every time the surveyor went to see resident #2, she was lying on her right side with her ear rubbing on a pillow. Resident was seen once in the recliner, on 8/24/12 at 8:30 a.m. Resident #2 was positioned correctly, and was very comfortable. There was no grimacing on her face. Family members A and B were grateful, and said that resident #2 enjoyed being up in the recliner. Resident #2 was not seen in the recliner on 8/25/12 or 8/26/12. 12) Upon record review of resident #2 ' s Braden Scale, it was determined that she was rated as an "8," which puts her at a very high risk for skin breakdown. 13) During an interview on 8/24/12 at 11:30 a.m. the administrator brought up the fact that resident #2 ' s pressure sores were caused by low [MEDICATION NAME] levels. The last [MEDICATION NAME] level obtained for resident #2 was on 4/6/12. It was 3.0, with the normal range being 3.1-4.6. Resident #2 was just on the low side of being normal. 14) Upon record review of the facility 2009 Staging of Pressure Ulcers policy, it is noted that the policy reads, " A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ~ Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ... Procedures: ...Component III: Prevention ...5. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behavior, such as: ... C. Ignoring the patient ' s/resident ' s needs ..., etc .... 6. Ongoing assessment, care planning, monitoring of those patients/residents with special needs that may lead to neglect, for example: ...E. Patient ' s/Resident ' s requiring excessive nursing care or staff attention ... " ~ Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ... Procedures: ...Component III: Prevention ...5. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behavior, such as: ... C. Ignoring the patient ' s/resident ' s needs ..., etc .... 6. Ongoing assessment, care planning, monitoring of those patients/residents with special needs that may lead to neglect, for example: ...E. Patient ' s/Resident ' s requiring excessive nursing care or staff attention ... " ~ Abuse Prohibition Policy (Screening): 15) Review of the personnel files for 3 of 6 unlicensed employees employed more than one year (Staff B, C, and D) revealed that these employees had been employed in the facility more than one year and had not been screened through the Employee Misconduct Registry as required by the State Survey Agency (DADS). The date of hire for the employees were as follows: Staff B - 7-23-01 - no annual screening through the EMR present Staff C - 11-11-05 - no annual screening for EMR and NAR present Staff D - 2-22-11- no annual screening for EMR and NAR present None had been screened through the NAR and/or EMR on an annual basis. Review of the personnel files for 2 of 10 unlicensed employees (Staff A and E) employed less than one year revealed that these employees had been employed in the facility less than one year and had not been screened through the Employee Misconduct Registry and/or the NAR prior to hire as required by the State Survey Agency (DADS). Staff A had a date of hire of 7-17-12 and had not been screened through the EMR or NAR. Staff E had a date of hire 12-20-11 and had not been screened through the EMR prior to hire. Review of Staff F ' s personnel file revealed that no reference checks had been conducted for this employee. This staff member had a date of hire of 11-17-10.Interview with the ADON on 8-24-12 at 4:30 p.m. revealed that Staff F had been employed in the facility within the last " couple of weeks ... " Review of State regulation TAC 19.1921(l) revealed that all unlicensed employees must be screened through the NAR and EMR prior to hire. Review of State regulation TAC 19.1921(o) revealed that all unlicensed employees must be screened through the NAR and EMR on an annual basis. Interview with the Administrator on 8-29-12 at 10:50 a.m. revealed that the facility ' s employee screening procedures included obtaining 2 references from potential employees and contacting these references. Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... 5. The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ...Procedures: Component I: Screening...1. Pre-employment background screening is mandated for all employees of facility: A. Facility state-specific Background Investigation Policy is available through your HR representative. ... " Review of the Human Resources Policies and Procedures revised 1/2007 documented ... " Subject: Background Checks. HR Policy 3.2. Policy: We will verify and certify the accuracy of information provided by applicants, employees, and independent contractors in a resume or application ...A final offer of employment may not be made without completion of the background investigation ...Procedures: 1. Scope: Background investigations include an examination and verification of : A. References ... " Further review of Review of the facility's Abuse Prohibition Policy dated 10/2010 documented "Subject: Abuse, Neglect and Misappropriation of Property...Policy: ... 5. The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit ...neglect ... of a patient/resident ...Procedures: Component I: ... 2. The Facility Standard of Conduct...C. Section V, compliance With Laws and Regulations (2012) ...In General ... The Company and its Employees shall operate in accordance with all laws and regulations at all levels of government..."

Based on record review, interview, and observation, it was determined that the facility failed to ensure that staff provided care that was not neglectful. Resident #2 developed a stage 2 pressure sore to her right ear in which staff was not aware of, and which was preventable due to resident not being turned off of right side. The practice of not preventing pressure sores to the residents could potentially affect 1 of the 3 sampled residents who have pressure sore. This in turn could affect the 5 residents in the facility with wounds. The practice of not preventing pressure sores could potentially affect the 48 residents in the facility who are either bedfast or in the chair most of the time. The failure to prevent pressure sores could cause worsening of the condition, including the development of infections. The evidence is as follows: 1) Upon record review of the facility 2009 Pressure Ulcers policy, it was noted that the policy read " 2. Re-evaluate pressure ulcers at least weekly. If the patient condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. " 2) It was observed on 8/21/12 at 10:45 p.m. that resident #2 had a pressure sore to the right ear. 3) During an interview on 8/21/12 at 10:50 a.m., LVN #3 said that she was not aware of the pressure sore to resident #2 ' s right ear. She looked at the treatment sheets, and said that there were not treatment orders for the ear and that she would call Hospice and have them come assess the wound. 4) Upon record review of resident #2 ' s August Wound Treatment and Progress Record on 8/23/12, it was noted that there was still no treatment orders for resident #2 ' s right ear pressure sore. There were no physician orders found in the record for treatment of [REDACTED].#2 ' s right ear pressure sore. The last nurse ' s note found in resident #2 ' s record was for 7/12/12. 5) During interview on 8/24/24 at 12:15 p.m., the DON said that her nurse should have documented more in resident #2 ' s chart since 7/12/12. There had been 42 days without any documentation about resident#2 ' s care. 6) During an interview on 8/25/12 at 3:30, LVN #3 said " I didn ' t know about resident #2 ' s right ear wound because every time I see her, she is lying on her right side, so her ear was against the bed." LVN #3 said she did not turn the resident to look at the right side. I didn't know about the right ear on 8/21/12. I didn't document that there was an ear wound or that I called Hospice and talked to April. April told me that a nurse was supposed to come and look at it. I have not done a [MEDICATION NAME] dressing change to the ear; there were no orders for dressing changes, and no orders on the treatment record. I should have documented those things, 7) Upon record review of resident #2's August Weekly Skin Documentation Form, it was documented on 8/5/12. 8/12/12, and 8/19/12 that resident # 2 had a pressure area to her right ear. This was unknown by staff, and was left untreated. 8) During an interview on 8/22/12 at 11:25 a.m., the DON said that staff had tried to get resident #2 up, but she got uncomfortable. " Her husband is her responsible party, and we take direction from him. We have not tried putting her in the recliner. 9) During a confidential interview, family members A and B both stated that they wanted resident #2 to be out of bed more, and that she was comfortable sitting in the recliner at the bedside. 10) During an interview on 8/24/12 1t 12:05 p.m., the DON said that staff were not turning resident to her left side because of the fact that she had a pressure sore to her left side. This constant lying on the right side caused that rubbing of the right ear against the pillow, causing the pressure sore to the right ear. 11) It was observed throughout the survey between 8/20/12 and 8/26/12 that every time the surveyor went to see resident #2, she was lying on her right side with her ear rubbing on a pillow. Resident was seen once in the recliner, on 8/24/12 at 8:30 a.m. Resident #2 was positioned correctly, and was very comfortable. There was no grimacing on her face. Family members A and B were grateful, and said that resident #2 enjoyed being up in the recliner. Resident #2 was not seen in the recliner on 8/25/12 or 8/26/12. 12) Upon record review of resident #2 ' s Braden Scale, it was determined that she was rated as an "8," which puts her at a very high risk for skin breakdown. 13) During an interview on 8/24/12 at 11:30 a.m. the administrator brought up the fact that resident #2 ' s pressure sores were caused by low [MEDICATION NAME] levels. The last [MEDICATION NAME] level obtained for resident #2 was on 4/6/12. It was 3.0, with the normal range being 3.1-4.6. Resident #2 was just on the low side of being normal. 14) Upon record review of the facility 2009 Staging of Pressure Ulcers policy, it is noted that the policy reads "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. 15) During a confidential interview, family member B said that staff was not getting resident #2 up out of bed. Family member A was told that staff did not get Resident #2 up out of bed because she was too hard to get up out of bed, and that Hospice was supposed to take care of her. Family member A said, " They almost never get her up. " 16) During an interview on 8/22/12 at 11:25 a.m., the DON said that the CNAs comments about resident #2 being too difficult to get up and hospice does resident #2 ' s care were " wrong answers, and staff will be re-educated. " 17) During an interview on 8/22/12 at 11:25 a.m., the DON said, "We have attempted to get resident out of bed. She's uncomfortable. Her husband is her responsible party, and we take direction from him. When asked if staff had attempted to place resident into the recliner, the DON said, "No." 18) When asked on 8/22/12 at 11:30 a.m. why resident was not being turned, the DON said, " We keep her off of her left side because she has a wound to her left buttock. " The DON verified that staff was not placing pillows behind resident #2 and turning her on her left side. 19) During an interview on 8/22/12 at 11:35 a.m., the DON said, "We have used a Hoyer lift with her before, but her husband doesn ' t like it, so we don ' t use it. " 20) When asked on 8/24/12 at 12:15 p.m. why staff had not used the Hoyer lift with resident #2, the DON said, "I don ' t have a satisfactory answer for that question." 21) During a confidential interview, Family member A said that the facility had never approached family about the use of a Hoyer lift. "They used a Hoyer at the other place, and it worked well. Family member A also said, "I have asked them to get resident #2 up more, but they won ' t do it." Family members A and B said that they wanted the resident to be transferred to the recliner.