Every finding on record at Prairie Village Healthcare CTR

Based on observation and interview, the Facility failed to ensure residents were treated with dignity and respect for 2 of 3 residents (R6, R7) reviewed for resident rights in the sample of 9. Findings include:On 8/11/26 at 8:48 AM, V6, Housekeeper, was pushing a housekeeping cart down the hallway and had no visible identification badge. V6 stated he forgot his identification today. On 8/11/26 at 8:50 AM, V3, Licensed Practical Nurse (LPN), was sitting at the nurse's station with no visible name badge. V3 stated she is a new employee, so she does not have a name badge yet. On 8/11/26 at 8:53 AM, V7, Certified Nursing Assistant (CNA), was assisting a resident with no visible identification badge. V7 stated she left her badge in her car. R6's Minimum Data Set (MDS) dated [DATE] documented R6 was moderately cognitively impaired. On 8/11/26 at 1:15 PM, R6 stated some staff wear identification badges and some do not. R7's MDS dated [DATE] documented R6 was moderately cognitively impaired. On 8/11/26 at 1:18 PM, R7 stated some of the employees wear identification badges, but not all of them do. On 8/11/26 at 1:48 PM, V1, Administrator, stated there has been a long turnaround getting identification badges made, so they are looking for a temporary solution until the official ones can be made. The Facility's Identification Badges Policy revised 12/2006 documents, All employees must wear name identification badges. All personnel are required to wear identification tags/badges during their work shifts. Employees will be responsible for maintaining their identification badges and wearing them to work.

Based on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 52 residents living in the facility. Findings include: On 5/12/2026 at 2;54 PM, during the tour in the kitchen the ice machine in the kitchen had no air gap present. The white drainage hose from the ice machine went directly into a pump with no air gap present. This allows for potential backflow into the ice machine from the sewage drain. There is no air gap between the hose and the drain.On 5/12/2026 at 2:55 PM, V13, Dietary Manager stated she was not sure why there was no air gap. V13 stated she uses the ice machine for all of the residents in the facility.On 5/12/2026 at 2:59 PM, in the walk-in fridge, there were three, 2 quart metal containers each containing BBQ (barbeque) ribs, chicken patties, and a large tray of deli sandwiches that were being stored on a rack above the raw potatoes, raw tomatoes, and raw onions. On 5/14/2026 at 10:36 AM, V9, Plumber stated, I was at the facility this morning. Whoever installed the ice machine should have had an air gap. The state plumbing code requires an air gap. All ice machines should have an air gap to prevent backflow and possible contamination. On 5/14/2026 at 11:01 AM, V13, Dietician stated, I would expect all meat, including BBQ Ribs, chicken patties, and deli sandwiches to always be stored on the bottom shelf, as no meat should be stored above any raw food. No meat should ever be stored above raw products.The Facility Food Policy undated documents, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid form dated 5/12/2026 documents the facility has 54 residents living in the Facility.

Based on observation, interview and record review the facility failed to respect resident rights for 4 (R3, R7, R34, R61) of 4 residents reviewed for resident rights in a sample of 33. Findings include: 1. R3's Quarterly Minimum Data Set (MDS), dated [DATE] documents R3 is cognitively intact and has an indwelling catheter. On 5/12/2026 at 1:50 PM R3 was sitting up in his wheelchair in his room. R3's door had gowns and gloves and documented on the wall noted EBP (enhanced barrier precautions.) R3 stated staff come in and garb up with gown and gloves just to come in his room and talk to him and he thinks it's ridiculous. R3 stated he goes out of his room all day long and no one wears gowns and gloves with him, and it makes him feel like he is gross. R3 stated he understands he has an indwelling catheter and staff have to wear a gown and gloves to empty it but it's over the top to wear all this just to walk in his room and talk to him. On 5/14/2026 at 1:40 PM V19, Infection Control Nurse (ICP) stated when a resident has a device like a catheter or is on dialysis and has a dialysis or catheter then she automatically has them on EBP which is extra infection control precautions. V19 stated she expects all staff, including surveyors who do not provide hands-on care, to wear a gown and gloves when entering a resident's room that is on EBP. On 5/15/2026 at 11:11 AM V2, Director of Nurses (DON) stated when a resident is on EBP she expects staff to garb up with gown and gloves when they go into a room to provide hands on care, if staff aren't going to provide hands on care then they aren't required to wear gown and gloves. 2. R34's MDS dated [DATE] dated he is moderately impaired for cognition. On 5/15/2026 at 10:00 AM, R34 had PPE (Personal Protective Equipment) outside of his room and a sign on his door that documents he is on Enhanced Barrier Protection Precautions. On 5/15/2026 at 10:03 AM, R34 stated, I assume everyone that enters my room has to wear a gown and mask, but it seems like an overkill to me. I go out to the dining room, so I do not know why people who just want to talk to me must wear all that stuff. It makes me feel like I am an alien. 3. R7's POS for May 2026 documents a diagnosis of Primary generalized (osteo)arthritis; Chronic obstructive pulmonary disease, unspecified; Type 2 diabetes mellitus without complications; Gastrostomy status; End stage renal disease; Dependence on renal dialysis; Morbid (severe) obesity due to excess calories. R7s MDS dated [DATE] documents R7 was moderately impaired for cognition for activities of daily living. R7 is dependent on staff for most ADL's. He uses a manual wheelchair. He has impairment on one side on both her upper and lower extremities. On 5/15/2026 at 10:14 AM, R7 has PPE outside of his room and a sign on his door documenting Enhanced Barrier. On 5/15/2026 at 10:24 AM, R7 stated, I am on dialysis and I have a port. I do not want the port to get infected. I do go out to the dining room, and nobody has to wear gowns and mask when they are around me. I am not sure why they have to wear them when they come in my room, but I trust the facility and if that is required then that is required. I would rather have somebody just be able to walk in to talk to me because I like to talk but I don't want to get an infection either. 4. R61's Undated Face Sheet documents R61 was admitted to the facility on [DATE] and has a medical diagnosis of Non-pressure chronic ulcer of abdomen, Cellulitis of abdominal wall, and Hypertension. R61's Physician Order dated 5/13/2026 at 3:13 PM documents Enhanced Barrier Precautions. R61's Progress Note dated 5/13/2026 documents R61 is alert and oriented ( A & O). On 5/15/2026 at 10:45 AM Personal Protective Equipment (PPE) including gloves, gowns, and masks were observed hanging on the outside of R61's door. A sign on R61's door states Enhanced Barrier Precautions. On 5/15/2026 at 10:50 AM R61 stated every staff member who enters her room puts on gloves and a blue gown. R61 stated it is silly for staff to put on gloves and a gown to just come in and talk to her or answer her questions. R61 stated she understands if staff are going to provide care to her that they would wear the gown and gloves due to her having a wound, but not to talk to her. The Facility's Enhanced Barrier Precautions sign documents Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The Facility's Isolation-Categories for Transmission-based Precautions policy dated 1/20/2025 documents The facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections.

Based on observation, interview and record review, the facility failed to treat residents with dignity for 1 (R3) of 1 resident reviewed for dignity in the sample of 33. Findings include: R3's Quarterly Minimum Data Set (MDS), dated [DATE] documents he is cognitively intact and has an indwelling catheter. On 5/12/2026 at 1:50 PM R3 stated he was upset because he asked a CNA (Certified Nurse Aide) to empty his catheter last night (5/11/2026) and she laughed at him. A catheter was observed under R3's wheelchair in a black bag. On 5/12/2026 at 2:00 PM V2, Director of Nurses (DON) stated R3 just reported a grievance against a CNA that worked last night and he reported that he requested the CNA to empty his catheter and she laughed at him. On 5/14/2026 at 1:48 PM V17, CNA stated she worked night shift on 5/11/2026 from 7:00 PM to 7:00 AM on 5/12/2026 and she observed R3's call light was on. V17 stated she went to his room and R3 requested his catheter be emptied and as she walked out of his room she laughed because she and other staff stated they knew he wanted his catheter emptied again. A Resident Grievance/Complaint Form, dated 5/14/2026 documents R3 reported to V2, Director of Nurses (DON) that on 5/12/2026 R3 asked for his catheter bag to be emptied. R3 stated the CNA laughed at him. Staff documented V17, CNA was laughing but not at the resident (R3) unrelated. The Facility's Quality of Life - Dignity reviewed [DATE] documents resident shall be treated with dignity at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited.

Based on interview and record review the facility failed to review and revise the care plan for resident's needs for transfer assistance for 1 of 8 (R49) residents investigated for accidents in a sample in 33.Findings include:R49's EMR (Electronic Medical Record) dated 12/11/2025 documents a diagnosis of Nontraumatic subarachnoid hemorrhage, unspecified.R49's EMR dated 02/01/2026 documents a diagnosis of Cognitive communication deficit.R49's MDS (Minimum Data Set) dated 1/29/26 documents a BIMS (Brief Interview for Mental Status) score of 7 out of 15. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed to chair transfer, and toilet transfer.No care plan noted for transfers on this resident.R49's Nursing Note dated 2/4/26 at 10:08 AM documents that the Resident transfers with x2 staff members.On 5/15/26 at 9:34 AM, (V20), Director of Rehab stated (R49) was an assist of 2 staff. She stated that therapy does not use mechanical lifts. She stated that the therapy department encourages the floor staff to use the (mechanical lift) but if the resident is having a bad day then they should use the (mechanical) lift. She stated that therapy does not use mechanical lifts, so she does not know if it requires 1 or 2 staff.On 5/15/26 at 9:58 AM, (V20) stated that the treatment encounter note for that time period states that the resident with total x 2 for initial trial. Noted with all others with mod x 2. Addressed education with caregivers with observation and questions regarding current transfer status of currently resident noted with increased needed encouragement with active participation as well as assistance fluctuation at this time. She stated that it means if the resident is not feeling well or having weakness then staff should use a mechanical lift.On 5/15/26 at 12:00 PM, a Restorative Nurse stated that R49 should have a care plan for transfers. She stated that she would add that to her care plan.Facility's Safe Lifting and Movement of Residents policy dated 1/2026 documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.

Based on interview and record review the facility failed to properly transfer a resident using a mechanical lift with one staff member for 1 of 8 (R49) residents investigated for accidents in a sample of 33. Findings include:R49's EMR (Electronic Medical Record) dated [DATE] documents a diagnosis of Nontraumatic subarachnoid hemorrhage, unspecified.R49's EMR dated [DATE] documents a diagnosis of Cognitive communication deficit.R49's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 7 out of 15. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed to chair transfer, and toilet transfer.No care plan noted for transfers on this resident.R49's Nursing Note dated [DATE] at 10:08 AM documents that the Resident transfers with x2 staff members.On [DATE] at 1:25 PM, V14, CNA (Certified Nursing Assistant) Supervisor stated that when the incident happened in February, (R49) was using a sit to stand for transfers. She stated that (V15), CNA was using the sit to stand by herself to transfer (R49). She stated that the battery died on the (mechanical lift) when (R49) was in the sling. She stated that (V21), CNA who no longer works at the facility and (V16) who no longer works at the facility, went into (R49's) room to help (V21). She stated that the resident was not harmed, and the resident was not crying.On [DATE] at 1:47 PM, (V15), CNA stated that she went to transfer (R49) with the sit to stand machine with the nurse (V16). She stated that (V16) left the room. She stated that she got (R49) into the sling and raised up in the (mechanical lift) by herself. She stated that at that time, staff were using a (mechanical lift) to transfer (R49). She stated that they are supposed to use the (mechanical lift) with 2 staff. She stated that the after getting (R49) raised up in the machine that the battery died. She stated that she yelled into the hall for help and (V16) came into the room to help her. She stated that the resident was not injured but that the resident was anxious. On [DATE] at 9:34 AM, (V20), Director of Rehab stated (R49) was an assist of 2 staff. She stated that therapy does not use mechanical lifts. She stated that the therapy department encourages the floor staff to use the (mechanical lift) but if the resident is having a bad day then they should use the (mechanical) lift. She stated that therapy does not use mechanical lifts, so she does not know if it requires 1 or 2 staff. On [DATE] at 9:58 AM, (V20) stated that the treatment encounter note for that time period states that the resident with total x 2 for initial trial. Noted with all others with mod x 2. Addressed education with caregivers with observation and questions regarding current transfer status of currently resident noted with increased needed encouragement with active participation as well as assistance fluctuation at this time. She stated that it means if the resident is not feeling well or having weakness then staff should use a mechanical lift. On [DATE] at 10:19 AM, (V22), R49's husband stated that he was in the room when the incident happened. He stated that the CNA was using the mechanical lift device by herself. He stated that his wife was tangled in the sling, and the machine would not come down. He stated that his wife was screaming and cryingXXX[DATE] at 11:42 AM, V2, DON (Director of Nursing) stated that she expects staff to use 2 staff while using a sit to stand.Facility's Safe Lifting and Movement of Residents policy dated 1/2026 documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview and record review, the facility failed to follow physician's orders regarding tube feeding for 1 (R2) of 2 residents reviewed for tube feeding the sample of 33.Findings include: R2's Undated Face Sheet, documents R2 was initially admitted on [DATE] and diagnosis included dysphagia (difficulty swallowing.) R2's Physician's Order Sheet (POS) dated 3/12/2026 elevate the head of the bed 30 to 45 degrees during feeding unless contraindicated. A physician's ordered dated 4/29/2026 NPO (nothing by mouth) enteral feeding: continuous: Jevity 1.2 @ 55 mL (militers)/hr (hour) x 24 hr. Flushed w/ (with) 125 mL H20 (water) q (every) 6 hr continuous may use automatic pump.On 5/12/2026 at 11:05 AM R2 was laying flat in bed with tube feed on with water flush on a pump 55 ml/hr with 125 ml water flush every 6 hours on and working properly resident was sleeping. The Facility's Gastric Tube Feeding Policy, dated revised 5/2017 documents the head of bed (HOB) will be maintained at 30-45 degrees while tube feeding is running via pump.

A. Based on interview and record review the facility failed to obtain a urine sample timely and properly insert a catheter for 1 of 5 residents (R13) reviewed for urinary tract infections in the sample of 27. This failure resulted in the untimely collection of a urine specimen, with collection not occurring until 4 days after the order was received. During this time R13 suffered increasing symptoms with ultimately a malposition foley catheter being inserted into R13's urethra with a partially inflated balloon, despite the order given being for a straight catheter. R13 developed urosepsis and septic shock with hospital stay from [DATE]-[DATE] with ICU care for 7 days and ultimately death on [DATE] caused by sepsis and UTI.The immediate jeopardy began on [DATE] when R13 was transferred to local hospital due to change in condition in which the facility had not obtained a urine sample. R13's labs at the local hospital indicated R13 had a UTI. The facility inserted a foley catheter improperly causing obstruction, resulting in R13 being transferred to another hospital to ICU for septic shock. The Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. B. Based on interview and record review the facility failed to follow infection control guidelines while cleansing a catheter, failed to provide an ordered cream when cleansing a catheter, failed to provide a securing device for a catheter, failed to provide catheter care in a comfortable manner, and failed to complete incontinence care for five residents (R14, R21, R12, R9 and R18.) Findings include: 1.R13's undated face sheet documents R13 was admitted to the facility on [DATE] with metabolic encephalopathy, dementia and no history of Urinary Tract Infections (UTI's). R13's Minimum Data Set (MDS) dated [DATE] does not document an interview of mental status. R13's MDS does document that R13 is dependent on staff for toileting hygiene. R13's MDS documents R13 is always continent of urine. R13's care plan dated [DATE] documents bladder incontinence related to weakness, encephalopathy, dementia, history of prostate cancer s/p prostatectomy. R13's care plan documents the following interventions: 6/6 report any sign of skin breakdown (sore, tenderness or red broken areas) 6/6 report signs of UTI (acute confusion, urgency, frequently bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain R13's progress notes dated [DATE] R13 was noted with agitation and aggression and order for urine C/S obtained. Facility staff did not obtain a urine sample from [DATE]-[DATE]. R13's hospital ED report date [DATE] documents history decreased loc, and urine output x 2 days. Nausea and vomiting today. Order Hx. Hematuria history of Surgery: prostatectomy prostate cancer. Report documents the urinary bladder is decompressed. Foley catheter is identified. Non-dependent gas in the urinary bladder, likely related to catheterization. R13's ED labs dated [DATE] at 10:15 documents urine cloudy, mucous present, trace of bacteria, Red Blood cells 11-25. R13's hospital report dated [DATE], generated [DATE], documents encounter [DATE] documents R13 seen and examined at bedside. Transferred out of ICU today after resolution of septic shock. Currently awake and confused but calm. No acute distress. Foley draining clear amber urine. The report documents Assessment/Plan Septic shock secondary to foley-associated UTI with proteus bacteremia (resolved); required ICU admission and vasopressor support, now off Levophed;hemodynamically stable, blood cultures growing proteus, afebrile, improving leukocytosis, continue with IV ceftriaxone monitor WBC, vitals, fever curve, urology following, transition of oral antibiotics when appropriate 2) Urosepsis/complicated Uti: in setting of mispositioned foley catheter, associated hematuria and obstruction Plan: maintain foley care, ensure proper positioning, strict I/o's 4) Mild hydronephrosis/possible polynephritis; seen on AT a/p, likely secondary to obstruction/infection plan: continue antibiotics, monitor renal function, urology follow up 5) traumatic hematuria secondary to foley malposition (improved); balloon partially inflated in urethra on admission, hematuria resolving Plan continue foley monitoring, irrigation prn, notify urology if recurrence 10) History of prostate cancer s/p prostatectomy 7/2024 with possible metastatic lymphadenopathy; cat showing retroperitoneal lymph nodes On [DATE] V1, Administrator inserted a foley catheter to obtain a urine sample. R13's order was for a straight catheterization instead of a foley catheter and V1 left the foley to urinary drainage bag due to inability to obtain specimen. R13 was transferred to the local hospital due to change in condition of not opening eyes, not eating/drinking and blood-tinged urine. R13's hospital record documented R13 was found to have the foley catheter inserted incorrectly and obstructed in the urethra with balloon partially inflated causing hematuria obstruction/infection. R13's record documents R13 was in the ICU for 7 days and received IV antibiotics for Septic Shock secondary to foley associated UTI, Urosepsis in setting of mispositioned foley catheter, likely secondary to obstruction/infection. R13 remained in the hospital until [DATE] when R13 ultimately expired. R13's death certificate dated [DATE] document cause of death: sepsis, UTI V35, physician stated R13 has no history of UTIs and that he agrees with the death certificate and that Urosepsis could cause death. R13's progress notes dated [DATE] at 7:23AM documents Urine collected per sterile technique for UA C & S at 0650 and transported to JMH Lab at this time. On [DATE] at 1:39PM V35, physician per telephone interview stated he could agree with Urosepsis as cause of death. V35 stated R13 does have a standing order in place for straight catheterization a resident for urine specimen. V35 stated when catheterizing a resident for a specimen you should get enough urine for a specimen if the catheter is in the bladder. V35 stated R13 did not have frequent UTIS On [DATE] at 9:27 am V1, Administrator stated a catheter was inserted to obtain a urine specimen on R13. V1 stated R13 had a change in condition and was sent out to the hospital with foley before results came back. V1 stated R13 's wife called the next day and said R13's foley was not inserted correctly. V1 stated it was inserted correctly as she inserted the foley. V1 stated the wife had been notified of foley being inserted. V1 stated R13 was sent to the hospital and did not return. V1 stated R13 died a few weeks later. On [DATE] 5:00PM V41, Medical Director of the [NAME] hospital stated R13 had decreased urinary output and the cat scan showed left hydronephrosis which shows R13 has a structural problem which indicated R13 more susceptible to UTI. V41 stated delay in treatment could be why R13 had to be sent to Emergency Department. V41 stated R13 had leukocytosis at outlying hospital and blood cultures showed proteus in R13's blood. V41 stated R13 was sent to the [NAME] hospital admitted to ICU due to septic shock. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Starting on [DATE], All nurses including nurses on leave or on vacation were in-serviced on the following: Insertion of foley catheter and care on male and female residents; conducted by RN Regional Nurse Consultant with completion date of [DATE]. Assessment of residents who have a catheter for signs and symptoms of urinary tract infection. Inservice Completion date of [DATE]. Nurses will complete post tests to gauge understanding of in-services. Post tests completed per [NAME] RN/DON with completion date of [DATE]. Starting on [DATE], all CNA staff, including CNAs on leave or on vacation, were in-serviced on signs and symptoms of urinary tract infection and notify nurses if noted. Inservice conducted by RN/DON with completion date of [DATE]. CNAs will complete post tests to gauge understanding of in-service. Psot test completed by [NAME] with completion date [DATE]. Starting on [DATE], All residents with an indwelling catheter device were assessed for a urinary tract infection. Any resident with signs and symptoms of urinary tract infection will be monitored, and provider will be notified. Completed by LPN with completion date [DATE] All care plans for residents with Catheters have been reviewed and updated with completion date of [DATE]. A QA study will be performed randomly twice weekly for three months to staff knowledge on catheter insertion and care by the Director of Nursing/Designee beginning [DATE]. A QA study will be performed randomly twice weekly for three months to ensure residents with catheters are assessed for urinary tract infections by Director of Nursing/Designee [DATE]. QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 2. On [DATE] at 10:14AM during catheter care V25 CNA entered room with enhanced barrier sign posted outside door did not put on a gown or sanitize hands prior to entering room. With R14 on his back V25, CNA with basin water and complete bath and body wash V25 applied soap on wet cloth from basin. V25 cleansed left and right side of groin with soaped cloth, cleansed penis and catheter tubing. At no time during catheter care did V25 rinse or dry R14. R14' s care plan dated [DATE] documents R14 has an indwelling foley catheter. R14's care plan documents intervention dated [DATE]; provide catheter care every shift as needed. R14's undated face sheet documents a diagnosis in part of obstructive and reflux uropathy. 3. R21's Face Sheet, dated [DATE], documents R21 was originally admitted to the facility on [DATE] with diagnosis of Chronic Kidney Disease-stage 3, Acute Kidney Failure, Cystitis, Tubulo-Interstitial Nephritis, Anemia, Hypothyroidism, Type 2 Diabetes Mellitus, and Ogilvie syndrome. R21's Care Plan, dated [DATE], documents R21 requires a suprapubic catheter related to urinary retention. Interventions: Enhanced barrier precautions (EBP), keep catheter system a closed system as much as possible, document urinary output every shift, record the amount, type, color, odor, observe for leakage. R21's Minimum Data Set (MDS), dated [DATE], documents R21 is cognitively intact and is dependent on staff for toileting. R21 has urinary catheter in place and is frequently incontinent of bowel. On [DATE] at 11:22 AM, V9, Certified Nursing Assistant (CNA), entered R21's room to provide peri-care and catheter care on R21. There was an EBP sign with Personal Protectant Equipment (PPE) hanging on door and V9 failed to put on PPE prior to providing resident care. V9 donned gloves, obtained a wet washcloth from a water basin, wiped around R21's suprapubic catheter site, then used the same soiled gloves to obtain another wet washcloth and cleaned R21's right and left groins. V9 obtained another wet washcloth from the water still using the same soiled gloves and wiped R21's penis and scrotum. V9 obtained another wet washcloth and rinsed all areas, then obtained a dry towel and dried all areas cleaned. V9 then covered up R21 all while using the same soiled gloves. V9 failed to put ordered cream on V21 after peri-care and failed to put a secure device in place for catheter with catheter hanging freely from opening site. R21's Physician Order (PO), dated [DATE], documents Catheter: Supra Pubic Catheter continuously for retention. R21's PO, dated [DATE], documents Enhanced Barrier Precautions. R21's PO, dated [DATE], documents Catheter: Change securement device weekly Once a Day on Sun; 2nd Shift. R21's PO, dated [DATE], documents Catheter: Clean Supra Pubic catheter site every shift. Every Shift: 1st Shift, 2nd Shift. R21's PO, dated [DATE], documents Catheter: Clean Supra Pubic catheter site PRN. As Needed. R21's PO, dated [DATE], documents May keep moisture barrier cream at bedside. R21's PO, dated [DATE], documents Site: Peri area/Buttock May apply moisture barrier with each incontinent episode. Special Instructions: May keep barrier cream at bedside for CNA to apply. R21's PO, dated [DATE], documents Site: Suprapubic Catheter- cleanse with soap and water, pat dry, apply nystatin powder and drain sponge. Secure with paper tape. R21's Hospital Record, dated [DATE], documents in part Patient presented to the ER (Emergency Room) with decreased urination. The patient has a chronic suprapubic catheter. He reports that he has been weak but denied any nausea, vomiting, fever chills. He denies any chest pain, shortness of breath or difficulty breathing. In the ER, Hemoglobin 7.4, WBC (white blood cell) 3.79, Potassium 5.6, BUN (Blood Urea Nitrogen) 44, Creatinine 2.88, UA (urinalysis) consistent with UTI (urinary tract infection). bladder wall is mildly thickened. There is a suprapubic catheter again demonstrated with some inflammatory changes present along the course of the suprapubic catheter. The patient was treated with IV (intravenous) antibiotics for his urinary tract infection. R21's Nursing Note, dated [DATE] at 10:06 PM, documents in part Supra pubic catheter draining clear dark yellow urine w/o difficulty. Continues on an antibiotic for UTI. No adverse effects noted. Extensive staff assistance provided for transfers, mobility, eating, and toileting. 4. R12's Face Sheet, dated [DATE], documents R12 was originally admitted to the facility on [DATE]. R12's Care Plan, dated [DATE], documents R12 has Urinary Incontinence related to impaired mobility, pain, diabetes mellitus (DM). Interventions: Apply moisture barrier to skin, ensure adequate bowel elimination, keep call light in reach, provide assistance for toileting, provide incontinence care after each incontinent episode. R12's MDS, dated [DATE], documents R12 has moderate cognitive impairment and is dependent on staff for toileting, bathing, dressing, substantial/moderate assistance for transfers. R12 is frequently incontinent of both bowel and bladder. R12's PO, dated [DATE], documents Enhanced Barrier Precautions - Isolation. R12's PO, dated [DATE], documents Site: Peri area/Buttock May apply moisture barrier with each incontinent episode. May keep barrier cream at bedside for CNA (Certified Nursing Assistant) to apply. On [DATE] at 10:19 AM, R12 was assisted to the toilet by V26, CNA, and V28, CNA. R12 was assisted to stand and pivoted to the toilet and lowered. R12 stated she was done so V26 used a handful of wipes and reached between R12's legs and wiped once from front to back. V26 got another handful of wipes and again reached between R12's legs and wiped once again from front to back. R12 asked them to be careful because she is very tender, then complained that it hurt upon wiping. R12's buttocks and anal area appear reddened and slightly excoriated. V28 pulled up R12's same incontinence brief and pants and assisted her to sit back in her wheelchair. There was no cleaning of R12's vagina, front side/peri-area, or a clean incontinent brief applied. There was no barrier cream applied to R12's sore buttocks/anal area and no hand hygiene and glove changes when going from soiled areas to clean areas. 5. R9's Face Sheet, dated [DATE], documents R9 was admitted to the facility on [DATE]. R9's Care Plan, dated [DATE], documents R9 has alteration in skin integrity. Interventions: Encourage/assist with turning/repositioning every 2 hours and PRN, keep clean and dry as possible, minimize skin exposure to moisture, provide/assist with continence care as needed, utilize incontinence briefs to prevent trapping moisture against the skin, utilize incontinent skin barriers such as creams, ointment, pastes, and film-forming skin protectants as needed to protect and prevent further skin breakdown, keep linens dry and wrinkle free to prevent further pressure forces. R9's MDS, dated [DATE], documents R9 has severe cognitive impairment and is dependent on staff for ADLs. R9 is frequently incontinent of both bowel and bladder. R9's PO, dated [DATE], documents Site: Peri area/Buttock May apply moisture barrier with each incontinent episode. Special Instructions: May keep barrier cream at bedside for CNA to apply. On [DATE] at 8:55 AM, V14, LPN/Wound Nurse, was seen doing wound care on R9. R9 rolled to her left and her incontinent brief removed and appeared slightly wet. V14 provided wound care to R9 and when asked about incontinence care or putting a brief back on, V14 stated I like to let her air out. and covered R9 back up. There was no cleaning or incontinence care done on R9 at that time. On [DATE] at 9:03 AM, V39, CNA, stated I check on my residents about every 15 minutes and I am always walking up and down the hall checking on the residents. If a resident is on EBP, I put on the PPE before I take care of that resident. I do complete incontinent care, even if the resident is on the toilet I will clean all areas. I change my gloves between wiping soiled areas and then will do hand hygiene at that time. On [DATE] at 9:07 AM, V5, CNA stated I check on my residents all the time and provide complete incontinent care when needed. On [DATE] at 10:55 AM, V2, Director of Nursing (DON), stated I would expect all staff to perform complete and timely incontinent care, even if they are assisting the resident on a toilet. I would expect all staff to do hand hygiene and glove changes when appropriate. 6. On [DATE] at 10;09AM during incontinent care V5 CNA removes adult diaper with R18 standing hanging on to walker. The adult diaper is saturated with urine, and stool. With R18 standing V5 with wet towel, swipes from behind R18's visible stool on towels and on V5's gloves. R18 then has to sit down, V5 then leaves room and returns with gloves and cleansing wipes. With R18 standing holding on to the walker again. R5 with cleansing wipes swipes in from back with R18 standing hanging onto walker, V5 does not cleanse inner thighs, buttocks, or dry R18. R18's MDS dated [DATE] documents a BIMS of 9. R18's MDS documents R18 is dependent on staff for toileting hygiene. R18's MDS documents R18 is frequently incontinent of bowel and bladder. On [DATE] at 10:20 AM V25, CNA stated he forgot to rinse and dry R14 during catheter care. The facility policy Cauterization, intermittent, male dated revise [DATE]. The policy documents the purpose of procedure is to relieve retention of urine in the bladder, to obtain a urine specimen for diagnostic purposes, and to determine the amount of residual urine retained in the bladder. The policy documents verify physician order for the procedure; collect the specimen into the specimen into the specimen container; pinch the catheter until the urine flow ceases. Remove the catheter gently and slowly. The policy documents to document the amount of urine drained, character, clarity and color of urine, any changes in resident condition, any complaints or problems made by resident related to the process. Notify the physician of any abnormality. The facility policy Catheter Care, Urinary dated, revised [DATE] documents the purpose of the procedure is to prevent infection of the resident's urinary tract. The policy documents for the male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm soap and water to cleanse and rinse the catheter from insertion site to approximately four inches outward. The facility policy Perineal Care dated, revised [DATE], documents the purpose is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The policy documents the following equipment wash basin, towels, washcloth, soap or cleansing agent. The policy documents wash and dry hands thoroughly and apply gloves, fill the wash basin one- half full of warm water Place the wash basing on the bedside stand within easy reach The policy documents for a female resident: wet washcloth and apply soap or skin cleansing agent, wash perineal area, wiping from front to back, separate labia and wash area downward from to the back, gently rinse and dry the area the area., continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side and using downward strokes, rinse perineum thoroughly in same direction, gently dry perineum instruct, or assist resident the resident to turn on side with top leg slightly bent if able rinse wash cloth and apply soap or skin cleansing agent. Wash rectal area thoroughly, wiping from base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia, rinse thoroughly using the same technique as described above. Dry area thoroughly. The Facility's Suprapubic Catheter Care Policy, dated 2005, documents in part The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract.

Based on interview, observation, and record review, the facility failed to don Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precaution (EBP) and Contact Isolation, and to do hand hygiene and glove changes when necessary for 4 of 4 residents (R9, R12, R15, R21) reviewed for infection control in the sample of 30.The findings include: 1. R9's Face Sheet, dated 4/6/26, documents R9 was admitted to the facility on [DATE].R9's Physician Order, dated 4/17/26, documents Strict Isolation Type: Contact: Wound- Abdominal Wall Cellulitis, follow Contact Isolation.On 4/7/26 at 8:55 AM, a Contact Isolation sign was seen on R9's door with Personal Protectant Equipment (PPE) hanging on the door. Both V14, Licensed Practical Nurse (LPN)/Wound Nurse, and V7, Certified Nursing Assistant (CNA), entered R9's room for wound care with no PPE on. Before, during, or after wound care, there was no PPE worn except for gloves.2. R12's Face Sheet, dated 4/6/26, documents R12 was originally admitted to the facility on [DATE]. R12's Physician Order, dated 2/3/26, documents Enhanced Barrier Precautions (EBP) - Isolation.On 4/9/26 at 10:19 AM, a EBP sign and PPE were seen hanging on R12's door. V26, CNA, and V28, CNA were seen assisting R12 to use the restroom and to provide peri-care. Neither CNA donned appropriate PPE prior to assisting R12 with toileting.3. R15's Face Sheet, dated 4/15/26, documents R15 was admitted to the facility on [DATE].R15's Care Plan, dated 2/18/25, documents R15 requires Enhanced Barrier Precautions (EBP) due to indwelling medical device. Interventions: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting, gown and glove use when performing high-contact resident contact activity, have adequate PPE available, practice good hand washing, teach resident/caregiver the chain of infection/methods of transmission, use principles of infection control and enhanced barrier precautions.R15's Physician Order, dated 2/9/26, documents Enhanced Barrier Precautions.On 4/7/26 at 9:25 AM, An EBP sign was seen on R15's door with PPE hanging on the door. V11, Licensed Practical Nurse (LPN), was seen going into R15's room to fix R15's gastric tube (g-tube). V11 did not don PPE while working with the g-tube as the g-tube had become disconnected and R15 was holding it in her hands. V11 donned gloves only, then put the g-tube back together. V11 stated It keeps coming apart, so I figured maybe I'll use an alcohol pad to clean it real good would help it stay connected. V11 did not don PPE during process and doffed her gloves and exited the room without hand hygiene.4. R21's Face Sheet, dated 4/7/26, documents R21 was originally admitted to the facility on [DATE].R21's Physician Order, dated 2/3/26, documents Enhanced Barrier Precautions.On 4/7/26 at 11:22 AM, V9, CNA, entered to provide peri-care and catheter care to R21. There was an EBP sign with PPE hanging on door. V9 failed to don PPE when providing care to R21. V9 used one pair of gloves while performing peri-care and catheter care on R21, including getting wet washcloths from a water basin using soiled gloves. V9 also used same soiled gloves to dry all areas cleaned and then cover R21 up with his sheet/blanket. V9 failed to change gloves and do hand hygiene when going from dirty areas to clean areas of R21, including catheter care.On 4/16/26 at 9:03 AM, V39, CNA, stated I check on my residents about every 15 minutes and I am always walking up and down the hall checking on the residents. If a resident is on EBP, I put on the PPE before I take care of that resident. On 4/16/26 at 9:07 AM, V5, CNA, stated I check on my residents all the time. When asked about a EBP sign on the door, V5 stated I don't remember what that is. V5 stated If someone is on Contact isolation, I would wear a gown, gloves, and a mask.On 4/21/26 at 10:55 AM, V2, DON, stated I would expect all staff to don appropriate PPE when a resident is on EBP or any type of isolation. I would expect all staff to perform hand hygiene before, during glove changes, and after care. I would expect all staff to change gloves when soiled and when going from soiled area to a clean area.The Facility's Enhanced Barrier Precaution Policy, dated 3/21/25, documents in part It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO (Multidrug Resistant Organisms) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).The Facility's Hand-Washing/Hand Hygiene Policy dated 10/2025, documents in part It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. 4. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: a) before direct contact with residents; b) after direct contact with a resident but prior to direct contact with another resident; c) before donning gloves; d) before performing any non-surgical invasive procedures; f) before handling clean or soiled dressing, gauze pads, etc. g) before moving from a contaminated body site to a clean body site during resident care; h) before and after putting on and upon removal of PPE, including gloves; i) after contact with a resident's intact skin; j) after handling used dressings, potentially contaminated equipment, etc. k) after contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated; l) after contact with potentially infectious material; m) after removing gloves. 6. The use of gloves does not replace compliance with hand-washing/hand hygiene procedures.The Facility's Isolation - Categories of Transmission-Based Precautions Policy, dated 3/3/25, documents in part Appropriate precautions shall be used either at all times (Standard Precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (Transmission-Based Precautions). Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. C. Gloves and Handwashing: 1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. 2) While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). 3) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent (handwashing is required with C.diff/ Clostridioides difficile). 4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room.The Facility's Infection Control Policy, dated 10/2025, documents in part It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to prevent or eliminate when possible, the development and transmission of disease and infection.

Based on interview, observation, and record review, the facility failed to administer an antibiotic to a resident with a diagnosis of Urinary Tract Infection (UTI) and failed to follow physician orders to administer medications for 2 of 5 residents (R21, R22) reviewed for medication administration in the sample of 30.The findings include:1. R21's Face Sheet, dated 4/7/26, documents R21 was originally admitted to the facility on [DATE].R21's Care Plan, dated 4/6/26, documents R21 requires a suprapubic catheter related to urinary retention. Interventions: Enhanced barrier precautions, keep catheter system a closed system as much as possible, document urinary output every shift, record the amount, type, color, odor, observe for leakage. R21's Minimum Data Set (MDS), dated [DATE], documents R21 is cognitively intact and is dependent on staff for toileting. R21 has urinary catheter in place and is frequently incontinent of bowel.R21's Hospital Record, dated 4/10/26, documents in part Patient presented to the ER (Emergency Room) with decreased urination. The patient has a chronic suprapubic catheter. He reports that he has been weak but denied any nausea, vomiting, fever chills. He denies any chest pain, shortness of breath or difficulty breathing. In the ER, Hemoglobin 7.4, WBC (white blood cell) 3.79, Potassium 5.6, BUN (Blood Urea Nitrogen) 44, Creatinine 2.88, UA (urinalysis) consistent with UTI (urinary tract infection). bladder wall is mildly thickened. There is a suprapubic catheter again demonstrated with some inflammatory changes present along the course of the suprapubic catheter. The patient was treated with IV (intravenous) antibiotics for his urinary tract infection.R21's Physician Order, dated 4/10/26, documents Cefdinir 300 MG (milligram) Every 12 hours: 7:00 PM and 7:00 AM X 10 days Dx (diagnosis) UTI (urinary tract infection). This order was discontinued on 4/13/26. R21's Nursing Note, dated 4/13/26, documents Cefdinir allergy discussed with Doctor, may continue to give medication beginning today. POA (power of attorney) aware.R21's Physician Order, dated 4/13/26, documents Cefdinir 300 MG Twice a Day, Every Day, 6:00 AM and 6:00 PM, X 10 days Dx UTI.R21's Medication Administration Record (MAR), dated 4/1/26 through 4/20/26, documents R21 had Cefdinir 300 MG every 12 hours ordered on 4/10/26. R21 only received one dose of Cefdinir from 4/10/26 until 4/13/26.R21 was sent to the hospital on 4/6/26 and returned on 4/10/26 with the hospital discharge order for Cefdinir 300 MG every 12 hours. This was started on 4/11/26 on the day shift, then was not given until 4/13/26 when the order changed on 4/13/26.On 4/16/26 at 9:02 AM, V2, Director of Nursing (DON), stated The night shift nurse gave (R21) his antibiotic from the (medication dispensing machine) at 6:00 AM on 4/11/26, then the same nurse worked the night shift on 4/11/26 and the antibiotic was not given at 7:00 PM or the 6:00 AM dose on 4/12/26. The pharmacy did not send the antibiotic due to an allergy alert for Cefdinir. When asked why the doses were not given if they were available in the (medication dispensing machine) and V2 stated I don't have an answer for that. When asked if the antibiotic should have been given from the machine, V2 stated Yes, they should have given the medication from the machine. When asked if the pharmacy was not sending the medication due to an allergy alert, why did it take until 4/13/26 for the nurses to ask the physician about it, V2 stated I don't have an answer for that.R21's Physician Order, dated 12/20/25, documents Folic Acid 1 MG Once a day, every day at 6:00 AM. This order was discontinued on 4/9/26.R21's Physician Order, dated 4/10/26, documents Folic Acid 1 MG Once a day, every day at 6:00 AM.On 4/7/26 at 11:30 AM, While in the room observing care on R21, there was a light yellowish pill lying on the side table along with two medicine cups of creams: one with a mixture of creams. V11, Licensed Practical Nurse (LPN), was notified and stated I didn't give (R21) any medications this morning because he gets them at 6:00 AM. Those creams look like they mixed an antifungal cream with something else, and I believe that was supposed to be put on (R21's) bottom. V11 opened medication cart and reviewed each of R21's medications and stated, It looks like the nurse gave the stock Folic Acid which was only 400 MCG (micrograms) instead of his Folic Acid 1000 MCG that he has on a card that he should have gotten.On 4/7/26 at 11:35 AM, V2, DON, was notified and stated, That should not happen, and it will not happen again. 2. R22's Face Sheet, dated 4/7/26, documents R22 was originally admitted to the facility on [DATE] with diagnosis of Chronic Kidney Disease-stage 4, Dependence on renal dialysis, Congestive Heart Failure (CHF), Type 2 Diabetes Mellitus, Seizures, Benign neoplasm of colon, Tubulovillous Adenoma of colon, Anemia, Atherosclerotic heart disease, Atrial Fibrillation, Peripheral Vascular Disease, Anxiety Disorders, Major Depressive Disorder, Osteoarthritis, Atrioventricular block first degree.R22's Care Plan, dated 3/18/26, documents R22 receives dialysis on Monday, Wednesday, and Friday related to Chronic Kidney Disease-stage 4 (severe). R22 is at risk for side effects related to the use of Levetiracetam (anticonvulsant). Interventions: Gradually discontinue levetiracetam to reduce the risk of withdrawal symptoms such as increased seizure frequency and status, Levetiracetam may cause nonpsychotic symptoms such as aggression, agitation, anger, nervousness, etc. R22's Physician Order, dated 3/1/25, documents Levetiracetam 500 MG; Special Instructions: Once a Day on Sunday, Tuesday, Thursday, Saturday; 08:00 AM.R22's Physician Order, dated 3/1/26, documents Levetiracetam tablet; 500 MG; amt (amount): 2 tabs; oral. Special Instructions: Once a Day on Monday, Wednesday, Friday; 08:00 AM.On 4/7/26 at 9:30 AM, V11, LPN, was seen passing medications to R22. V11 stated (R22) is supposed to get Levetiracetam (Keppra) 500 MG today, but we are out of it. While giving R22 her medications, V11 told R22 that she will have to wait until tomorrow (4/8/26) to get her Levetiracetam because they were out of it, and she won't get it from the pharmacy until tomorrow.On 4/20/26 at 3:15 PM, V3, LPN, stated We have Keppra in the (medication dispensing machine). If (R22) was out of it, the nurse should have gotten it out of the (medication dispensing machine) and given it to R22.On 4/20/26 at 3:20 PM, V2 stated The nurse should have gotten (R22's) Keppra from the machine so she did not miss a dose. The nurse should have documented something about it and should have notified the physician.On 4/20/26 at 10:30 AM, V30, Registered Nurse (RN)/Infection Preventionist (IP), stated If I find any resident that is missing a medication, I would first check to see if we have it in the (medication dispensing machine), and if not, I will document that it was not given and why, then I would check the order and call the pharmacy. Our pharmacy is very good at sending us medications quickly when called.On 4/21/26 at 10:55 AM, V2, DON, stated I would expect the nurses to call the pharmacy and/or backup pharmacy for a missing medication, then notify the physician, and put in a progress note regarding the missing medication. I would expect the nurses to try to get the medication out of the Pyxis if available to avoid the resident missing a dose.The facility's Medication Administration Policy, dated 10/24/25, documents in part Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. 4) Five Rights: Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. 5) Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container is not flagged, indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. 11. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. B. Administration: 2) Medications are administered in accordance with written orders of the prescriber. 4) When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured. 18) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on interview and record review the facility failed to replace a broken c-pap mask timely for 1 of 3 residents (R1) reviewed for respiratory therapy in the sample of 30. Findings include:1 R1's progress notes dated 2/2/2026 at 2;57PM documents Resident's c-pap mask is broke, and medical supply company is bringing a new one tomorrow 2/3. Oxygen on at 3L (liters)/NC. (nasal cannula)R1's progress notes dated 2/1 2026 at 11:37PM documents Resident complained of Shortness Of Breath (SOB) at bedtime (hs). Nebulization treatment administered per order. Post-treatment SpO2 improved to 92%. Noted mask is broken and requires replacement; Resident continues to be monitored for further respiratory distress, on continuous O2 therapy via at 4L via nasal cannulaR1's undated face sheet documents a diagnosis in part of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory failure wit hypoxia, Dependent on supplemental oxygen, and obstructive sleep apnea. R1's physician orders dated 1/31/2026 documents 02 (oxygen) at 3L (liters) per nasal cannula if refuses c-pap or if not available for any other reason. R1's PO dated 10/24/2025 documents c-pap-bi-ap on nap time and at night to maintain oxygen saturation greater than 92%. On 4/13/2026 at 10:40AM V2, Director of Nursing (DON) stated if something is wrong with a mask, the medical supply provider is notified and mask is sent out. V2 stated sometimes same day or next day. V2 stated If a resident has a history of respiratory failure and is having SOB and no mask available, the physician should be notified and see what he recommends. V2 stated R1 should have a mask as ordered On 4/13/3036 11:29AM V33, medical supply provider stated a c-pap mask was sent to the facility on 2/3/2026. V33 stated they did not have a specific name but only request for mask that had been received from the facility.The facility policy CPAP/BIPAP support date, revised April 2007 documents the purpose is to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen, to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive obstructive lung disease and to promote comfort and safety. CPAP (continuous positive airway pressure ) can be used in conjunction with ventilation to improve oxygenation. CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. The policy documents the mask should fit firmly but does not need to be airtight, the mask should fit firmly but does not need to be airtight.

Based on interview, observation, and record review the facility failed to properly treat pressure sores, including following physician orders, for 1 of 4 residents (R9) reviewed for care of a pressure ulcer in the sample of 30. The findings include:1. R9's Face Sheet, dated 4/6/26, documents R9 was admitted to the facility on [DATE].R9's Care Plan, dated 3/25/26, documents R9 has alteration in skin integrity as evidence by pressure ulcer, wound healing may be hindered due to resident noncompliance with being turned every two hours, and offloading her buttocks, resident prefers to lay on her back. Interventions: Encourage/assist with turning/repositioning every two hours and PRN (as needed), keep clean and dry as possible, minimize skin exposure to moisture, provide/assist with continence care as needed, keep linens dry and wrinkle free to prevent further pressure forces, maintain head of bed at/or below 30 degrees or at lowest degree of elevation consistent with the resident's medical condition to prevent sliding and shear-related injury that may prohibit wound healing and/or cause further wound development, measure and document wound characteristics observations weekly, minimize pain by assessing and administering pain medication as ordered by physician, reduce friction and/or shearing to prevent wound from declining and further wound development.R9's Minimum Data Set (MDS), dated [DATE], documents R9 has a severe cognitive impairment and is dependent on staff for Activities of Daily Living (ADLs). R9 is frequently incontinent of both bowel and bladder. R9's Physician Order, dated 3/4/26, documents Site: Right Buttock- Cleanse, pat dry, apply hydrocolloid dressing. Special Instructions: Apply Q (every) 3 Days and PRN (as needed). Once A Day Every 3 Days; 1st Shift. This order was Discontinued on 3/11/26 when R9 was hospitalized . R9's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated 3/1/26 through 3/31/26, documents the order placed on 3/4/26 was signed off as completed on 3/4/26, then not again until 3/8/26, and then on until 3/11/26. R9 was sent to the hospital on 3/11/26 and returned to the facility on 3/16/26 with diagnosis of Pneumonia.R9's Physician Order, dated 3/17/26, documents Site: Peri area/Buttock May apply moisture barrier with each incontinent episode. Special Instructions: May keep barrier cream at bedside for CNA (Certified Nursing Assistant) to apply.R9's Physician Order, dated 3/17/26, documents Site: Bilateral Buttocks- Cleanse, pat dry, apply a dime thick layer of triad paste. Special Instructions: Apply daily and PRN. Once A Day; 1st Shift.R9's MAR-TAR, dated 4/1/26 through 4/30/26, documents Site: Bilateral Buttocks- Cleanse, pat dry, apply a dime thick layer of triad paste. Special Instructions: Apply daily and PRN. Once A Day; 1st Shift. This was signed off as completed daily from 4/1/26 through 4/14/26. On 4/7/26 at 8:55 AM, V14, Licensed Practical Nurse (LPN)/Wound Nurse, stated I work on Tuesdays through Fridays and the other days the regular nurses do the wound care. V14 was seen providing wound care to R9. A Contact Isolation sign was on the door with Personal Protectant Equipment (PPE) hanging on the door. Both V14, and V7, CNA, entered R9's room for wound care with no PPE on. R9 was rolled to her left and her incontinent brief was removed and appeared slightly wet. V14 removed R9's undated dressing to her coccyx/buttocks and stated that it was a Hydrocolloid dressing, stated their policy is to not date the dressings. V14 used Normal Saline and poured it over the wound, then used 4x4 gauze to pat dry the wound with no cleaning or wiping of the wound site. V14 then applied Triad Paste to the area and rolled R9 back to her backside. When asked about a dressing or incontinent brief back on, V14 stated I like to let her air out. and covered R9 back up. There was no PPE worn except for gloves during wound care.On 4/15/26 at 8:35 AM, V14 stated (R9) had orders for the hydrocolloid dressing up until she was hospitalized on [DATE]. When she came back on 3/16/26, she was seen by the wound NP (Nurse Practitioner) and she placed an order to put Triad paste on instead of the dressing. That Hydrocolloid dressing that we saw on (R9) should not have been on there. I'm guessing the weekend or Monday nurse did the wrong wound care.On 4/21/26 at 10:28 AM, V30, Registered Nurse (RN)/Infection Preventionist (IP), stated If I have to do wound care, I will look in the resident's TAR for the order and what to do. If the order was changed, the old order should be marked off as discontinued in the TAR and the new order should be put on the TAR in its place.On 4/21/26 at 10:55 AM, V2, Director of Nursing (DON), stated I would expect the nurses to follow the physician's order for wound care and to discontinue any order that has changed and to enter the new order so it will be followed.The facility's Pressure Wound Treatment Policy, dated 1/2025, documents in part The purpose of this procedure is to provide guidelines for the care of existing pressure injuries and the prevention of additional pressure injuries. Pressure injury treatment requires a comprehensive approach, including: 1. Debridement. 2. Managing infections. 3. Managing systemic issues (edema, venous insufficiency, etc.). 4. Maximizing the potential for healing. 5. Pain control.

Based on observation, interview and record review the facility failed to ensure a residents' foot was free of insects for 1 of 3 residents (R2) reviewed for foot health. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. R2's Care Plan, dated 10/20/2025 documents R2 has an open lesion on the foot which appears to be small crack in the skin between her 4th and 5th toe on her right foot. Goal: lesion will show improvement by decreasing in size and showing no signs and symptoms of infection by next review date. Approaches: administer dressing/treatment to address/stabilize specific wound characteristics as ordered by the physician, encourage appropriate footwear is worn at all times and encourage R2 not to walk/propel chair around barefoot or in just socks/stockings, ensure footwear for proper sizing, ensure shoes are in good condition, inspect feet during ADL (activities of daily living) care and showers/bathing, report any abnormalities to physician, keep skin clean and dry, observe lesion characteristics weekly to monitor for effectiveness of treatment, notify physician if lesion shows evidence of decline, wound physician consult as needed per physician order and monitor for signs and symptoms of infection such as pain, odor, changes in exudate (drainage) characteristics, redness, edema, or cellulitis, notify physician if observed. No documentation of maggots on R2's feet documented. R2's Progress Note, dated 10/20/2025 at 12:45 PM, documents resident seen by podiatrist this AM, new area noted to right 5th toe. Appears to be a crack in skin. New order for TAO and dry dressing daily per physician. Also, daily skin checks to be completed. POA (Power of Attorney) aware of order. RD (Registered Dietitian) updated on new area. Verified that resident has properly fitting shoes a neatly trimmed nails. On 10/23/2025 at 11:30 AM R2 sitting up in wheelchair in her room. R2 was alert and stated she had a sore on her right foot, but she laughed and stated no bugs on her feet she's aware of. R2 stated staff do the dressing on her right foot daily and she's never had bugs or maggots on her feet that she's aware of. V4, LPN entered room and removed R2 slippers and socks. There was a 2 x 2 gauze between R2's 4th and 5th toe on her right foot at that time. V4 stated R2 had no wounds and no bugs on her feet and no other residents have bugs and she does wound treatments every day and follows physician's orders. Observation of R2's feet showed a very small cut between 4th and 5th digit on right foot and no wounds or redness on either heel. R2's left foot also assessed and no wounds and no maggots or bugs on either foot at that time. V7, LPN entered R2's room and stated she is the facility's wound nurse. V7 stated she returned to work from leave on 10/21/2025 and she received report that R2 had maggots on her feet but didn't have any additional information. R7 stated she never observed maggots on R2's feet. V7 showed a small cut like wound between R2's 4th and 5th digit and stated staff are cleaning the area with normal saline then apply TAO and gauze to the area. V7 stated she doesn't have access to R2's podiatry notes because the podiatrist doesn't send them to the facility for their review. V7 stated while she was on leave V5, LPN was the acting wound nurse and floor nurses were responsible for administering wound treatments to residents. R2's Physician's Order Sheet (POS), dated 10/20/2025 documents a new order right 5th toe cleanse area with normal saline pat dry apply TAO and place dry gauze between 4th and 5th toe change daily and PRN once a day. R2's POS, dated 10/21/2025 documents a new order for skin assessment daily. R2's Wound Management dated 10/20/2025 at 1:38 PM documents right pinky toe, 4th toe crack in skin that measured 0.2 centimeters (CM) x 0.2 cm. Staff documented, Area noted to be a small crack in the skin between 4th and 5th toe.R2's Treatment Administration Record (TAR) dated 10/20/202 documents staff are providing skin assessments and wound treatment per physician's orders. On 10/23/2025 at 3:33 PM V5, LPN stated she works night shift at the facility and was at the facility early in the morning on 10/20/2025 when V13, Podiatrist entered to assess residents. V5 stated no staff round with V13 because he comes to the facility around 5:30 AM. V5 stated V13 reported to her that R2 had maggots in between her toes and he's never seen that before and R2 has a wound on her right foot between her 4th and 5th digit. V5 stated she assessed R2's feet as soon as V13 reported this to her. V5 stated she wiped between R2's toes and assessed maggots, V5 couldn't recall which foot had maggots but stated R2 had maggots between her toes. V5 stated she reported R2 had a newly identified wound and maggots between her toes to V1, V2 and V6. V5 stated she was very busy at that time and didn't document the assessment or removal of maggots from between R2's toes because she forgot. On 10/23/2025 at 12:30 PM V6, LPN stated she was the acting wound nurse while V7, LPN was on leave. When she got to the facility in the morning on 10/20/2025 staff (unknown name) reported to her that V13 rounded that morning and stated R2 had maggots on her foot. V6 stated her and V9, CNA/Shower Aide assessed R2's feet at that time and there were no maggots assessed. V6 stated no staff including V5 reported to her that R2 had maggots and they cleaned her feet. V6 stated she would expect staff to document R2 had maggots on her foot/feet so she could report that to R2's provider for further treatment orders. On 10/23/2025 at 1:20 PM V2, Director of Nurses (DON) stated V13 reported to a nurse that R2 had maggots on her feet but V6, LPN had assessed R2's feet the morning that V13 assessed R2's feet and there no maggots present. V2 stated she didn't assess R2's feet that day because V6 had already assessed R2's feet. V2 stated R2 didn't have maggots on her feet that day and no staff reported R2 had maggots on her feet. V2 stated if R2 had maggots on her feet she expected a nurse to assess R2's feet then document the assessment in R2's medical record. V2 stated no residents, including R2 had maggots on their feet.On 10/24/2025 at 11:54 V13, R2's Podiatrist stated he assessed R2's feet early in the morning on 10/20/2025 and he noted a family of insects on R2's right foot between her 4th and 5th toes at that time and there was a small abrasion in that space as well. V13 notified the floor nurse (name known) of the concern and the nurse entered R2's room and cleansed the area and he noted the abrasion wasn't red and no signs or symptoms of infection were present. V13 stated he told the nurse to report this to the facility's wound nurse and if the wound nurse felt it was medically necessary to notify R2's PCP (Personnel Care Provider) to see if he/she wanted to order an antibiotic or not. V13 stated he wasn't done documenting R2's progress note dated 10/20/2025 and that was why the maggots weren't documented on R2's note and he had recently put an addendum to R2's podiatry progress note, dated 10/20/2025 to include the insects were present. V13 stated he can't say what specific insects were between R2's 4th and 5th digit on her right foot because he's not an insect specialist but that they shouldn't have been present. V13 stated he expected the nurse who assessed and cleansed the insects from R2's right foot should have documented the assessment and observation in R2's nurse's notes so her medical record was accurate and up to date and she should have notified the wound nurse of the insects presence as well. R2's Podiatrist Progress Note, dated 10/20/2025 documents V13 added an addendum dated 10/24/2025 small insects in webspace between 4th and 5th toes also seen by nurse, so nurse was cleaning both feet The facility's Charting and Documentation policy, revised 8/2006 documents all services provided to the resident, or any changes in the resident's medical condition shall be documented in the resident's medical record. All observations must be documented in the resident's medical record. All changes in resident's condition must be recorded which includes the date and time, name and title of who provided the care and the assessment data and/or any unusual findings obtained during the treatment, notification of physician if indicated.

Based on record review and interview the facility failed to maintain a complete and accurate medical record for 1 (R2) of 3 sampled residents in review of complete and accurate medical records. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. On 10/24/2025 at 3:33 PM V5, LPN stated V13, Facility Podiatrist entered the facility early in the morning on 10/20/2025 and assessed residents, including R2. R2's Electronic Medical Record (EMR) dated 10/23/2025 no documentation of V13's progress notes. On 10/23/2025 at 2:20 PM V1, Administrator stated V13, Facility Podiatrist doesn't share/send his progress notes with the facility, and he never has. On 10/24/2025 at 11:54 V13, R2's Podiatrist stated he is the facility podiatrist, and sees over 25 plus patients at the facility approximately four times a year. V13 stated his office sends the facility his progress notes within 2-3 days after he assesses the residents so his progress notes should be uploaded in the residents' medical records system. V13 stated he wasn't aware the facility wasn't receiving his progress notes or that his office wasn't forwarding his progress notes to the facility. The Facility's Charting and Documentation Policy, revised 8/2006 documents all observations and services performed must be documented in the resident's clinical record.

Based on interview, observation and record review, the facility failed to follow physician's orders for twice-daily pulse oximetry checks for 2 of 3 residents (R1 and R2) reviewed for quality of care in the sample of 4. Findings include: 1. R2's undated face sheet documented he was admitted to the facility on [DATE] and has the following diagnoses polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, right below the knee amputation, and obstructive sleep apnea. R2's minimal data set (MDS) dated [DATE] documented he is cognitively intact. R2's care plan updated 6/5/25 documented wound care interventions, depression, peripheral neuropathy, dialysis, pain, nutrition, and diabetes. There was no problem including oxygen saturation monitoring noted in his care plan. R2's physician order dated 4/21/25 documented Oxygen: Oxygen saturation (pulse oximetry) (SPO2) twice daily. R2's oxygen saturation recordings reviewed in the electronic medical record (EMR) and documented daily except for 6/5/25 and 6/18/25. Oxygen saturations were not performed twice daily as ordered 17 times during the first 25 days of June. 2. R1's undated face sheet documented she was admitted to the facility on [DATE] with the following diagnoses fibromyalgia, diabetes, chronic obstructive pulmonary disease, asthma, pulmonary hypertension, and congestive heart failure. R1's MDS dated [DATE] documented she is cognitively intact. R1's care plan last revised on 2/23/25 documented problems with chronic obstructive pulmonary disease, activity intolerance, and decreased cardiac output. R1's order dated 4/22/24 documented to monitor oxygen saturations every shift (twice per day) and as needed. R1's oxygen saturation result documentations reviewed in the EMR for the first 25 days in June with only one day documenting twice daily reading and on 12 of the days there were no oxygen saturation levels recorded for that day at all. On 6/26/25 at 10:00 am, V8, Certified Nursing Assistant (CNA), stated that the CNA's take the routine pulse ox with the vital signs and chart it on a paper copy which is given to the nurse who puts it in the EMR. V8 added that the CNA's do not do any EMR charting. The resident's information is handed to the nurse who puts it in the EMR. On 6/26/25 at 10:05 am, V9 (CNA) stated pulse ox are obtained with the residents' scheduled regular vital signs between 7:00 am - 10:00 am and given to the nurse to put in the EMR. If a pulse ox was low or a resident was short of breath, V9 stated she would notify the nurse right away. On 6/26/25 at 10:20 am, V6 (CNA) stated that the residents needing vital signs/pulse ox for the day are listed on a paper vital sign sheet and that day's vital sign paper was shown. On 6/26/25 at 10:24 am, V10 (LPN) stated that the CNA's perform the routine vital signs with pulse ox and write them on a paper which they hand to her, and she puts them in the EMR. The policy titled pulse oximetry (assessing oxygen saturation) revised March 2004 documented that the purposed of this procedure is to monitor arterial blood oxygen saturation without the use of invasive devices. Steps in the procedure include explaining the procedure to the resident and record oxygen saturation reading. The following information should be recorded in the resident's medical record. The date and time the procedure was performed, and if the resident refused the procedure, the reason why and the intervention taken. Notify the supervisor if the resident refuses the procedure.

Based on interview, observation and record review, the facility failed to identify a stage 2 pressure ulcer on the upper intergluteal cleft in a timely manner for 1 of 3 (R2) residents reviewed for pressure ulcers in a sample of 4. Findings include: R2's undated face sheet documented he was admitted to the facility on [DATE] and has the following diagnoses polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, and right below the knee amputation. On 6/25/25 at 9:40 am during skin check of R2's buttocks area with V3 Licensed Practical Nurse (LPN)/ wound nurse, V5 (LPN/wound nurse) and surveyor, a new pressure wound to upper intergluteal cleft was found measuring 0.5 cm x 0.2 cm which V3 acknowledged was a stage 2 pressure wound. V3 and V5 stated they were unaware of a pressure wound to this area. On 6/25/25 at 10:30 am, V3 stated she had received orders from V15 (Facility Physician) and was bringing in wound care supplies to provide wound care to the new upper intergluteal pressure wound. R2's minimum data sheet (MDS) dated [DATE] documented he is cognitively intact and requires use of a wheelchair for mobility. R2 requires staff set up for eating, oral hygiene, and upper body dressing. R2 requires supervision for toileting and personal hygiene, lower body dressing, putting on and removing footwear and showering. R2 is at risk of developing a pressure ulcer and has two unstageable pressure ulcers. On 6/25/25 at 2:15 PM, R2's shower sheet dated 6/25/25 had no documentation of any buttock wounds present on R2. No documentation on any shower sheet referenced a wound on the upper intergluteal cleft. On 6/25/25 reviewed R2's May and June TARs (Treatment Administration Record) were reviewed and showed for skin assessment no presence of a pressure wound to the buttocks at the last skin assessment performed on 6/22/25. R2's care plan last reviewed on 6/5/25 at 5:11 PM documented he has a penile wound infection, open lesion to penis, unstageable pressure ulcer to the left heel, hemodialysis, diabetes, pressure ulcer risk, fall risk. R2 is at risk for pressure ulcers related to impaired mobility. The goal is that skin will remain intact. The interventions include conduct a systematic skin inspection during shower days paying particular attention to the bony prominences. Maintain the head of the bed at the lowest degree of elevation possible. Remind and assist R2 to turn and reposition regularly. Report any signs of skin breakdown. Use moisture barrier product to perineal area. Use pressure reducing cushion for pressure reduction when R2 is in chair. Use pressure reducing mattress for pressure reduction when R2 is in bed. When R2 has episode of incontinence, provide incontinence care after each incontinent episode. Avoid hot water and use a mild cleansing agent that minimized irritation and dryness to the skin. Prevention of Pressure Wounds policy with effective date of January 2017 documented the purpose of this procedure is to provide information regarding identification of pressure injury, risk factors and interventions for specific risk factors. Interventions and preventative measures include general preventive measures by identifying risk factors for pressure injury development. For a person in bed, change position at least every two hours or more frequently if needed, determine if resident needs a special mattress. For a person in a chair, change position at least every hour and use a foam, gel or air cushion as indicated to redirect pressure. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury.

Based on interview, observation, and record review, the facility failed to identify and prevent a pressure ulcer for 1 of 7 (R37) reviewed for pressure ulcers in the sample of 29. This failure resulted in R37 developing a pressure ulcer on the left heel while at the facility. Findings Include: On 5/13/25 at 8:50 AM, R37 stated he has a pressure ulcer on his left heel. R37 stated he did not know it was there and a nurse found it. R37 stated he was concerned because he lost his right leg due to a pressure ulcer on his foot that never healed, and they had to amputate his leg. R37 was questioned if the dressing is changed every day, R37 stated no it is not. On 5/13/25 at 12:53 PM, V8, Wound Nurse Practitioner, was at the nurses' station with the wound treatment cart. V8 is wearing gloves. V8 entered R37's room to provide left heel pressure ulcer treatment. V8 removed R37's shoe, sock, and pressure ulcer dressing. The dressing was dated 5/11/25 and had a moderate amount of brownish drainage on it. V8 rubbed the wound with her gloved hand. V8 retrieved wound cleanser and gauze from the cart and cleansed the pressure ulcer. V8 retrieved a wound ruler from the cart and measured the pressure ulcer. The pressure ulcer in its' entirety measured 5 centimeters (cm) by 4 cm. The middle of the pressure ulcer had a necrotic area that measured 3 cm x 2.5 cm. The pressure ulcer area that was not necrotic had beefy red tissue. V8 retrieved betadine and gauze from the cart and cleansed the pressure ulcer. V8 retrieved calcium alginate with silver, torn off a piece to cover the necrotic area and placed it over the necrotic area, placed the remaining calcium alginate with silver in the packaging and placed it back in the cart. V8 retrieved a gauze roll out of the cart, wrapped R37's left heel, retrieved scissors out of the cart, cut the gauze, placed the remaining gauze in the packaging, and placed it in the cart. V8 removed her gloves, retrieved tape out of the cart, taped R37's gauze wrap, and placed the tape back in the cart. On 5/13/25 at 1:04 PM, V8 stated R37's pressure ulcer did not appear overnight. V8 stated it appears the necrotic area was larger, but some has fallen off. V8 stated the wound will be difficult to heal but it will heal. R37's Face Sheet, undated, documents R37 was admitted [DATE] and has diagnoses of Diabetes, dependence on Renal Dialysis, and Polyneuropathy. R37's Progress Note, dated 5/8/25, documents He is able to move himself in bed and side to side and he is able to move his heel off of bed but he said he doesn't have much feeling on his left foot, writer did skin check tonight and he was noted with an open wound on his outer heel, cleaned and dressing applied foot offloaded, went through reasoning behind offloading his heel and how to prevent skin breakdown etc. (etcetera). He voices plan and acknowledgment, V9's (Physician) office updated and requested tx. (treatment). R37's Skin Integrity Conditions, dated 5/9/25, documents R37 has a facility acquired left heel unstageable pressure ulcer that was noted on 5/9/25. The pressure ulcer measures 3.5 cm x 5 cm x unknown depth, the wound bed has 50% eschar and 50% slough, is moist and necrotic, and has moderate serosanguineous drainage. R37's Physician Orders, dated 5/9/25, documents, cleanse left heel with NS (normal saline) apply calcium alginate cover with dry dressing/foam change daily and prn (as needed) Once A Day 07:00 AM - 07:00 PM. R37's May 2025 Treatment Administration Record fails to document R37's pressure ulcer treatment being done on 5/11/25. R37's Braden Scale for Predicting Pressure Sores, dated 3/20/25, documents R37 is not at risk for developing pressure ulcers. R37's Minimum Data Set, dated dated [DATE], documents R37 is cognitively intact and does not have a pressure ulcer. R37's Care Plan, dated 3/20/25, documents, Problem: (R37) is at risk for pressure ulcers R/T (related to) impaired mobility. Approach: Report any signs of skin breakdown (sore, tender, red, or broken areas). The policy Prevention of pressure Wounds, dated January 2017, documents, General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decreased of circulation to that area and subsequent destruction of tissue. 2. The most common site of a pressure injury is where the bone is near the surface of the body including the back of head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. It continues, 5. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. 6. The facility should have a system / procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Interventions and Preventive Measures: 9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 10. Immediately report any signs of a developing pressure injury.

Based on observation, interview and record review the facility failed to provide a full time Director of Nursing (DON) and to provide a Registered Nurse (RN) 8 hours a day seven days a week. This failure has the potential to affect all 46 residents at the facility. Findings include: On 05/12/25 at 01:23 PM V1, Administrator stated she has not had a DON for 6 weeks. V1 stated the facility had advertised on different platforms and a DON is to start employment on 5/15/2025. The facility staffing schedule dated 4/28/2025-5/15/2025 documents 8 days out of 17 days the facility failed to provide RN coverage 8 hours a day on 4/30, 5/2, 5/8, 5/10, 5/11/, 5/13, 5/14, and 5/15/2025. On 5/13/2025, 5/14/2025 and 5/15/2025 a RN was not observed on duty at the facility. On 5/13/2025, 5/14/2025 and 5/15/2025 during the survey. There was no DON observed at the facility during the survey process from 5/12/20205-5/15/2025. The CMS-671 Long-Term Care Facility Application for Medicare and Medicaid dated 5/12/2025 documents a census of 46. The facility Staffing Policy, undated documents it is the policy of the facility to provide adequate number of staff to successfully implement resident functions and to meet resident needs. The policy documents the facility operates in compliance with applicable federal, state and local laws, regulations and codes with accepted professional standards and principles that apply to professionals. The policy documents a Registered Nurse (RN) will be scheduled seven days a week at least one continuous 8 hour shift. The policy documents all Department Directors will be employed for a forty hour week and generally work during normal business hours, except when necessary to provide supervision and support to other shifts and weekend staff. TH policy documents in addition to actual work hours, the administrator and Director of Nursing will be on call during non-working hours or will designate a qualified staff member to be on call.

Based on interview, observation, and record review, the facility failed to dispose of expired medications, date multi-use medication vials, and insulin pens. These failures have the potential to affect all 46 residents living in the facility. Findings include: On 5/12/25 at 4:00 PM, the 300/400 hall medication cart was reviewed with V4, Licensed Practical Nurse. R38 had a Glargine insulin pen that had an open date of 3/24/25. R12 had a Glargine insulin vial that had an open date of 2/3/25. There was a stock vial of Lispro with an open date of 3/19/25. On 5/12/25 at 4:15 PM, the 100/200 medication room was reviewed with V3, Registered Nurse. In the medication refrigerator, there was an open used vial of Aplisol (tuberculin) without the open date. On 5/13/25 at 8:00 AM, V1, Administrator, stated all inulin pens, insulin vials, and any multi- use injectable medication should have the opened date on it. The nurses are the ones that use the TB (tuberculin) injection when a resident is admitted to the facility. On 5/13/25 at 3:24 PM, V1 stated the facility only keeps one Aplisol vial in the facility at a time. The Aplisol insert, undated, documents, Vials in use for more than 30 days should be discarded. The policy Storage of Medications dated 10/25/2014, documents, when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulations/guidelines required different dating. The Insulin Storage Recommendations, undated, documents Vials Opened Room Temperature Lispro and Glargine 28 days. Lantus (Glargine) pen Open Room Temperature 28 days. The Resident Census and Conditions of Residents, CMS 671, dated 5/13/25, documents that the facility has 46 residents living in the facility.

Based on interview, observation, and record review, the facility failed to store food in a manner to prevent contamination by pests. This failure has the potential to affect all 46 residents residing in the facility. Findings include: On 5/13/25 at 11:10 AM, the dry storage was toured with V2, Dietary Manager. There was a large plastic storage bin that held an open 25 pound bag of breadcrumbs and an open 25 pound bag of flour. There was a large plastic storage bin that held an open 25 pound bag of sugar and an open large bag of instant oats. The storage bins did not have lids. The facility had one trash bag draped over each of the storage bins. On 5/13/25 at 11:25 AM, V2 agreed pests could crawl under the trash bag and get into the food. The policy Storage of Dry Goods/ Foods, undated, documents, 3. plastic containers with tight - fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. (etcetera). It continues, Open products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents. The Resident Census and Conditions of Residents, CMS 671, dated 5/13/25, documents that the facility has 46 residents living in the facility.

Based on observation, interview and record review, the facility failed to provide supervision to prevent falls, investigate falls thoroughly to determine a root cause analysis and implement progressive interventions to prevent falls, provide safe transfers, and ensure transfer equipment is in good condition for 5 of 8 residents (R9, R10, R14, R17, R27) reviewed for falls and transfers in the sample of 31. This failure resulted in R17 falling 5 times,sustaining bumps to the back of her head, and another fall resulting in R17 going to the emergency room and receiving 8 staples to the back of her head. Finding include: 1.R17's Face Sheet, undated, documents R17 was admitted on [DATE] and has diagnoses of cerebral infarction, dementia with behavioral disturbance, anxiety, personal history of (healed) traumatic fracture of right tibia and left femur. R17's Minimum Data Set (MDS), dated [DATE], documents R17 is severely cognitively intact, has inattention and disorganized thinking that fluctuates and changes in severity, requires extensive assistance of 1 staff member for bed mobility, walking in room and hallway, locomotion on unit, not steady only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, and surface to surface transfer. R17's Safety Events - Fall Event Full Body and Pain report, dated 1/11/22 at 7:09 PM, documents, Description: Resident walked across hall and fell on her buttocks in someone else's room. This report documented that prior to this fall R17 was walking in her room. The report documented this fall was witnessed. The report documented She walked into room bumped into the bedside table, lost balance and fell in a spin, landing on her buttocks and hitting her head on floor. The report documented that R17 was calm and confused and usually required of assistance of one when walking. The report documented Initial Observation or complaint of injury: Right side / back pain, no bruising, skin tears, or other injuries noticeable. Observation of skin on trunk / torso / lower body: C/O (complaint of) tenderness. Physical symptoms: Resisting certain movements. Description of Pain: Back pain. Other: Right side pain. Medical Care provided after fall: Transferred to ER for evaluation. R17's Occurrence Report, dated 1/11/22, documents, Nurse Note of what happened: Her alarm sounding went to investigate and observed resident sitting on her buttocks in room across hallway from resident's room. Witness Statement: (R62) stated, she walked in my room and the next thing I know is she was on the floor. The Report documented R17 was barefoot and an alarm sounded. The Report Conclusion documented Resident stood from her w/c (wheelchair) in her room and ambulated across the hallway into another resident's room, lost her balance and landed on her buttocks. The Report documented the Root cause as Due to resident action or internal risk factors. The Report Recommendation documented toilet every hour. R17's Nurse's Note, dated, 1/11/22, documents, Resident fell in room across the hall from hers at (7:00 PM) and was found in the sitting position at (7:05 PM). She is c/o (complaining of) Right side and back pain. Unable to take a deep breath and is desatting without oxygen on. VS (vital signs): 97.8 (temperatures), 78 (pulse), 14 (respirations), 140/78 (blood pressure), 90-93% (oxygen saturation level). Writer is going to send her to the ER (emergency room ) for eval (evaluation). R17's MDS, dated [DATE], documents R17 is moderately impaired, has inattention and disorganized thinking that fluctuates and changes in severity, requires extensive assistance from 2 staff members for bed mobility, transfers, locomotion did not occur and requires extensive assist from 1 staff member for eating. This MDS also documents R17 is not steady and only able to stabilize with staff assistance for moving to seated to standing, walking, surface to surface transfer and uses a wheelchair for mobility. The facility failed to provide a Care Plan for R17 that was before 1/13/22. R17's Care Plan, dated 1/13/22, document, (R17) is at risk for falls with injury visual impairment, on psychoactive and cardiac medication, and recent fall in the room with injury on 1/11/22. The Care Plan Interventions dated 1/17/22 documented When (R17) is up in her w/c (wheelchair) she is to be under supervision of staff and in a populated area. When (R17) is fidgety and won't stay seating take her for a walk using gait belt. Provide toileting assistance at least every hour, as needed, or when she becomes restless. Provide proper well-maintained footwear. Provide (R17) an environment free of clutter. Pressure alarm to (R17's) bed and wheelchair. Occupy (R17) with meaningful distractions: music, one on ones, crafts, laundry to fold, etc. Non-skid to w/c seat. Non skid socks on when up to wheelchair. (R17) is to use HI/LO bed for safety. (R17) is not to be left in dining room unattended. Give (R17) verbal reminders not to ambulate/transfer without assistance. Encourage (R17) to wear her eyeglasses and that her eye glasses are clean and in good repair. Do not leave in bathroom unattended. Assure (R17) is wearing non skid socks at all times, including while in bed. Assure brakes are always locked on wheelchair when not being used for locomotion. R17's Safety Events - Fall Event Full Body and Pain report, dated 2/8/22 at 6:28 PM, documents an unwitnessed fall. The Report documents Resident fell to the floor in dining room. The Report documented R17 was drinking coffee prior to the fall. The Report documents Resident fell forward after standing up on own and landed under a dining room table. The Report documents that R17 was in her wheelchair prior to the fall. The Report documented Resident stated she has a headache. Observation of skin on head / neck: Redness, swelling, c/o tenderness. If any describe including size, color, exact location: 4 cm (centimeters) x 4 cm bump in the middle of the back of head, then down approximately 4.5 cm is a 2.5.cm x 2.5 cm bump. She also had a 2.5 x 3 red area to the right forehead just above the eyebrow. Description of pain: Headache. Medical care provided after fall: Basic first aid. Interventions and immediate Measures taken: analgesics, cold application. Evaluation: no documentation. R17's Occurrence Report, dated 2/8/22 at 6:40 PM, documents, Nurse's Note of what happened: (V24. Licensed Practical Nurse) called to dining room by (V11) Licensed Practical Nurse (LPN) notified of resident observed on floor under dining room table. The Occurrence Report documents a Witness Statement of what happened as (R14) in dining room at time of incident stated, she was sitting in her w/c (wheelchair) with her head lying on the table asleep, next thing I knew she was at another table on the floor. I did not actually see it happen, I think she got up from her w/c and walked over to the other dining room table and fell . The Report documented R17's alarm was sounding. The Report documented Conclusion (R17) was upright in her w/c in dining room with her head laying on dining room table asleep, according to interviewable resident in dining room at the time of incident. Interviewable resident stated that she did not see her fall just happened to look up and resident was on the floor at a different table and that w/c was still in place at the table where she was last seen by this resident. Resident arose from her w/c, ambulated to another table without assistive device which caused her to land on the floor. Root cause: Due to resident action or internal risk factors. This Report did not document that staff were present in the dining room at the time of the incident and supervising R17. R17's Fall Care Plan Intervention, dated 2/9/22, documented (R17) is to be the last one in the dining room and the first out of the dining room. R17's Safety Events - Fall Event Full Body and Pain report, dated 2/10/22 at 3:33 PM, documents, Resident fell to the floor in resident's room. The Report documented that R17 was in her bed prior to the fall and the fall was not witnessed. The report documented Resident 'walking around in the kitchen' bumped into dresser and pulled TV off and on top of her. The Report documented Observation of skin on head / neck: Skin tear / laceration. If any describe including size, color, exact location: 3 cm (centimeter) x (by) 2 cm laceration to the back left side of head. Objective symptoms: Nonverbal sounds of distress such as crying, groaning, moaning, whimpering, whining. Medical care provided after fall: Transferred to ER for evaluation. Interventions and immediate measures taken: cold application, direct pressure to wound. The Report documented Evaluation: Her room was moved closer to the nurse's station to be closely monitored. R17's Facility Report Form, dated 2/16/22, documents, Reportable Event Occurred On: 2/10/22 at 3:20 PM. Description of Occurrence: Alleged resident fall resulting in a laceration to posterior left side of her head. M.D. (Medical Doctor) examined at the time with orders to transfer to (local hospital) for evaluation / treatment. This investigation fails to document a root cause. R17's Nurse's Noted, dated 2/10/22, documents, At 3:20 PM Res (resident) heard by Maintenance yelling for assistance, noted sitting on floor of room, with TV on floor, stated 'I was walking to kitchen' fell into dresser knocking it over and tv fell on top. Res was laying on roommates' side of room, No witnesses, VS: T:98.0, P:78, R:16, B/P:106/70, SPO2 (oxygen level): 97% RA (room air), has open area to back of head, (V29 Doctor) here at facility, checked Res. ordered to send res to (local hospital) to eval (evaluation) and tx (treatment). The Nurse's Note did not document her bed alarm was sounding at the time she was found. R17's Nurse's Note, dated 2/10/22, documents, Res returned from ER, Had CT (Computed Tomography) of cervical spine, Head, area to back of head closed w (with)/staples. R17's Nurse's Note, dated 2/11/22, documents, WEEKLY SKIN NOTE: Resident continues with 8 staples to back of head. No s/s (signs and symptoms) of infection. No complaints of pain. R17's Fall Care Plan Intervention for Falls, dated 2/11/22, documented (R17) moved closer to nurse's station and Anti-tippers to w/c. R17's MDS, dated [DATE], documents R17 is moderately impaired, has inattention and disorganized thinking that fluctuates and changes in severity, requires extensive assistance from 2 staff members for bed mobility, transfers and requires extensive assist from 1 staff member for locomotion and eating. This MDS also documents R17 is not steady and only able to stabilize with staff assistance for moving to seated to standing, walking, surface to surface transfer and uses a wheelchair for mobility. R17's Safety Events - Fall Event Full Body and Pain report, dated 5/1/22 at 10:41 AM, documents, Description: Fall to floor. Location of fall: Dining Room. What was the resident doing just prior to fall? Sleeping. Was fall witnessed? Yes. Detailed description of fall: fell right against wall and slid down wall hitting the floor. What was the resident's location prior to fall? In bed. Mental status prior to fall: confused, sleepy. Resident's usual ambulatory status: assist of one with / without device. Describe, if necessary: Resident tends to get up on own and ambulate very unsteady. Initial observation or complaint of injury: No injuries and no c/o pain at this time. Evaluation: Drinks to be placed in front of (R17) prior to leaving her at the table. R17's Occurrence Report, dated 5/1/22 at 6:52 AM, documents, Conclusion: (R17) was sitting in the dining room at her table waiting for staff to get her a drink. Staff turned around to go get the drink and (R17) got up without assistance to attempt to get it herself. Root cause: Due to cognition (R17) attempted to get her own coffee instead of waiting for staff. R17's Nurse's Note, dated 5/1/22, documents, At 6:52 AM this morning this nurse was called to the dining room where resident had fallen to the floor. There were no injuries noted and neuro checks were initiated. Staff got (R17) up out of bed for breakfast, brought her into the dining room and placed her at the table. Staff left her side to go get her some coffee that she was requesting. D/t (due to) her cognitive status and short-term attention span, (R17) was attempting to stand up to go get her own coffee when she fell to the right against the wall and slid down to the floor. A full body assessment was completed and no injuries were noted. Another resident was in the dining room at the time and stated that (R17) had hit her head against the wall, so neuro checks were initiated. The resident needs to have her water and coffee at the table before she arrives to the table so that in the future this can possibly be prevented. R17's Fall Care Plan Fall Intervention, dated 5/1/22 documents Drinks to be placed in front of (R17) prior to leaving her at table. R17's Safety Events - Fall Event Full Body and Pain report, dated 5/10/22 7:06 PM, documents, Description: Fall. Location of fall: Hallway. What was resident doing just prior to fall? sitting in chair. Was the fall witnessed? Yes. Description of fall: resident lowered self to back. What was resident's location prior to fall? in wheelchair. Mental status prior to fall: calm, confused. Residents' usual ambulatory status: assist of one with / without device. Initial observation or complaint of injury: No injuries. Evaluation: N/A event still open. R17's Occurrence Report, dated 5/10/22, documents, Nurses note of what happened: Resident was standing unassisted and lowered self to floor. Witness statement of what happened: Resident stood up, told her to sit down, then resident lowered herself to floor. Alarm: None. Conclusion: (R17) is at risk for falls with injury visual impairment, on psychoactive and cardiac medication. Root cause: Due to resident action or internal risk factors. This Report documented that no alarm was in place. R17's Nurse's Note, dated 5/10/22, documents, Resident had witnessed fall in corridor, no injuries noted, ROM intact, resident remains confused per baseline, resident did not hit head, Resident stated she was standing because she was waiting for a kiss, and then laid down, no c/o pain. VS 97.2, 68, 18, 126/58, 97% RA. R17's Fall Care Plan Intervention, dated 5/10/22, documented When (R17) rises from her w/c without assistance and staff are near a gait belt is to be immediately placed on her person. On 6/15/22 at 10:02 AM, V11 LPN, stated, She (R17) doesn't know her limits. She likes to get up. She was in the dining room screaming for coffee. The aide (does not remember who) got up and went to get her coffee to make her stop screaming. The next thing you know she is under the table. When she gets impulsive with me, I keep her within arm's reach. In my opinion the aide should not have left her but I think she was just trying to make her stop screaming. On 6/13/22 at 12:38 PM, V8 CNA, stated, She (R17) is constantly up and down. She is a high fall risk. We have an alarm on her, we try to redirect her, walk her around and she gets cold so we put lots of blankets and her and that seems to help. On 6/16/22 at 8:00 AM, V1, Administrator, stated, She (R17) is hard. When questioned if R17 should have been left alone at the table while she was screaming for coffee as impulsive as she is, V1 stated, I am going to have to review the notes. I am not sure. V1 stated, I was here the day she got the laceration. (V29, Physician) was in the building. We had (V29) evaluate her and he gave us orders to take her to ER. We got the bleeding to stop. We applied ice. (R17) was awake and alert. I and the van driver drove her to the hospital and stayed with her until her Power of Attorney arrived. On 6/16/22 at 12:15 PM, V1stated, She (R17) should have footwear on but she does take her socks off. She really needs a one on one which we don't have the staff for. I am not giving that as answer though. The last fall she was sitting next to the nurse. She is very impulsive. 2. R14's MDS, dated [DATE], documents R14 is totally dependent of 2 staff members for transfers. R14's Care Plan, dated 1/11/22, documents, (R14) is at risk for falls due to [CONDITION(S)]. (R14) uses assist of 2 staff (mechanical) lift for transfers. On 06/13/22 at 1:16 PM, V13 CNA was standing behind R14's wheelchair. V8, CNA was operating the controls while pushing the full body mechanical lift. R14 was swinging in the air. V13 and V8 were transferring R14 using a white sling. There was signage on the wall documenting R14 should use a blue sling only. On 6/14/22 at 12:58 PM, V13 and V12, CNA, entered R14's room to transfer R14 to bed with a mechanical lift. R14 was sitting on a white mechanical lift sling. V12 and V13 attached the sling to the lift. V12 raised the lift while V13 stood behind the wheelchair. While R14 was being raised it was observed that the sling had a hole in the back of the sling the approximate size of an orange. V12 pushed R14 over to the bed. V13 stood on the right side of the bed. V13 at no time held the sling while R14 was being pushed over to the bed. On 6/14/22 at 1:10 PM, V12 was questioned about the signage on R14's wall documenting, Use Blue sling only. V12 stated, We are supposed to use a blue sling on her but she threw up on it last night and I had to send it to laundry. V12 stated, The difference between the blue and white slings is the blue is a full body sling and it is wider so it doesn't push her so much. V12 also stated that she was unaware of the hole in the white sling and that the aides are supposed to check the straps for rips or threads. On 6/15/22 at 12:00 PM, V1, Administrator, stated, The laundry aides should look at all the slings and inspect them. They should have noticed the hole in that sling that should not have happened. 3. R9's Care Plan, dated 1/11/2022, documents (R9) is limited in ability to transfer self R/T (related to) unsteadiness on feet, generalized muscle weakness, and hx (history) of falls. (R9) has diagnoses of hx of displaced intertrochanteric fracture of left femur, diabetes mellitus due to underlying condition with diabetic [CONDITION(S)], unspecified systolic (congestive) heart failure, other persistent [CONDITION(S)], [CONDITION(S)] of B-cell type in remission, chronic kidney disease, stage 4 (severe), [CONDITION(S)], unspecified, [CONDITION(S)] [CONDITION(S)], unspecified, other [CONDITION(S)], other specified depressive episodes, gastro-[CONDITION(S)] reflux disease without esophagitis, restless legs syndrome, primary pulmonary hypertension, [CONDITION(S)], unspecified. (R9) needs ADL assistance. (R9) is alert and oriented times three with some confusion. The Care Plan documents (R9) requires limited to extensive assistance of one to two staff for transferring and toileting. The Care Plan documents The amount of assistance required may fluctuate throughout the day. Provide the amount of assistance required and document every shift, daily. R9's MDS, dated [DATE], documents extensive assist of 2 staff for transfers. On 6/13/2022 at 10:30 AM V7, CNA transferred R9 on and off the toilet without the use of a gait belt. V7 grabbed R9 by the arm and assisted her into the standing position pulled up R9's pants and then grabbing hold of R9's pants transferred her into the wheelchair. The facility's Gait Belts policy, dated 4/13, documents General: Gait belts are used to help prevent injury of staff or residents during transfers and ambulation. Policy: Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. 9. To transfer the resident, assist to standing by holding the belt at the waist and pivot the resident to the chair. 10. To ambulate the resident, stand at the resident's weak side and grasp the belt at the waist underneath. 4. R10's Care Plan, dated 5/27/2022, documents (R10) is at risk for falling R/T [CONDITION(S)] (stroke) causing right sided weakness. The Care Plan documents Assist (R10) to assume a standing position slowly. R10's Care Plan Intervention, dated 4/16/22, documents Alarming floor mat on floor beside bed. R10's Care Plan Intervention, dated 11/11/21 documents Pressure alarm to w/c (wheelchair). R10's Care Plan Intervention, dated 12/2/21, documents Pressure alarm in bed also. R10's MDS, dated [DATE], documents R10 requires extensive assist of 2 staff for transfers. On 6/13/2022 at 12:10 PM V8 and V7 transferred R10 to the toilet without a gait belt. R10 was sitting on the toilet with no gait belt on. At 12:18 PM R10 stated that she was finished. V8 stated that R10 had to wait until they got a gait belt. At 12:20 PM R10 stated that she has never worn a gait belt and no one has asked her to wear one. At 12:22 PM V8 assisted R10 into a standing position and assisted with cleansing. V7, alone, ambulated R10 from the bathroom to the bed. R10 had an unsteady balance when ambulating. On 6/13/2022 at 12:23 PM, V8 stated that she did not use a gait belt when transferring R10 to the toilet. V8 stated that she had R10 hold on to the bar and helped her stand and sit on the toilet. V8 stated that they are to use a gait belt when transferring R10 but she did not have one on her. On 6/14/2022 at 12:12 PM, R10 was ambulating in room and no alarm was sounding. At 12:13 PM., R10 was standing at bathroom door with V27, CNA, no alarm sounding. V27 requested a gait belt. V27 then ambulated R10 from the bathroom to the bed, no gait belt applied. There was an alarm pad on the floor, partially beneath the bed and alarm box unattached. Once in the bed V27 then removed the alarm box from the wheelchair cross the room and attached it to the alarm pad. On 6/14/2022 at V27 stated that she was passing the room and saw R10 coming from the bathroom. V27 stated that R10 is a high fall risk and that she requires monitoring. On 6/16/2022 at 12:10 PM V11, LPN, stated that she would expect the staff to use a gait belt when manually transferring a resident. 5. R27's Care Plan, last review dated 4/20/2022, documents Problem: (R27) is at risk for falling R/T weakness. It continues Approach: assist (R27) to assume a standing position slowly using the sit to stand and two staff. It also documents Problem: (R27) is a [AGE] year-old Caucasian male that admitted to facility from outlying hospital where he was being treated for generalized weakness, small bilateral pleural effusion, stercoral [CONDITION(S)], small to moderate pericardial effusion, CKD (Chronic Kidney Disease) stage 3, [CONDITION(S)], and [CONDITION(S)] (Urinary Tract Infection). (R27) is alert and able to make his needs known. On 6/13/ at 12:40 PM V9, CNA and V10, CNA, assisted R27 with a transfer from the wheelchair to the recliner. V9 and V10 applied the gait belt to R27 and lifted R27 into a standing position with knees bent. V9 and V10 then turned R27 and pulled him over in front of the recliner, dragging R27's feet. V9 and V10 then sat R27 into the recliner. R27 did not participate in the transfer. On 6/13/2022 at 10:15 AM R27 stated that he needs help with getting into his chair. R27 stated that sometimes the staff transfer him themselves and sometimes they use the lift. R27 stated that it depends on who is here. R27 stated that he is supposed to use the standup lift. On 6/13/2022 at 12:30 PM V7, CNA, stated that someone was going to assist R27 into the bed they were trying to find the mechanical lift. On 6/16/2022 at 12:10 PM V11, LPN, stated that R27 requires the standup (partial) mechanical lift to transfer and would expect the staff to transfer R27 with the standup mechanical lift. On 6/16/2022 at 10:00 AM V20, Restorative Nurse, stated that she had a list of how residents are transferred. V20 stated that R27 did require a partial mechanical lift but now requires a 2-person manual transfer. V20 stated that R27 is receiving therapy and therapy changed his transfer. V20 stated that if R27 is not bearing weight and not participating in the transfer than he would need a mechanical lift. On 6/16/2022 at 10:15 AM V18, Therapy Director, stated that R27 is being seen by therapy. V18 stated that per the documentation therapy is working on transfers with R27. V18 stated that R27 was requiring max assist with verbal cues for therapy. V18 stated that R27 had increased leaning back with transfers and when standing still. V18 stated that if you didn't have hold of him, he would fall. V18 stated that R27 had decrease lateral stepping movement for pivoting cause R27 not to move feet with transfer. R27 stated that when transferring the resident therapy is performing the manual transfer. V18 stated this is not the transfer that nursing is doing. V18 stated that they would not tell nursing to perform an unsafe transfer. V18 stated that although it may look good in therapy notes it is actually saying he is having a decline. When notified of the care plan documenting partial mechanical lift, V18 stated that this would be the correct transfer. V18 stated that therapy would not change the residents transfer unless they are sure it would be safe. V18 stated that as current decline they are not at a point where they would change R27's transfer from a partial mechanical lift to a 2-person manual transfer. On 6/16/2022 the Facility Transfer policy was requested. The facility did not provide a policy. The policy Falls, dated 8/2008, documents, 5. The staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events, etc. 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the vindictive continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. a. After more than one fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the course or the management of falling and fall risk. Treatment Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls ant to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuations (for example if a resident continues to try and get up and walk without waiting for assistance.)