Every finding on record at Princeton Medical Lodge

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and hazards. The facility failed to ensure CNA E properly transferred Resident #1 without a gait belt causing significant bruising and pain to her left upper arm. The noncompliance was identified as PNC. The non-compliance began on 08/14/26 and ended on 08/27/26. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, or harm.Findings included: Record review of the admission Record for Resident #1 dated 08/31/26 reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Non-traumatic Hematoma of Soft Tissue (localized collection of blood outside the blood vessels within muscles, fat, or other soft tissues that develops without any clear history of an external injury or physical trauma), Age-related Osteoporosis without Current Pathological Fracture (patient has low bone density with no broken bones), and Parkinson's Disease (slow, progressive brain disorder that causes problems with movement, balance, and other body functions). Record review of the MDS Assessment for Resident #1 dated 06/09/26 reflected Resident #1 required complete assistance with toileting and substantial to maximal assistance with transferring from chair to bed and bed to chair. Resident #1 scored a 03 on the Brief Interview for Mental Status indicating Resident #1 has severe cognitive impairment. Record review of the Care Plan for Resident #1 dated 02/26/23 reflected Resident #1 was at risk for injury/immobility due to need for quarter or half rails to assist with turning and repositioning. Resident #1 needed assistance with ADLs related to increased weakness and Parkinson's. As of 08/18/26 Resident #1 was noted to require Hoyer life for all transfers. Resident was at risk for complications due to receiving anticoagulant therapy. Record review of the Incident Report for Resident #1 dated 08/15/26 reflected Resident: [Resident #1].Incident Description: Nursing Description: .report to this nurse that he noticed swelling on resident's left arm. Resident Description: Resident unable to stated [sic] she cannot remember what happened. Resident she [sic] felt pain last night.Immediate Action Taken Description: Assessment done. Resident noted with swelling and bruising to left shoulder extending to the left arm.New order STAT left should x-ray.Lay left arm in sling. Avoid use of left hand until further discussion after x-ray results.Injury Type 'Bruise' Injury Location.Left shoulder (front).Level of Pain: Numerical 5 [scoring for pain was 0-10 with 10 being the worse pain imaginable]. Record review of the ADL-Bathing for Resident #1 reflected Resident #1 received a bed bath on 08/15/26 and did not receive one on 08/18/26 as scheduled. Record review of the Radiology Results for Resident #1 dated 08/15/26 reflected Diagnostic Exam: Left should x-ray Date completed: 8/15/26. There is no acute fracture or dislocation. The soft tissues are grossly unremarkable.Impression: No evidence for acute bony injury.New Orders Received:.ice pack 10 minutes on and 10 minutes off for 48 hours prn. Record review of the Progress Notes for Resident #1 written by LVN G dated 08/15/26 reflected on call [NP] called for updated report on patient. Nurse provided most recent vitals, xray results and condition - ice pack removed pt asked to remove sling due to being uncomfortable nurse advised we could not remove but instead repositioned and provided pillow underneath. Spoke with on call nurse about schedule and prn pain medication. Will administer prn muscle relaxer for pain if indicated. Record review of a Handwritten Statement by CNA F dated 08/15/26 reflected After coming from lunch [Resident #1] was sitting in her wheelchair in the hall. [CNA E] asked me to her with [another resident]. So I told her lets lay [Resident #1] down first. She took [Resident #1] to the room. Changed the dirty pad to a clean one. [CNA E] then put her arms around [Resident #1] waist and lifted her up. [Resident #1] then started yelling like if she is in pain. I tried to grab her pants but [CNA E] had already put her in bed. So I left the room to go attend [to another resident]. Record review of a Handwritten Statement by Family Member per Resident #1 dated 08/15/26 reflected [Resident #1] said that her should [sic] started hurting after the ladies helped lift her into the bed this morning. She said they lifted her under her arms like a little kid. She said one lifted her around her arms, the other lifted her legs. She said that she thinks the one with pink hair lifted her up top. She also said that she felt like this was when it finally cracked. They lifted her over the bed rail, she said, and didn't lower it. Record review of Hospital Records for Resident #1 dated 08/16/26-08/19/26 revealed Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. Note Date: 08/16/26.History and Physical-Chief Complaint: Swelling and pain in the arm and chest.The patient is a [AGE] year-old female who resides at [facility]. On Saturday, 08/15, family members were visiting and noticed swelling on her arm and chest. When her [Family Member] reached over to giver her a hug, she winced in pain. Swelling was noted on left side of the chest, left arm. The family notified the nursing staff, as the aides had not reported this to them. Initially, it appears as though her shoulder might be dislocated. An X-ray and blood were ordered at the facility. The X-ray did not show any fractures, and the blood work did not reveal significant abnormalities. Ice was applied to the affected area. On Sunday, 08/16, family members returned and observed that the swelling appeared to have increased. Patient was brought here for further evaluation. The patient reports that every time she was moved, the area became more sore. Pain worsens whenever she was being transferred from the chair to the bed and from the bed to the chair.Test Results CT Chest.08/16/26).Impression: 1. Within the left axillary [space between the shoulder joint/arm pit] region/chest wall there is an intramuscular/intermuscular heterogeneous [within the muscle and between the muscle the visita appearance] density fluid collection measuring approximately 7.0 x 11.8 x 5.6 cm, likely a hematoma [bruise]. The fluid collection extends to the medial aspect of the left arm.Shoulder.Impression: No acute osseous injury.Test Result MR Upper Extremity-LT [left].Impression 1. Left anterior [situated at or directed toward the front of the body] left axillary and anterior upper left chest wall intramuscular/subcutaneous [under the skin] hematoma, suspected measuring at lead 11 cm in greatest cross-section diameter.2. No acute of healing fracture. Record review of the Progress Notes for Resident #1 dated 08/16/26 reflected Lab results reviewed with no critical results. Send resident to ER for evaluation. Record review of the Transfer Out Note for Resident #1 dated 08/16/26 reflected .Clinical Condition/Reason for Transfer:: Left shoulder pain/swelling Interventions Attempted Prior to D/C:: Left should x-ray done. No fractures of dislocation observed. CBC, CMP completed. No critical findings. Routine narco [sic Norco] administered PRN ice pack applied. Record review of the Progress Note for Resident #1 dated 08/19/26 reflected Therapy screen completed. Pt out to the hospital. Pt to be transferred using Hoyer lift. In an interview with the DON on 08/31/26 at 8:50a.m. revealed Resident #1 was sent to the hospital. Resident #1 was described to be alert and oriented and was able to explain what happened. Resident #1 had bruising to her shoulder and they worked on an investigation. The DON stated the investigation showed a CNA lifted Resident #1 and transferred Resident #1 incorrectly, not using a gait belt. In an interview with Family Member of Resident #1 on 08/31/26 at 9:19a.m. revealed about two weeks ago, Saturday (08/15/26), the family was visiting Resident #1. As they were getting ready to leave, the Family Member went to give Resident #1 a hug. The Family member felt Resident #1's arm and stated it did not feel right, there was swelling. The Family Member stated the shoulder appeared to be dislocated. The Family Member stated they went to the nurse and the Manager on Duty. At that point an x-ray and blood work were ordered. The facility started an investigation and learned a CNA did not properly transfer Resident #1 on Friday evening or Saturday morning. On Sunday morning (08/16/26) there was no clear cause to why there was swelling and bruising so Resident #1 was transferred to the hospital. Resident #1 reported to the Family Member that a lady lifted her under her arm, like a kid. And noted CNA was a lady with pink hair. The Family Member stated they had never been concerned about poor treatment of Resident #1 but concerned that this occurred. In an interview with Resident #1 on 08/31/26 at 9:54a.m. revealed she was doing better but still had a little pain in her arm. Resident #1 stated she was transferred from her chair to her bed. Resident #1 stated the person picked her up under her arms. Resident #1 stated no one had transferred her that way again. Resident #1 stated this was done a couple of times. Resident #1 stated she did not think the CNA was trying to mistreat her, she just transferred her wrong. Resident #1 stated she told the CNA she was hurting. Resident #1 stated she was now being transferred with a lift. Resident #1 was not able to describe or say who the person was. In an interview with CNA D on 08/31/26 at 10:06a.m. revealed Resident #1 was scheduled for bed baths on Tuesday, Thursday and Saturdays. Prior to Resident #1 going to the hospital CNA D stated she gave Resident #1 a bed bath. CNA D stated she did not notice any bruising to Resident #1. Resident went out to the hospital over the hospital and when she returned Resident #1 told her she was transferred wrong which caused the bruise. CNA D stated Resident was able to stand and assist with transfers previously. CNA D stated Resident #1 was a one-person gait belt transfer but had been changed to a lift transfer. In an interview CNA E on 08/31/26 at 10:17a.m. revealed she did not know what happened to Resident #1. CNA E stated she had worked at the facility for three months and she was never told Resident #1 was a two-person transfer. CNA E stated she would pick Resident #1 up with the waist band of her pants or with a gait belt. CNA E stated on the day in question there was another CNA in the room assisting her. CNA E stated she was not able to remember the other CNAs name. CNA E stated she was supposed to give Resident #1 a bath that morning but stated she never got around to it during the shift. CNA E stated she learned Resident #1 had bruising on her arm after the family came into visit. Resident #1 reported she had been hurting through the night. CNA E stated she wore her hair in different colors. CNA E stated she recently wore orange hair but did not indicate pink. In an interview with CNA F on 08/31/26 at 10:59a.m. revealed she was working on the hall with CNA E. After lunch Resident #1 was up in her wheelchair. CNA E asked her for assistance with lift transfer. CNA F stated she asked CNA E to put Resident #1 to bed first since she had been up a while. CNA E pushed Resident #1 in her wheelchair to her room, up to her bed. CNA E then put her arms around Resident #1 and lifted Resident #1. CNA F explained CNA E did not use a gait belt and she did not wait for her to help assist her. Resident #1 yelled out in pain. About an hour after the incident, she was called by the nurse to see what happened earlier in the day. CNA F stated she did not assist CNA E the day before and did not previously assist her with any transfers. CNA E stated she was not familiar with Resident #1. In an interview with CNA H on 08/31/26 at 11:14a.m. revealed when she came in to work her shift that night (08/15/26) Resident #1's family was observed in the room and showed her the bruising on Resident #1's arm. CNA H stated she had not seen the bruising. CNA H stated Resident #1 did not tell her what happened. CNA H described Resident #1 as a one-person gait belt transfer. In an interview with CNA I on 08/31/26 at 11:28a.m. revealed she was working on the hall where Resident #1 resided. CNA I stated she did not work with her during this time and did not assist CNA E. CNA I described Resident #1 to previous be a one-person gait belt transfer but not required the lift. CNA I stated she worked with CNA E on 08/14/26 and 08/16/26 on the same hall. CNA I denied seeing bruising on Resident #1. In an interview with LVN G on 08/31/26 at 11:34a.m. revealed she was the nurse on duty when Resident #1's Family Member came to her concerned about Resident #1's arm being swollen and bruised. LVN G stated she asked CNA E, she denied knowing about the bruise. LVN G stated she went and assessed Resident #1's arm and noted it was swollen and bruised. LVN G notified the physician, DON, and got x-rays of the arm. The x-ray results showed no fractures or other injuries, and her blood work came back normal. The following day Resident #1 was still having pain and swelling so she was sent out to the hospital. LVN G stated Resident #1 did not specify to her what happened. LVN G stated at the time of the incident Resident #1 was a one-person gait belt transfer. In an interview with Former Administrator on 08/31/26 at 1:22p.m. revealed the family of Resident #1 was at the facility and noticed a bruise to Resident #1's shoulder and notified nursing. Resident #1 was sent out to the hospital. CNA E was suspended pending investigation. Due to investigations, staff interviews and resident interviews it was determined the bruise was likely caused by improper transfer. CNA E was ultimately terminated after the investigation. CNA E was described by the resident and staff as having pink hair. The Former Administrator stated the DON and he both attempted to get a statement and talked with CNA, but she became very loud and aggressive and would not give a statement to them. In an interview with the Housekeeping Supervisor on 08/31/26 at 1:51 p.m. revealed she was Manager on Duty on 08/15/26 and 08/16/26. The Housekeeping Supervisor stated LVN G stated Resident #1's Family Member needed to speak with her. The Housekeeping Supervisor stated Family Member stated she had a bruise on her shoulder. The Housekeeping Supervisor and Lead CNA went down to Resident #1's room. When Resident #1 was asked what happened she stated it had happened the day before or that the pain started the day before. Resident #1 stated the CNA with the pink hair, she's nice but she put me in bed wrong. Resident #1 explained she did not put the bed rail down and that CNA had lifted her over the bed rail. Resident #1 denied that the CNA used a gait belt. The Housekeeping Supervisor stated she was not able to find CNA E for a while. The Housekeeping Supervisor stated CNA E had pink and blonde hair at the time of the incident. When she spoke with CNA E, she was very rude and aggressive. The Housekeeping Supervisor stated CNA E would not provide any information to her except said CNA F was there too. The Housekeeping Supervisor stated she spoke with CNA F who denied assisting with the transfer as CNA E stated. CNA F only stated she was in the room when CNA E transferred her. In an interview with the Lead CNA on 08/31/2026 at 1:58p.m. revealed her job was to educate CNAs, complete proficiency checks on new staff and annually including things like hand washing and ensuring staff were trained to transfer correctly according to their policy. The Lead CNA explained she was working on the floor as a CNA that day and went in with Housekeeping Supervisor to talk with Resident #1. The Lead CNA stated Resident #1's arm appeared to be dislocated and there was bruising. Resident #1 did not move her arm. The Lead CNA stated Resident #1 reported to them that her CNA transferred into bed and stated she could be difficult, but the staff were very nice. Resident #1 stated the CNA with pink hair grabbed her and pulled her onto the bed. Family Member reported CNA E came in and told them she picked Resident #1 up by the legs and the other CNA (CNA F) had her body. After this the Former Administrator and the DON were notified. The Lead CNA explained CNA E had pink hair at the time of the incident. The Lead CNA stated Resident #1 was able to assist with the pivot and transfer previously but was not being transferred with the lift for safety concerns. The Lead CNA stated CNA E had not been an employee for too long and explained she did her proficiency and stated CNA E did them correctly with the use of a gait belt. When the investigation was being conducted, she did education with the CNAs and went and watched them to ensure they were all checked off and correctly transferred residents. The Lead CNA stated all CNAs were provided with a gait belt and many of the residents had gait belts in their rooms. In an interview the DON on 08/31/26 at 2:07p.m. revealed all residents were noted on their care profile whether they required a two-person or lift transfer. If a resident required assistance with transfer by one-person this was not specifically documented anywhere. The DON explained if a transfer was required on any resident a gait belt was required. Gait belts were used for the safety of the resident and the staff. The DON noted that concerns such as Resident #1 resulted when not done properly. Record review of Transfer of Patient policy, undated, revealed Purpose: To safely move resident from one place to another. Equipment:1. Gait belt2. Wheelchair3 Non-skid shoesProcedure:1. Check physicians orders carefully2. Explain to resident what you are going to do.3. Make sure resident is wearing non-skid shoes.4. Position wheelchair at a 45 angle.5. Help resident to sit on edge of the bed with legs an [sic] feet hanging over the edge.6. Stand in front of the resident with a firm grasp on the gait belt that has been secured around waist.7. Help resident to stand.8. Pivot your body helping resident to pivot towards chair. 9. Bend your knees back straight and help resident to sit.One Person Pivot TransferPurpose: To safely get resident from one surface to another by allowing resident to participate by weight bearing during transfer. Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot.Equipment: 1. Gait Belt2. One staff memberProcedure1. Explain procedure to resident.2. Clear obstacles. Lock wheels/brakes, remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed.3. Assist resident to get on nonslip footwear.4. Assist resident to sit at bedside with feet on the floor. The resident's knees should be separated to provide a wide base of support.5. Apply gait belt snugly around waits.6. Stand in front of resident. Keep your feet apart, knees bend, and back straight.7. Place one hand under each side of the gait belt using and underhand grip.8. Instruct the resident on the count of three to lean forward and push up from the bed with his/her hands while you assist brining the resident's weight forward with the belt. Support the resident's knees and feet by placing your knees and feet firmly against them.9. Assist resident to pivot until the knees touch the back of the chair and the resident can reach the arm rests with his/her hands.10. Bend your knees and assist the resident to lower himself or herself into the chair.11. Remove the transfer belt.12. Adjust the wheelchair legs and footrests.13. Reverse the procedure to return to resident to bed. Record review of In-sevice Training Report dated 08/15/26 revealed training began on 08/15/26 indicating must follow resident care profile and use gait belts when transferring residents. Record review of Lift/Transfer Safety Checks dated 08/15/26-08/27/26 revealed each CNA was observed and checked to ensure proper training and ensuring transfers were being appropriately executed and gait belts were being utilized. Record review of the Grievances May through August 2026 revealed no concerns were reported about transfers. Record review of the Resident Council Minutes reviewed for past three months (June, July and August 2026) revealed no concerns were reported about transfers. Observations were made of CNA D, CNA B and CNA C on 08/31/26 11:00a.m. to 12:00p.m. and no concerns were observed. All performed one and two person transfers per policy and with a gait belt. Telephone interviews conducted with CNA F, Lead CNA, CNA H, CNA I and CNA J on 08/31/26 from 8:30a.m. through 2:00 p.m. revealed all were able to accurately explain how to execute a one- and two-person transfer utilizing a gait belt. Record review of Confidential Employee Corrective Action Form for CNA E dated 08/18/26 revealed .Policy Violation or Performance Issue.Failure to follow resident care plan related to transferring patients. This employe also failed to use a gait belt while transferring patient. Conduct that was observed and/or substantiated: Patient family reported significant bruising to patient arm/shoulder area. After investigation review and statement the multiple stories employee shared about the incident were able to be inaccurate and an attempt to cover up her failure to utilize 2 employees to transfer and not using her gait belt.These care concerns will result in a termination. Record review of a Separation Report dated 08/21/26 revealed CNA E was terminated due to Failure to follow residents plan related to transfer causing injury of resident. Terminated. The noncompliance was identified as PNC. The non-compliance began on 08/14/26 and ended on 08/27/26. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys accordance with professional standards for 1 (Resident #2) or 4 reviewed for the storage of drugs and biologicals. The facility failed to ensure Resident #2 did not have unsecured over the counter medications in her room when one container of Metamucil was observed sitting on the dresser in her room on 08/31/26. This failure could place residents at risk of diminished effectiveness, not receiving the therapeutic benefits of the medications, risk of medication misuse and administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries.Findings include: Record review of the admission Record for Resident #2 dated 08/31/26 reflected Resident #2 was an [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #2 was diagnosed with Hypo-osmolality and Hyponatremia (the amount of sodium in the body is too low), Cellulitis (common, potentially serious bacterial skin infection that affects the deeper layers of the skin and underlying tissues), Hypertension (high blood pressure). Record review of the Care Plan for Resident #2 dated 08/27/26 reflected no information to indicate Resident #2 was safe to self-administer her medications. NOTE: There was no current MDS due for Resident #2 due to her admission being 08/26/26. Record review of the Physician Orders for Resident #2 dated 08/31/26 reflected Resident #2 had an order for Psyllium Husk Powder (Metamucil), one packet by mouth in the evening for fiber. Record review of the MAR for Resident #2 dated August 2026 reflected Resident #2 had an order for Psyllium Husk Powder, one packet by mouth in the evening for fiber. Resident #2 had received doses on 08/27/26-08/30/26. Observation on 08/31/26 at 11:47 a.m. revealed Resident #2 had a container of Metamucil sitting under her television and on top of her dresser. Observation and interview on 08/31/26 at 12:23p.m. revealed RN A was not aware Resident #2 had Metamucil in her room. Resident #2 stated she took the medication 2-3 times per week, when she needed it. Resident #2 did not indicate when the last time she took the medication was. RN A explained she had to have a physician's order for her to take the medication and that Resident #2 was not able to store medications, unlocked in her room. Resident #2 expressed understanding and RN A removed the Metamucil, labeled the top of the container with Resident #2's information and stored it on the medication cart. In an interview with the DON on 08/31/26 at 12:45p.m. revealed RN A had informed her of the medication in Resident #2's room. The DON stated she first looked in Resident #2's chart to see if she was able to self-administer medication and stated Resident #2 had not been assessed and should not have had medications stored in her room. In an interview with the DON on 08/31/26 at 2:07p.m. revealed Resident #2 had to have brought the Metamucil in with her or had her family bring it to her. The DON explained due to the safety of the resident, and other residents, residents should not have medications unsecured in their room. Review of Storage of Drugs, undated, reflected All drugs and biologicals are stored in locked compartments under proper temperature controls.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #3) of 4 residents observed for infection control. CNA B and CNA C failed to follow Enhanced Barrier Precautions when they did not put on an isolation gown to perform a two person transfer with Resident #3. This failure could place residents at risk of cross contamination which could result in infections or illness.Findings include: Record review of the admission Record for Resident #3 dated 08/31/26 revealed Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was diagnosed with Diverticulitis (condition characterized by the formation of small pouches in the colon become inflamed or infected, leading to more severe symptoms), Cerebral Infarction (when a blood clot forms in an artery in the brain, disrupting blood flow and leading to brain cell death), and Hyperlipidemia (condition characterized by elevated levels of cholesterol in the blood, particularly low-density lipoprotein). Record review of the Nursing Admission/readmission Assessment for Resident #3 dated 08/25/26 revealed Resident #3 required assistance with toileting and transfers due to decreased strength by one or more people. Resident #3 had bed rails for positioning and support to promote increased independence or ability to assist in positioning, bed mobility and transfers. Resident #3 was noted to be receiving special treatments identified as intravenous medications. Record review of the Care Plan Report for Resident #3 dated 08/07/26 revealed Resident #3 was receiving IV medications. Resident #3 also required assistance with ADLs. Record review of the Physician Orders for Resident #3 dated August 2026 reflected Resident #3 had a midline (a catheter inserted in the upper arm) IV for antibiotics and flushes. Record review of the MAR for Resident #3 dated August 2026 reflected Resident #3 had finished her IV antibiotics on 08/25/2026. Observation and interview on 08/31/26 at 11:58a.m. revealed a sign on the outside of Resident #3's that indicated enhanced barrier precautions were to be followed in Resident #3's room. Resident #3 was lying in her bed. Resident #3 explained she had been in the facility for a couple of weeks being treated with IV antibiotics due to having an abscess in her colon and she was receiving therapy to get stronger to go home. CNA B and CNA C came in the room and explained to Resident #3 they were going to assist her out of bed for lunch. CNA B and CNA C then went into the bathroom to wash their hands. CNA B and CNA C put on gloves and then worked with Resident #3 to sit her up in bed and place a gait belt around Resident #3's waist. Together CNA B and CNA C transferred Resident #3 from her bed to her wheelchair and then removed the gait belt. CNA B and CNA C did not put on an isolation gown or any other PPE. In an interview with RN A on 08/31/26 at 12:20p.m. revealed Resident #3 still had her midline and was receiving flushes through the midline IV but was no longer receiving antibiotics. RN A stated Resident #3 finished her antibiotics on 08/25/26. The physician was waiting on some blood work results to determine if any additional antibiotics were needed before removing the midline IV. Observation and interview with Resident #3 on 08/31/26 at 12:22p.m. revealed she still had a midline in her upper right arm. Resident #3 stated she had an upcoming doctor appointment to determine if her infection was gone and if the midline could be removed. In an interview with the DON on 08/31/26 at 12:45p.m. revealed any residents who had an IV line (midline) was considered a resident at risk of infection and the staff should be following enhanced barrier precautions. In an interview with CNA B on 08/31/26 at 12:58p.m. revealed CNA B followed the sign posted at the door of the resident's room. CNA B pointed out that Resident #3 had switched from the B (by the window) to the A (closest to the door/hallway) bed and she got confused. CNA B confirmed she should have worn PPE while transferring Resident #3. In an interview with CNA C on 08/31/26 at 12:59p.m. revealed CNA C also was confused about Resident #3 being in the A bed instead of the B bed. CNA C stated she was a resident who required PPE while performing transfers. CNA C confirmed Resident #3 did not have a roommate. In an interview with the DON on 08/31/26 at 2:07p.m. revealed enhanced barrier precaution protocols were to be followed with any resident with an IV, foley catheter, wounds, infection in order to protect the resident, the staff and other residents from the spread of infection. The DON said PPE was to be utilized during transfers, and any care where the resident would be touched. Record review of the Enhanced Barrier Precautions (EBP) policy, undated, reflected Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for resident with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies, a peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for accidents and hazards. The facility left Resident #1 in a wheelchair unattended on the night of 7/15/26 and early morning on 7/16/26 and failed to check on her during that time. These failures could put residents at risk of frequent accidents and decline in health. Findings included:Record review of Resident #1's face sheet, dated 7/20/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following pertinent diagnoses: unsteadiness on feet, lack of coordination, dependence on wheelchair, unspecified dementia (a clear memory loss and thinking problem), anxiety disorder (a condition involving excessive, ongoing fear or worry that is hard to control), and insomnia (trouble falling asleep, staying asleep or waking up too early). Record review of Resident #1's Quarterly MDS Assessment, dated 6/24/26, reflected Resident #1 had severe cognitive impairment with a BIMS of 5. Section GG reflected Resident #1 required maximal assistance with ADLs and transfers. Record review of Resident #1's Care Plan Report, revised on 4/16/26, reflected .Resident requires assist with ADLs -prefers female staff for all care, 2 people in room when providing care Date Initiated: 11/14/2024 Revision on: 04/16/2025 Resident requires assist with ADLs - prefers female staff for all care, 2 people in room when providing care Date Initiated: 11/14/2024 Revision on: 04/16/2025 . Encourage independence in performance of self-care and mobility within limitations. Date Initiated: 11/14/2024 Female staff to provide care Date Initiated: 04/16/2025 Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs Q shift Date Initiated: 11/14/2024 resident is to use double handed cup with a lid to prevent spilling d/t tremors Date Initiated: 12/10/2024.Record review of video evidence from Resident #1 room, dated 7/15/26 at 6:33 p.m., reflected Resident #1's relative left the room and Resident #1 was sitting in her wheelchair. Record review of video evidence from Resident #1's room, dated 7/15/26 at 6:57 p.m., reflected an unknown staff member entered the room, checked Resident #1, who was sitting in her wheelchair, and talked to her. Record review of video evidence from Resident #1's room, dated 7/15/26 at 6:59 p.m., revealed RN A entered the room, assisted Resident #1's roommate and exited the room without checking on Resident #1. Resident #1 was sitting in her wheelchair. Record review of video evidence from Resident #1's room, dated 7/15/26 at 7:59 p.m., revealed Resident #1 was sitting in her wheelchair. Record review of video evidence from Resident #1's room, dated 7/15/26 at 11:58 p.m., revealed Resident #1 was sitting in her wheelchair. Record review of video evidence from Resident #1's room, dated 7/16/26 at 12:58 a.m., revealed Resident #1 was sitting in her wheelchair. Record review of video evidence from Resident #1's room, dated 7/16/26 at 1:08 a.m., revealed Resident #1 was sitting in her wheelchair bending forward in her wheelchair and stated help repeatedly, but the door was closed and no staff entered. Record review of video evidence from Resident #1's room, dated 7/16/26 at 2:45 a.m., revealed Resident #1 was sitting in her wheelchair still leaning forward with her torso bent on her lap and she rolled out of the wheelchair to the floor. Resident #1 was heard yelling help, but the door was still closed and no staff entered. Record review of video evidence from Resident #1's room, dated 7/16/26 at 3:17 a.m., revealed Resident #1 was not visible in her wheelchair and her legs and part of her feet were observed on the floor, laying underneath the wheelchair. CNA B entered the room observed Resident #1 on the floor and walked quickly to the door. Record review of video evidence from Resident #1's room, dated 7/16/26 at 3:18 a.m., revealed Resident #1 continued on the floor; CNA B returned and assisted her roommate. RN A rushed in and immediately called Resident #1's name and asked CNA B why wasn't she in bed, no response heard from CNA B. RN A asked Resident #1 if she was okay and what happened, Resident #1's response was unheard. RN A asked if she was in pain and if she was hurt, Resident #1 responded let me think, RN A told her she was going to move her leg and proceeded to move her leg. RN A spoke to CNA B and while RN A was holding Resident #1's hand and the video ended. An observation of Resident #1's room on 7/28/26 at 10:34 a.m. revealed the resident was not in her room. The room was observed to be free of hazards. An interview with LVN E on 7/28/26 at 11:30 a.m. revealed Resident #1 was usually very vocal about what she wanted and would tell staff when she was ready to be put in the bed. LVN E stated Resident #1 had been struggling recently with increased behaviors at night and at times would refuse to be transferred to her bed. LVN E stated she typically saw Resident #1 in her bed by the end of her shift at 6:00 p.m. daily. LVN E stated she typically checked on Resident #1 hourly due to her memory loss. An interview with CNA F on 7/28/26 at 11:36 a.m. revealed she checked on Resident #1 constantly due to her memory issues. CNA F stated she made it a habit to check on Resident #1 every time she passed her room. CNA F stated Resident #1 was unable to transfer herself and needed assistance to get from her wheelchair to her bed. CNA F stated she would try to put Resident #1 in her bed before the end of her shift at 6:00 p.m., but many times Resident #1 would refuse to be moved to her bed. CNA F stated if Resident #1 refused to go to bed she would have notified the nurse in charge. An interview and observation with Resident #1 with a relative on 7/28/26 at 1:31 p.m. revealed Resident #1 was very confused and unable to recall any events that had occurred. Resident #1 was sitting in her wheelchair in a common area of the building with her relative and was muttering random words. Resident #1's relative reported she was concerned and had video footage with Resident #1 in her wheelchair all night from 7/15/26 to 7/16/26 and no one ever checked on her. Resident #1's relative stated she was notified on 7/16/26 that Resident #1 had a fall at about 3am and when she looked at the video from Resident #1's room she saw no staff had ever put her to sleep and left her in her wheelchair all night. Resident #1's relative reported she was with her relative at the facility on 7/15/26, had fed her dinner and when she left, she told RN A her relative had gotten sleepy and was ready to be put in bed. Resident #1's relative stated when she reviewed the video footage staff had not entered Resident #1's room after about 7:30 p.m. on 7/15/26. A telephone interview with CNA B on 7/28/26 at 1:44 p.m. revealed on 7/15/26, she came on shift at 6:00 p.m. several hours into her shift she was informed she had to cover Resident #1's room because the assigned CNA had not showed up. CNA B was unable to recall the exact time she was assigned Resident #1's room. CNA B stated one of her colleagues took her to all the rooms she was covering and she glanced into Resident #1's room. CNA B stated she was busy that night taking care of another resident who needed close supervision and had not been able to check on Resident #1. CNA B stated at about 3:00 a.m. on 7/16/26, she walked into Resident #1's room and Resident #1 was on the floor and appeared to have fallen. CNA B stated she immediately told the nurse Resident #1 was on the floor. CNA B stated no one told her to put Resident #1 in her bed. CNA B stated the expectation was that she round and check on residents assigned to her every 2 to 3 hours. CNA B stated since the incident she was re-educated on rounding and following nurses' directives. CNA B stated the risk to the resident of her not rounding and putting Resident #1 in bed was her falling or something worse could have happened. An interview with RN G on 7/28/26 at 11:30 p.m. revealed Resident #1 was usually in bed at the start of his shift at 6:00 p.m. RN G stated if Resident #1 was not already in bed at the beginning of his shift he would have made sure she was in bed by 8:00 p.m. or 9:00 p.m. RN G stated at times Resident #1 would refuse to be transferred to bed and when that happened he would go back frequently until she allowed them to put her in bed. RN G stated at times Resident #1's relative would call to let staff know it was time to put Resident #1 in bed. RN G stated he checked on Resident #1 about every 1 to 2 hours because she struggled going to sleep and frequently woke up early. RN G stated 12:00 a.m. was too late to have Resident #1 in her wheelchair. RN G stated the risk to the residents of not putting them in bed at night timely would be they could fall.An interview with CNA H on 7/28/26 at 11:48 p.m. revealed Resident #1 was already in her bed when she arrived on shift at 6:00 p.m. and stated it was typical for her to be in bed by that time. CNA H stated if Resident #1 was not in bed at the beginning of her shift she usually had transferred her to the bed by 6:30 p.m. or 7:30 p.m. CNA H stated Resident #1 sometimes stayed awake all night and she would check on her every hour when she was awake. CNA H stated she would ensure Resident #1's door remained open throughout the night because Resident #1 would usually yell when she needed something. CNA H stated when she did her rounds at the facility if a resident was in their wheelchair, she would transfer them to their bed, and no dependent were ever in their wheelchair until midnight. CNA H stated it was important to round on Resident #1 and all residents to ensure they didn't need anything. CNA H stated the risk to the resident of not being checked on or transferred to their bed at night was they could have gotten injured or fallen from their chair. A telephone interview with RN A on 7/29/26 at 9:16 a.m. revealed she was the nurse for Resident #1 on the night shift on 7/15/26. RN A stated Resident #1's relative told her about 6:30 p.m. that Resident #1 was in her chair and ready for bed and she told the relative she would let the aide know. RN A stated she went back into Resident #1's between 6:30 p.m. and 7:00 p.m. to provide her roommate her medication at which time Resident #1 was yelling hello and RN A stated she asked her if she was ready for her medication. RN A stated Resident #1 stated no but she was ready for bed. RN A stated she told CNA B about putting Resident #1 in bed when RN A was notified CNA B was covering Resident #1's room. RN A stated she could not recall the time she had given CNA B report and told her to put Resident #1 to bed. RN A stated she told CNA B if Resident #1 gave her trouble she could assist with her, because CNA B was new and not familiar with Resident #1. RN A stated she had gotten busy with an emergency transfer of another resident to the hospital and a readmission and she had not checked on Resident #1 until she was informed by CNA B that Resident #1 was on the floor. RN A stated right before CNA B found Resident #1 on the floor, she asked CNA B how Resident #1 had done with the bed transfer and she stated CNA B appeared confused and CNA B left, went to Resident #1's room and then called her for help because Resident #1 was on the floor. RN A stated the last time she saw Resident #1 was about 7pm on 7/15/26 and had not seen her again until about 3am on 7/16/26 when CNA B told her the resident had fallen. RN A stated she typically checked on every resident during her shift every 2 to 3 hours. RN A stated Resident #1 was typically in bed when she started her shift but if Resident #1 was still in her wheelchair she tried to have her in bed shortly after her shift started. RN A stated she was not aware if anyone else checked on Resident #1 before 3am on 7/16/26. RN A stated she was re-educated on resident rights and rounding for residents on her shift. RN A stated the expectation was that she did rounds every 2 to 3 hours with her residents. RN A stated residents had the right to be checked on and their needs met; if they were not checked on, they could have gotten injured. RN A stated she completed an assessment of the resident and there was no injuries. An interview with the DON on 7/29/26 at 12:21 p.m. revealed the expectation for staff rounding at night and during the day was every 2-3 hours. The DON stated their investigation of Resident #1's fall revealed the RN A and CNA B failed to put Resident #1 in bed. The DON stated had the CNA and Nurse rounded they would have observed the resident was still in her wheelchair and could have put her in the bed sooner. The DON stated once the investigation was over the Administrator allowed RN A and CNA B to return to work and the DON provided them with one-on-one training. The DON stated she completed one on one training with RN A and CNA B on rounding, communication and charge nurses following up on delegated tasks. The DON stated the risk to the residents of not being checked on throughout the night would have been they could have fallen and gotten injured. The DON stated Resident #1 had no injury.An interview with the Administrator on 7/29/26 at 1:33 p.m. revealed he had investigated Resident #1's fall and had determined the nurse and CNA had not transferred Resident #1 back to bed and had not rounded resulting which resulted in her falling out of her wheelchair. The Administrator stated the expectation og of rounding, was staff needed to round on residents every two hours throughout the day and at night. The Administrator stated a resident should not be in their wheelchair from 6:30 p.m. to 3:00 a.m. The Administrator stated he included education with all staff on leaving residents in wheelchairs for extended periods when he discussed the expectation of frequent rounding. The Administrator stated the risk to the residents of not being transferred to their bed timely was falls. Record review of facility's Fall Investigation and Intervention Policy and Procedure with not revised date reflected .Investigate root cause of the fall .enter any new orders to Nurse Task and to the CNA, provide proof of education for any staff related incident, including therapy educaiton when appropriate.

Based on interview, record review and observation the facility failed to provide residents with the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 1 of 2 residents (Resident #2) reviewed for ADLs. The facility failed to assist Resident #2 for several hours in transferring from her bed to her wheelchair after she requested it on 7/28/26. This failure could place residents at risk of skin breakdowns, falls and affect their dignity and self-esteem.Findings included:Record review of Resident #2's face sheet, dated 7/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had the following pertinent diagnoses: multiple sclerosis (disease in which the body's immune system attacks the brain and spinal cord, disrupting the signals between the body and brain), other spondylosis (degenerative wear and tear of the spine) cervical region (neck), stiffness of unspecified joint, pain, nondisplaced fracture of neck of left radius (crack or break in the narrow part of the left arms radius bone), displaced intertrochanteric fracture of left femur (broken hip where the upper left thigh bone is cracked between its two outer bony knobs), nondisplaced fracture of left radial styloid process (a crack in the thumb-side wrist bone), and anxiety disorder (a condition involving excessive, ongoing fear and worry that do not go away and interfere with daily life). Record review of Resident #2's Quarterly MDS Assessment, dated 4/24/26, reflected Resident #2 was moderately cognitively impaired with a BIMS of 10. Section GG reflected Resident #2 she needed maximal assistance with ADLs which involved the use of her lower extremities and was fully dependent on staff for transfers. Record review or Resident #2's Care Plan Report, revised 9/22/25, reflected .Resident requires assist with ADLs Date Initiated: 08/29/2022 Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days Date Initiated: 08/29/2022 Revision on: 08/30/2023 Target Date: 07/12/2026 9/22/25- Hoyer lift for all transfers Date Initiated: 09/23/2025 Encourage independence in performance of self-care and mobility within limitations. Date Initiated: 08/29/2022 Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs Q shift Date Initiated: 08/29/2022 Provide level of support to complete transferring needs Q shift.Date Initiated: 08/29/2022 Reinforce use of aids to mobility as indicated Date Initiated: 08/29/2022.Record review of Report of Grievance/Complaint completed on 7/29/26 by Resident #2 reflected .[Resident #2] reporting issues with CNAs getting them up when requested.[Resident #2] state they are given the answer, 'I don't have time, I'm doing showers.' [Resident #2] state this happened the day shift of 6/22/26 and some weekends.An observation and interview with Resident #2 on 7/28/26 at 11:51 a.m. revealed Resident #2 was lying in her bed. Resident #2 stated she relied on staff for everything, could not walk or get out of bed unassisted. Resident #2 stated her concern was she had been waiting since 9:00 a.m. to get out of her bed. Resident #2 stated she told CNA C at about 9:00 a.m. she was ready to get out of bed and into her wheelchair and CNA C told her she needed to finish with a resident and would come and help her later. Resident #2 stated she then rang the call light again but could not provide a time and stated an unknown CNA responded and she once again told her she was ready to get out of bed. Resident #2 stated the unknown aid told her CNA C had been giving showers and when she was done, she would help her. Resident #2 stated she had also told LVN D she was ready to get out of bed when LVN D came to her room to ask when she wanted her breathing treatment. Resident #2 stated her preference to get out of the bed would be that she was assisted with getting out by 9 a.m. Resident #2 stated she was aware it took a lot of people to get her out of bed and therefore the staff typically would have her out of bed by 11 a.m. or after lunch. Resident #2 stated she felt as though staff had not wanted to assist her and staff did not care about her. An interview and observation of Resident #2 on 7/28/26 at 12:42 p.m. reflected Resident #2 was still in her bed. Resident #2 stated she had been waiting forever to get out of bed and LVN C had just responded to her call light and told her she was going to check on the CNAs to see what they were doing. An interview with CNA C on 7/28/26 at 12:46 p.m. revealed she came on shift at 6:00 a.m. and checked on Resident #2 at about 9:30 a.m. and at that time Resident #2 stated she wanted to get out of bed. CNA C stated she told Resident #2 she would get her out of bed when they were less busy. CNA C stated she had not been able to get her out of the bed because she had been giving other residents showers but planned to get her out of bed at lunch. CNA C stated she typically had gotten Resident #2 out of bed after lunch because Resident #2 had never told her she liked to be out of bed early. CNA C stated it was normal for Resident #2 to have to wait to get out of bed because she would wait until all her tasks were completed before she helped Resident #2 out of bed. CNA C stated the other CNA on the hall could not have helped Resident #2 get out of bed because they had also been doing showers. CNA C stated LVN D could not have assisted with getting Resident #2 out of bed sooner because she was busy passing out medications. CNA C stated Resident #2 told her in the past it was okay if she waited until she completed all her tasks to help her get out of bed. CNA C stated the resident having had to wait for 3 hours could have affected her in that she would feel like she was being neglected.An interview with LVN D on 7/28/26 at 12:56 p.m. reflected she had given Resident #2 breathing treatment mid-morning and stated Resident #2 had not mentioned wanting to get out of bed. LVN D stated about 12:00 p.m. she responded to Resident #2's call light and Resident #2 stated she had been waiting to get out of bed and told CNA C she was ready to get out of bed but she was still waiting. LVN D stated she told Resident #2 the CNAs would assist with getting her out of bed after lunch. LVN D stated she had two CNAs in the hall with her, and they were busy, so residents needed to tell them ahead of time when they wanted to get out of bed. LVN D stated she was not aware Resident #2 had expressed wanting to get out of bed at 9:00 a.m. nor was she aware Resident #2 stated it was her preference. LVN D stated the resident had refused to get out of bed early in the past. LVN D stated if the resident had waited since 9am to get out of the bed then it could have affected the resident by making them unhappy or mad. An interview with Resident #2 on 7/29/26 at 12:13 p.m. revealed staff transferred her out of bed on 7/28/26 at about 1:00 p.m. Resident #2 stated she was upset yesterday (7/28/26) that she had waited a long time to have been transferred out of her bed. An interview with the DON on 7/28/26 at 1:07 p.m. revealed the expectation of getting a resident out of bed would depend on what was going on in the hall the resident resided in; however, she would have expected the assistance to be timely or as soon as possible. The DON stated if staff were unable to assist a resident with a transfer when the resident requested it, the expectation was that staff would have communicated to the resident and notified them they were not able to transfer them immediately and sought out available staff that could have assisted with the task. The DON stated a resident waiting several hours to get out of bed would need to have been investigated to determine if it was acceptable and would look into the reason Resident #2 waiting that long. The DON stated her expectation on a regular day, if there wasn't a lot happening, would have been for the staff to get the resident out of bed within an hour of the resident request. The DON stated Resident #2 had a history of requesting to get out of bed frequently and only staying out of bed for a few minutes before requesting to go back to bed, having made it difficult to transfer her every time she requested. The DON stated residents had to wait a long time to get out of bed could have affected their resident rights. The DON stated she did not believe residents waiting several hours could have affected them in any other way besides violating their rights. An interview with the Administrator on 7/29/26 at 1:33 p.m. revealed he was not aware Resident #2's preference was to be out of bed by 9:00 a.m., he stated it was unlike her to have requested to get out of bed early in the morning. The Administrator stated when a resident requested to get in and out of bed the expectation was that staff got them out of bed as soon as possible. The Administrator stated he expected staff to notify residents when they were busy and could not transfer them and to notify another staff member to assist the resident with the transfer if the staff member was busy providing care and would have taken too long to transfer the resident. The Administrator stated the length of time Resident #2 waited to be transferred from her bed to her chair was not ideal and should have been done sooner. The Administrator stated he could not think of any negative effects to the resident of waiting a long time to get out of bed. The Administrator stated anything could have the potential for psycho-social harm, but he didn't believe the resident had to wait to get out of bed constituted psycho-social harm. Record review of the facility's, undated, Resident Right policy reflected The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence, self-determination and communication with and access to person and services inside and outside the facility.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biological were stored in locked compartments in accordance with State and Federal laws for three of eight residents (Resident #74, Resident #62 and Resident #69) reviewed for the storage of drugs and biologicals. The facility failed to ensure Resident # 74, Resident #62 and Resident #69 to have prescription and over the counter medication in a locked compartment. This failure could place residents at risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries.Findings included: 1. Record review of Resident #74's Quarterly MDS assessment, dated 01/20/26, reflected a [AGE] year-old male with an admission date of 08/12/25. Resident had a BIMS of 13 which indicated he was cognitively intact. Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels), diabetes and gastroesophageal reflux disease (heartburn and acid regurgitation).During an observation and interview on 03/10/26 at 1:30 p.m. revealed Resident #74 in his room lying in bed. Resident stated he was doing fair but stated he had a sore throat and had been coughing. A bottle of over-the-counter cough and congestion syrup and a bottle of Vapor Cool throat spray was noted to be on his over the bed table. The resident stated he had been taking the cough syrup about three times a day and was using the throat spray daily, but stated his throat was still sore. He stated he had told one of the nurses about his cough but was not sure which one and they told him he needed a prescription for cough syrup, so he called his family member and asked him to bring him some. Record Review of Resident #74's Physician order summary report dated 03/11/26 reflected an order for Guaifenesin Liquid 100/mg 5ml- give 10 ml by mouth every 4 hours as needed for cough.with a start date of 03/10/26 and an order for Chloraseptic mouth/throat liquid 1.4 % Give 4 spray by mouth every 4 hours as needed for sore throat. with a start date of 03/10/26. There were no orders for any medication at bedside.During an observation and interview made with LVN E on 03/11/26 at 1:50 p.m. in Resident #74's room. LVN E picked up the bottle of cough syrup and throat spray and stated the resident should not have the cough syrup at bedside and instructed the resident he needed to let them know if he needed something for his cough. Resident stated he had asked a nurse previously and she had told him he needed a prescription for cough syrup, so he just called his family member to bring him some. LVN E stated Resident #74 did have a previous order for the throat spray and he had been allowed to have that at bedside but stated the order had had not continued on the current orders. LVN E informed Resident #74 she would notify the doctor about his cough and sore throat and get something ordered for him. LVN E removed the items from the resident's room.2. Record review of Resident #62's quarterly MDS assessment dated [DATE] reflected an [AGE] year-old female with an admission date of 09/30/24. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She was independent to limited supervision for her ADLS. Diagnoses included Alzheimer's, osteoarthritis (wear-and-tear arthritis where the cartilage cushioning the ends of the bones wears down) and chronic obstructive pulmonary diseases (chronic airflow blockage, making it difficult to breath).During an observation and interview on 03/10/26 at 9:44 a.m. revealed Resident #62 in her room sitting on her bed. Resident was alert and very pleasant. Resident #62 stated she was doing good and had no complaints. A Proair HFA (albuterol sulfate) inhaler (used as short acting bronchodilator) was observed on her bedside table. She stated she had not used it in a while.Record review of Resident #62's Physician order Summary report dated 03/10/26 reflected an order for Albuterol Sulfate HFA Inhalation.1 puff inhale orally every 4 hours as needed for Shortness of breath.with a start date of 09/30/24. There were no orders for any medication at bedside.During an observation and interview with LVN E on 03/11/26 at 1:55 p.m. in Resident #62's room, LVN E picked up the ProAir HFA inhaler and informed Resident #62 she could not have it in her room. Resident #62 stated she had it ever since she had been here but stated she does not recall using it. In addition, the resident had a bottle of Bio Freeze (a topical menthol-based pain reliver) with a prescription label from Resident #62's previous facility and a fill date of May 2024. LVN E instructed Resident #62 she had orders for her inhaler and if she needed the Bio Freeze she could contact the physician.3. Record review of Resident #69's Annual MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date of 02/07/26. Resident #69 had a BIMS of 9 which indicated he was moderately cognitively impaired, required partial to moderate assistance with ADLS. Diagnoses included anxiety and chronic obstructive pulmonary diseases (chronic airflow blockage, making it difficult to breath).Record review of Resident #69 Physician order Summary report dated 03/10/26 reflected an order for Ventolin HFA Inhalation Aerosol solution ((Albuterol Sulfate) .2 application inhale orally every 4 hours as needed for wheezing/ Shortness of breath.with a start date of 02/07/26. There were no orders for any medication at bedside.During an observation and interview with Resident #69 on 03/10/26 at 10:18 a.m. Resident #69 opened his chest of drawers to show where he kept his nebulizer mask. In addition to the nebulizer mask, there was an albuterol sulfate inhaler. Resident #69 stated he used the inhaler in an emergency situation when he was short of breath. Resident #69 stated he used the inhaler a couple of times a day due to his chronic obstructive pulmonary disease. He stated he had not told the nurse when he used the inhaler. During an observation and interview with LVN E on 03/11/26 at 2:15 p.m. in Resident #69's room, LVN E picked up the Albuterol inhaler and informed Resident #69 he could not have it in his room. Resident #69 asked what he was supposed to do if he needed it and LVN E informed him he was to call them and they would provide him with his ordered breathing treatments. During the observation a bottle of over the counter sleep aid (doxylamine succinate) was also found on his bedside table. LVN E informed resident she would have to contact his physician for an order for a sleep aid if he was having trouble sleeping. Resident #69 stated he had not taken one for several weeks. LVN E removed both of the medications from Resident #69's room.During an interview with LVN E on 03/11/26 at 2:30 p.m. she stated none of the residents had been assessed to be able to self-administer medication and stated they were responsible for all of the medications the residents were to take. She stated having additional medication they were not aware of could pose a serious risk of overmedicating and or having a drug reaction with medications they were being given. She stated she was going to do a sweep of her hall to ensure no other medications were at residents' bedside. During an interview with the Regional Nurse Consultant and the new DON on 03/12/26 at 12:25.p.m., the Regional Nurse Consultant stated for a Resident to be able to leave medication at the bedside the facility had to complete a resident assessment to determine if the resident understood the directions for the use of the medication and the resident still must let the nurse know when they had administered the medication so it could be documented in the record. She stated none of the Residents had been assessed to have the capacity to manage their own medications. She stated the risk of leaving medications at the bedside was the resident could use the medication improperly, or some other resident could have access to a medication not prescribed for them. She stated it was the staff's responsibility to ensure the medications were kept secure and stored properly. She stated going forward they were starting at admission, going over with the resident and their family about the responsibility of the facility in managing all of their medications and instruct family to not bring in any medication including over the counter medications. She stated the staff should also be observing while in the Resident's room and reporting any medication they see at bedside to the Charge nurse and DON. Record review of the facility undated policy Drug Security, reflected, The facility establishes procedures for storing and disposing of drugs and biological in accordance with federal, state and local laws. A drug distribution cart is used by the facility and when not in use it will be locked and secured in the locked medication room.Self-administration medications will be kept in a locked cabinet in the resident's room. The facility will be responsible for medication security, accurate information, and medication compliance.All drugs must be prescribed by the resident's physician.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for the facility's only kitchen in that:The facility failed to ensure food items in the kitchen were appropriately covered on 3/10/2026.These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, if consumed and food contamination. Finding included: Observations on 03/10/2026 at 9:17 AM of the walk-in refrigerator revealed 6 heads of lettuce left open in a storage bin and 2 boiled eggs were left open in a plastic bag. Observations on 03/10/26 at 9:22 AM of the dry storage revealed a bulk container of thickener left open with lid not fully closed, 1/2 bag of pecans in a Ziplock bag left open to air, about 3/4 bag of cereal left in a plastic bag left open to air. In an interview on 03/11/2026 at 1:59 PM with the Dietary Manager revealed her expectation was all foods in the kitchen should be covered at all times. She stated that everyone in the kitchen including cooks, dietary aides, and herself were responsible for covering food items. She stated the risk of not appropriately covering food items was cross contamination of food, decreased freshness, and could make the residents sick. She stated that as a Dietary Manager she provided frequent in-services to all kitchen staff on appropriate food storage. In an interview on 03/11/2026 at 2:06 PM with [NAME] B stated all food items in the kitchen should be covered appropriately. She stated she had been a cook for 5 years in the kitchen. She stated that everyone who worked in the kitchen was responsible for covering food items. She stated that if the food was not covered, it needed to be discarded since it posed a risk of cross contamination and food borne illness to residents. In an interview on 03/11/2026 at 2:10 PM with Dietary Aide C stated that she had been working in the facility for about 3 years. She stated that everyone in the kitchen was responsible for covering food items She stated the risk of not appropriately covering food items was food contamination and food borne illness. She stated that she received in-services about appropriate food storage from the Dietary Manager at periodic intervals. Record review of facility policy operation/ resident care policies undated, reflected, .Food is stored, prepared, distributed and served to residents in accordance with professional standards for food service safety. Non-perishable foods must be maintained in air-tight closed containers to ensure freshness and for proper pest control measures.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one of four residents (Resident #10) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Resident #10. This failure could place residents who received oxygen therapy at risk of oxygen toxicity. Findings included: Record review of Resident #10's quarterly MDS assessment, dated 02/02/26, reflected a [AGE] year-old female, admitted to the facility on [DATE]. She had a BIMS score of 3 which indicated she was severely cognitively impaired. Diagnoses included chronic obstructive pulmonary disease (chronic airflow blockage, making it difficult to breath), dementia and acute upper respiratory infection (a viral infection affecting the nose, throat and sinuses). Resident #10 required moderate to maximum assistance with ADLS. Resident #10 had received oxygen therapy in the past 14 days. Record review of Resident #10's care plan, dated 01/28/26, reflected, Use of Oxygen Therapy continuous.Goal.Resident will maintain within normal respiratory functions x 90 days.Interventions.Apply oxygen as needed. Record review of Resident #10's Physician order summary report, dated 03/12/26, reflected, OXYGEN-CONTINUOSLY= Oxygen at 3 Liters per minute via nasal cannula continuously. Check every shift ., with a start date of 02/04/26. Record review of Resident #10's MAR, dated March 2026, reflected, .Oxygen at 3 liters per minute via nasal cannula continuously. with a start date of 02/04/26. The MAR was signed off by staff on the day shift and night shift from 03/01/26 through the day shift on 03/12/26 which indicated Oxygen was administered at 3 liters per minute. During an observation and interview on 03/11/2026 at 10:01 a.m. Resident #10 was sitting up in her wheelchair, next to her bed. Resident #10 was utilizing oxygen via nasal cannula at 2 liters per minute. Resident #10 had an E-tank (portable oxygen tank) attached to the back of her wheelchair. There was an oxygen concentrator in the corner of the room which was not running. Resident #10 stated she was doing well and had no concerns. During an observation on 03/11/2026 at 04:30 p.m. Resident #10 was observed up in her wheelchair in her room. Resident #10 had a nasal cannula connected to the E Tank on the back of her wheelchair. The E-tank was set to deliver 2 liters per minute. The dial on the E-tank indicated the tank needed to be refilled. During observation and interview on 03/11/2026 at 4:40 p.m. LVN F entered Resident #10's room and observed the E-Tank on the back of Resident #10's wheelchair and stated, that's not good. LVN F stated the resident should had been put back on her oxygen concentrator when they brought her back to her room from lunch. LVN F verified the E-tank was set to deliver 2 liters per minute. She placed the resident back on the oxygen concentrator. Resident #10 was not in distress and stated she has had some trouble getting a deep breath but denied any shortness of breath. LVN F stated she was going to come back and check the resident's Oxygen saturation level. LVN F went to the nurse's station and checked the computer and verified the resident was supposed to be on 3 liters per minute. LVN F then returned to Resident #10's room and checked the resident's oxygen saturation level which was at 98 % and verified the oxygen concentrator was set to deliver 3 liters per minute. In an interview with LVN F on 03/11/26 at 4:45 p.m. she stated the nurses were responsible for checking and verifying that residents receiving oxygen were receiving the physician prescribed amount of oxygen. She stated they will place residents on an E-Tank when they want to go out of the room for activities or go to the dining room for meals. She stated the CNAs could switch the residents from the concentrator to the portable tank but stated the Nurses were responsible for setting up the tank with the correct amount of oxygen per minute. She stated the CNAs would usually let her know when they had placed someone on an E-tank. She stated she was not sure who set up the tank Resident #10 was using. She stated not providing the resident with the prescribed amount of oxygen could lead to low oxygen levels, confusion and difficulty breathing. During an interview on 03/11/2026 at 4:50 p.m. with CNA G she stated she was assigned to Resident #10 today (03/11/26). She stated she was not the one who brought Resident #10 back to her room after lunch. She stated the CNAs can switch a resident from the E-Tank and put them back on the oxygen concentrator. She stated she checked and changed Resident #10 around 3 p.m. and got her back up in her wheelchair. She stated she did not check the E-Tank to see if it had air or not. During an interview with the Regional Nurse Consultant and new DON on 03/11/2026 at 4:55 p.m., the Regional Nurse Consultant stated oxygen should be set at the physician ordered delivery rate. She stated Resident #10 had not been using oxygen until last month when she had an upper respiratory infection. She stated the Nurses were responsible for monitoring any resident who was receiving oxygen and were supposed to check the oxygen levels each shift and as needed. She stated the CNAs could switch residents from the concentrator to an E-tank but stated they could not set the oxygen delivery rate. She stated all of the staff were able to check the gauge on the E-tank and change it out when it was empty. She and the DON would in-service the staff on the expectation of monitoring while a resident was receiving oxygen. She stated the risk of a resident not receiving the prescribed amount of oxygen was low oxygen levels, increased confusion and difficulty breathing. Record review of the facility's undated policy titled, Administration of Oxygen, reflected, Purpose- to aid in breathing as ordered by the physician.Equipment: Oxygen per tank or oxygen converter.Check doctor's order.The flow of oxygen is started and regulated at the rate ordered by the doctor.Report immediately to charge nurse all signs or symptoms or any failure of equipment.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6.25 %, based on 2 errors of 32 opportunities, which involved one of five residents (Resident #74) and one of five staff (MA D) reviewed for medication errors, in that: The facility failed to ensure MA D administered Resident #74's 7 a.m. dose of Alpha-Lipoic Acid 600 mg (antioxidant use to treat nerve pain) and Protonix oral packet 40 mg (proton pump inhibitor used to treat acid reflux) on 03/11/26 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.The findings include: Record review of Resident #74's Quarterly MDS assessment, dated 01/20/26, reflected a [AGE] year-old male with an admission date of 08/12/25. Resident had a BIMS of 13 which indicated he was cognitively intact. Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels), diabetes and gastroesophageal reflux disease (heartburn and acid regurgitation). A record review of Resident #74's Physician's order summary report, dated 03/11/2026, reflected Resident #74 was to receive the following medications: Alpha-Lipoic Acid Oral Tablet 600 mg .Give 1 tablet by mouth one time a day related to nerve pain due to diabetes.with a start date 11/13/25.Protonix Oral Packet 40 mg.Give 1 tablet by mouth two times a day for gastroesophageal reflux disease.with a start date of 02/22/26. During a medication pass observation on 03/11/26 at 07:43 a.m., revealed MA D administered the following medications to Resident #74:Aspirin 81 mg 1 tabletVitamin D2 25 mcq (1000 units) 1 tabletEmpagliflozin 25 mg 1 tabletLactobacillus 1 capsuleMultivitamin 1 tabletSertraline HCL 50 mg 1 tabletSingular 10 mg 1 tabletMiraLAX oral powder 17 gm/ scoop -1 scoopCetirizine 10 mg 1 tabletMetoprolol Tartrate 25 mg 1 tabletGabapentin 300 mg 1 capsuleTramadol HCL 50 mg 1 tabletMA D did not administer Alpha-Lipoic Acid Oral Tablet 600 mg and Protonix Oral Packet 40 mg. Record review of Resident #74's March 2026 medication administration record on 03/11/26 at 03:23 p.m. reflected Alpha-Lipoic Acid Oral Tablet 600 mg 1 tablet and Protonix Oral Packet 40 mg oral packet 1 tablet was signed out as given on 03/11/26 at 07:00 a.m. by MA D During an interview with MA D on 03/11/2026 at 03:30 p.m. she stated she had not administered any additional medications to Resident #74 since her morning medication administration. Upon reviewing the medication administration record and searching the medication cart for the Alpha-Lipoic Acid and Resident #74's Protonix she acknowledged she could not find the medications in the cart and had not administered the Alpha-Lipoic Acid oral tablet and stated she thought the Protonix had been administered earlier by the night shift staff. She stated she had signed them both out as administered. She stated by signing the medication off as given, it would not have triggered to indicate it still needed to be administered, and no one would be aware the medication was missed. She stated the risk of not administering the resident's medication as ordered would be the resident would not receive the medication that was ordered for him. During an interview with the Regional Nurse Consultant and the new DON on 03/12/26 at 12:20 p.m., the Regional Nurse Consultant stated she expected the staff to follow the 5 rights of medication administration which were right drug, right dose, right route, right patient, and right time. She stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to a worsening of the condition the medication was intended to treat. She stated they do skills checks annually and the pharmacy consultant observed medication administration monthly with random staff. She stated in reviewing the issue with Resident #74's medication and in talking with the pharmacy it was determined the order had been put in as Protonix packet instead of tablet and the pharmacy had requested clarification and no one from the facility had gotten back with the pharmacy, so the medication was not sent to the facility. She stated they would be in-servicing all of the medication aides as well as the nursing staff on follow up with the pharmacy to ensure the correct medications were submitted to the pharmacy and available for the resident. She stated they had implemented a new staffing ADON who would be responsible for staff training and proficiency checks. Record review of the facility undated policy titled Medication Cart, Administration of Drugs, reflected, .Read medication orders on medication sheet and have medication cup ready.Place appropriate dosage into souffle cup. Re-read label and medication sheet and return drug to its proper location.Administer medication to resident.Mark appropriate entry on E-MAR.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 22 (Residents #94, Resident #13, and Resident #18) reviewed for comprehensive care plans. 1. The facility failed to include in Resident #94's comprehensive care plan, revised on 12/16/24, her dental needs and interventions to address the problem. 2. The facility failed to include in Resident #13's comprehensive care plan, revised on 10/21/24, her dental needs and interventions to address the problem. 3. The facility failed to include in Resident #18's comprehensive care plan, revised on 11/20/24, her diagnosis of eczema and her rash and interventions required to address the problem. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: 1. Record review of Resident #94's annual MDS assessment, dated 12/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS of 8 which indicated she was moderately cognitively impaired. Her diagnoses included hypertension and coronary artery disease. She had no indication of dental concerns. Record review of Resident #94's care plan, with a review date of 12/16/24, reflected she did not have a care plan for dental concerns or interventions to address those concerns. Record review of Resident #94's progress notes reflected the Social Worker referred the resident to the dental provider per the family's request on 02/13/24. In an interview with Resident #94 on 01/07/25 at 01:20 p.m. she stated the dentist had come and pulled one of her teeth. She stated she needed additional teeth pulled so she could obtain her dentures and had not been told when they were coming back. She stated the dentist had text her some messages, but her family member told her not to worry about them, she was talking with the dentist. In an interview with the Social Worker on 01/08/25 at 12:07 p.m. she stated there was a financial responsibility the family member was aware of and as far as she knew it had not been met. She stated she had not followed up with the dental provider to determine where they were in the process, but stated she would check today. In a follow up interview with the Social Worker on 01/08/25 at 01:15 p.m. she stated she had reached out to the dental provider. She stated the resident had a tooth extraction on 10/08/24 and was going to need 4 more teeth pulled and then fitted for denture. She stated there was an issue with her applied income and the amount the family was going to have to pay, which was why they had not progressed. She stated the dental provider had told her they had reached an agreement with the facility, and they were going to go forward with the tooth extractions and dentures. She stated the dental provider was coming out next week and assessing Resident #94. In an interview with the Dental Provider Representative on 01/08/25 at 01:27 p.m. she stated the facility had sent them a referral in [DATE]. She stated the resident was wanting dentures but stated there was an applied Income issue and they had communicated with the family about what their responsibility was going to be. She stated the resident later required a tooth extraction which was performed on 10/08/24. She stated the resident was still requesting dentures. She stated the facility's BOM had been working with Medicaid and the family. She stated sometime in December 2024 she, the BOM and the Social Worker met and determined the facility would cover the $1000 dollars needed to for removing 4 additional teeth and fitting the resident with Dentures. She stated they were scheduled to come out to the facility next week. 2. Record review of Resident #13's quarterly MDS assessment, dated 10/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS of 12 which indicated she was moderately cognitively impaired. Her diagnoses included hypertension and coronary artery disease. She had no indication of dental concerns. Record review of Resident #13's care plan, with a review date of 10/21/24, reflected she did not have a care plan for dental concerns or interventions to address those concerns. In an interview and observation on 01/07/25 at 09:38 a.m. with Resident #13 she stated she had been at the facility for about a year and half. Resident #13 was observed to have her front teeth missing. She stated she saw the Dentist at the facility about 6 months ago. She stated she needed a new partial. She stated her Medicaid was not approved until July 2024. She stated she asked the Social Worker in November 2024 when the dentist was going to get her partial done. She stated she still had not heard anything. In a follow up interview on 01/08/25 at 12:55 p.m. with Resident #13 she stated she had a partial when she admitted to the facility. She stated it had become bent and she was not able to wear it anymore. She stated it was not the fault of anyone, and was not sure how it bent, but stated she had it for several years. She stated she was seen by the dentist sometime before July 2024. She stated the BOM had told her that when her Medicaid went into effect it would cover a new partial for her, so she opted to wait until her Medicaid went into effect. She stated her Medicaid went into effect in July 2024. She stated she was waiting on was the completion of her dental work. In an interview with the Social Worker on 01/08/25 at 12:12 p.m. she stated she would have to call the dental office and see what the status was on Resident #13's dental work. She stated the BOM was currently out on medical leave. She stated Resident #13 probably did speak with her in November 2024, but stated she could not remember what the issues was with the dental. In a follow up interview with the Social Worker on 01/08/25 at 01:16 p.m. she stated she had reached out to the dental provider and found out Resident #13 had been seen in November 2024 for a teeth cleaning and again in December 2024 for X Rays. She stated she was on the schedule for this coming Monday (01/13/25) and should have her partial by the end of the month. The Social Worker stated she made all the referrals for ancillary services for the facility. She stated she had not been tracking or following up with each of the providers on where people were in the process. She stated she was doing the best she could do with just getting all the referrals made. In an interview on 01/08/25 at 01:30 p.m. with the Dental provider Representative she stated the facility had sent them a referral in April 2024. She stated they saw Resident #13 in May 2024 and evaluated her for a new partial. She stated the resident was pending Medicaid. She stated they reached out to the resident and family and gave them the option of paying or waiting until the resident was approved for Medicaid. She stated they found out in August 2024 the resident had been approved for Medicaid. She stated they sent the facility the form 1263 B around the third week of October 2024, for the physician to complete and they got that back from the facility around the first of November 2024. She stated she was not sure why it took her company so long to send the facility the form they needed. She stated it was not common for it take as long as had taken for this resident. She stated once they got the completed form back from the facility physician, they saw the resident in November for teeth cleaning and again in December for X-rays. She stated they do that to ensure they were attaching her partial to strong healthy teeth. She stated she should be getting her partial by the end of the month. In a follow interview with the Administrator on 01/08/25 at 02:09 p.m. he stated his expectation was the Social Worker should be documenting the progress of any dental procedures and the timeline of completion of care. He stated they did not have a good system in place to track the process at this time. He stated the facility would approve any necessary dental and pay even if it was not covered by Medicaid. He stated dental care should be in the care plan so they everyone had a clear picture of where the process was for the residents and what necessary intervention needed to be in place to ensure any dental needs were met timely. He stated they had checked to see why the documentation from the dental provider was not uploaded into the electronic record and discovered the dental provider had the wrong E-mail address for their medical records. He stated that had been corrected and they were now receiving the documentation from the dental provider which would help them stay on track on the process and assist in timely interventions and communication amongst the staff. He stated going forward this would be a part of the care planning process. In an interview with MDS B on 01/08/25 at 02:40 p.m. she stated she was responsible for the long-term care plans. She stated they interview staff and the progress notes for any updates that need to be included into the care plan. She stated any dental procedure should be care planned, because often it required an adjustment to the resident's medication orders. She stated the Social Worker had not communicated any dental procedures. She stated she had not seen anything in the clinical record about any dental procedures for Resident #94 or Resident #13. She stated the care plan was the guide for all the care needs for the resident, so everyone involved in the resident's care were aware of the client's needs and the interventions put into place. She stated not having a comprehensive care plan in place could delay necessary care and not alert them to when additional interventions needed to put into place. 3. Record Review of Resident #18's Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), dementia (loss of cognition), osteoarthritis (arthritis affecting the joints), and allergic rhinitis (allergies of the nose) and a BIMS score of 7 (severely impaired cognition). Record review of Resident #18's care plan with a revision date of 11/20/24 did not address the resident's eczema or interventions to address the problem. Record review of Resident #18's nurse's progress note revealed an appointment return note, dated 04/23/2024, by Charge Nurse F: .Other comments: Resident's eczema now controlled well and her other treatments will continue as ordered . Review of progress note dated 05/01/2024 by Charge Nurse F revealed Resident #18 received Clotrimazole Cream 1% and Triamcinolone Acetonide Cream 0.1% to her whole body for itching. Review of progress note dated 06/26/2024 by Charge Nurse F revealed Resident #18 had red areas on both upper extremities due to itching. Further review revealed nurse's general assessment progress notes dated 07/24/2024, 08/07/2024, 08/21/2024, 09/04/2024, 10/02/2024, 10/16/2024, 10/30/2024, 11/13/24, 11/27/2024, 12/11/2024, 12/25/2024, and 01/08/2025 by Charge Nurse F, Resident #18 had itchy skin and a rash on her body and was treated with a topical prescription cream. Interview on 01/07/2025 at 1:36 PM with Resident #18 revealed her only concern was her itchy skin. Observation of resident's arm and neck revealed she had red and reddish-brown raised areas of her skin with small scratches and cracks. She stated her skin was itchy all over her body and it made it difficult to sleep at night. She stated she had seen a doctor in the past and the staff were putting a cream on her every night, and she also took Benadryl to help with the itching. She stated her skin had this issue before and it had gotten better, but not fully gone all the way away and it had gotten bad again around Christmas time. Interview on 01/08/2025 at 11:09 AM with CNA D revealed Resident #18 was pretty much independent and had rashes on her back and sides of legs and on her neck and commonly complained of itchy skin and was on medication that helped. CNA D stated when the resident complained about being itchy or she noticed the rash looked worse she informed the charge nurse. Interview on 01/08/25 at 11:44 AM with CNA E revealed Resident #18 had complained her skin itched and stated it had been going on for a while on her arms. She was not sure what was causing the rash. Observation and interview on 01/13/25 at 8:40 AM of Resident #18 with Charge Nurse F revealed Resident #18 had a red rash scattered around her stomach, lower and upper back, around the backs of her arms shoulders, and her neck. Charge Nurse F stated Resident #18's rash was all over her body and included her thighs and front of body. She stated that Resident #18 had seen a dermatologist and did not have a diagnosis yet. She stated she noticed a couple weeks ago Resident #18's skin had gotten worse, and the rash had spread. She documented it in the progress notes, and informed ADON C. She stated ADON C informed the Nurse Practitioner who had prescribed medication and they planned on having the resident see a new dermatologist. She stated there had been discussions during morning meeting and they discussed what possible causes of the rash and ADON C had asked the Nurse practitioner if allergy shots might help. The Nurse Practitioner stated a dermatologist would need to see the resident. Interview and observation on 01/13/25 at 10:45 AM with ADON C revealed Resident #18 had issues with itching. ADON C stated Resident #18 had an appointment scheduled on 01/09/2025 with a new dermatologist but bad weather resulted in it needing to be rescheduled. He stated they were not sure of a cause yet and were focused on symptom management by the Nurse Practitioner and medications like Atarax, Benadryl and topical creams. ADON C stated her rash recently had gotten worse and they planned to have Resident #18 see a different dermatologist. ADON C stated he thought she was seen by a new dermatologist recently and was not aware the resident missed her appointment due to the ice weather on 01/09/25. ADON C reviewed Resident #18's care plan and revealed the resident's eczema diagnosis was care planned on 01/09/2025 ADON C stated he was not aware the resident's skin condition was not care planned before 01/09/25. Interview on 01/13/2025 at 12:53 PM with MDS B revealed Resident #18 had a rash for quite a while, it was on and off and not consistent, she was not sure of exact date the issue started. The MDS Nurse B stated she was notified today (01/13/25) that Resident #18 had a diagnosis of eczema because the paperwork from the dermatologist visits on 04/23/2024 was found on 01/13/2025. She stated when a resident comes back from the doctor office with a new diagnosis or change in care it should be added into the plan of care. She stated she had not received any documentation from Resident's dermatology visit in April 2024. Interview on 01/13/25 at 1:15 PM with the Director of Nurses and Administrator revealed Resident #18's moderate eczema diagnosis from a dermatologist visit on 04/23/24 should had been care planned because it ensured causes and interventions were identified and a plan of care was followed. The Director of Nurses stated the symptoms of eczema can come and go and it was important to care plan the issue because it helped to identify possible causes and interventions. The Administrator stated he was aware that care plans were a work in progress and while they were good about immediately care planning falls and incidents, the chronic conditions were missed because it had gotten better at some point and there was not clear documentation by the nurse practitioner regarding the resident's skin condition. He stated while the interdisciplinary team was responsible for the care plan, ultimately it was the responsibility of MDS to enter in the information from the meetings into the care plan. The Director of Nurses stated staff needed to be trained on documenting skin issues such as eczema. Record review of the facility's undated policy, Comprehensive Person-centered Resident Care Planning, reflected, .The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care .Each resident's plan of care shall be periodically reviewed and revised by an interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessment to reflect the resident's current care needs. The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality; be provided by qualified persons in accordance with each resident's written plan of care . 49427

Based on observation, interview, and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 8 (Resident #18) residents reviewed for accuracy of records. The facility failed to ensure Resident #18's physician examination record from a dermatologist visit on 04/23/2024 was uploaded into the electronic health chart and failed to update her diagnoses to include moderate eczema. These failures could place residents at risk for delay in care or treatment and appropriate interventions. Record review of Resident #18's face sheet, dated printed 01/12/2025, reflected the resident had no dermatologist listed as a care provider and no diagnosis of eczema or other skin conditions. Record Review of Resident #18's Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), dementia (loss of cognition), osteoarthritis (arthritis affecting the joints), and allergic rhinitis (allergies of the nose) and a BIMS score of 7 (severely impaired cognition). Record review of Resident #18's care plan revealed she was at risk for skin breakdown, date initiated 03/02/2023 with interventions that included assess skin daily during care and report any redness or irritation, check for incontinent care, apply a moisture barrier every shift and as needed, notify dietary for nutritional assessment, pressure relieving device to bed/chair. Record review of Resident #18's nurse progress notes revealed a dermatology appointment return note, dated 04/23/2024, written by Charge Nurse F: Follow up appt : for 4 month .Other comments : Resident's eczema now controlled well and her other treatments will continue as ordered Further review of Resident #18's medical record revealed no documentation of a follow up visit with the dermatologist after 04/23/2024 and there was no physician examination record for the visit uploaded into the resident's electronic health record. Interview on 01/13/2025 at 9:13 AM with the Transportation CNA G revealed he was not sure where the physician examination record was for Resident #18's visit on 04/23/2024 was located and typically he made a copy for nursing and gave the original to medical records department in a box on their door. He stated he remembered taking Resident #18 to the appointment and she needed a follow up appointment in 4 months but she was better around that time and did not want to go to the dermatologist so a follow up was not scheduled. He stated recently the rash was worse and she had an appointment scheduled on 01/09/2025 that was rescheduled due to bad weather. Interview and observation on 01/13/2025 at 12:12 PM with the Director of Nursing reviewed Resident #18's electronic health record and stated she did not see documentation from the dermatologist visit on 04/23/2024. She stated the physician examination record from the dermatology visit should have been provided to staff by the transportation aide and should have been uploaded into the resident's electronic health record. She stated she was going to look for it immediately. Interview on 01/13/25 at 12:17 PM with ADON C revealed Resident #18's physician examination record from her dermatologist visit on 04/23/2024 was found in a drawer at the nurse's station today and he was not sure who placed it there and why it was not found earlier. He stated the transportation aide was supposed to make a copy for themselves and the nurses, and then they placed the original in the box for medical records. Record review of physician examination record for Resident #18 titled Physician Examination Record, dated and signed by Physician H on 04/23/2024, reflected resident had moderate eczema that was controlled, with new orders and instructions for a follow up appointment in 4 months. Interview on 01/13/25 at 12:59 PM with Medical Records revealed Resident #18's paperwork from her dermatology visit on 04/23/2024 was found in a drawer at the nurse's station and her diagnosis of moderate eczema had not been added to the medical record. She stated a situation like this had happened before and there was a box in the front of her door that was for the Transportation Aide to place original physician visit summaries. She stated the transportation aide was responsible to make a copy for themselves and nursing, MDS, and medical records gets the original plus any progress note or order to go with it. She stated if the process was not followed and medical records, they did not receive the appointment return paperwork, they were not able to treat residents properly. Interview on 01/13/25 at 1:15 PM with the Director of Nursing and Administrator revealed they were made aware today of Resident #18's missing dermatology physician examination record from April of 2024. She stated it was found in the drawer at the nurse's station, which was not their process for physician examination records. The Director of Nursing stated Resident #18's physician exam record should have been scanned and added to her electronic chart with an updated diagnosis of moderate eczema. She stated it was important for resident records to have updated diagnoses and after visit summaries in the resident's chart so they can ensure interventions were identified and a plan of care was followed. The Director of Nursing stated Resident #18's physician examination record should have gone from the transportation aide to the nurse, then the nurse placed the document in the medical records box to be scanned and upload to the electronic record and update the MDS or care plan if needed. The Director of Nursing stated they planned to improve the process and were going to discuss in morning meetings any residents with appointments the previous day to ensure the process was followed. The Administrator stated he expected staff to follow the process the Director of Nursing outlined regarding the clinical records and ultimately it was the MDS nurse's responsibility to update the resident's clinical record. The Administrator stated it was important the resident's records were accurate and updated to ensure the plan of care was followed. Review of facility's clinical records policy titled Clinical Records, undated, reflected .Clinical records are maintained on each resident in accordance with accepted professional standards and practices. Clinical records are complete, accurately documented, readily accessible and systematically organized .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #2) observed for infection control. 1. The facility failed to place Resident #2 in enhanced barrier precautions who had a dialysis central venous access device and peritoneal catheter (a tube that is placed through the abdomen into the peritoneum used to clean the blood inside your body). 2. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #2. These failures could place residents at risk of transmission of multidrug-resistant organisms. Findings included: Record review of Resident #2's Admission MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS score of 11 which indicated she was moderately cognitively impaired. Diagnoses included type 2 diabetes mellitus, end stage renal disease (kidney failure) and cerebral vascular accident. Resident #2 had received hemodialysis for the 14 days look back period. Record review of Resident #2's comprehensive care plan initiated on 12/17/24, did not reflect Resident #2 required Enhanced Barrier Precautions. Record Review of Resident #2's Physician Orders Report dated 01/09/25, reflected Dialysis port-(Peritoneal Abdomen) Cleanse with Normal saline, pat dry with gauze, apply skin prep to peri port, apply split gauze, secure/cover and tape every 72 hours .Dialysis-access site check- Check dialysis access site for thrill and bruit, redness, swelling, drainage, temperature of skin surrounding site, peripheral pulses, bleeding and intact every shift The orders did not indicate the resident required Enhanced Barrier Precautions. In an observation on 01/07/25 at 11:04 a.m. revealed no signage posted outside of Resident #2's room for enhanced barrier precautions. CNA A entered Resident 2's room to answer her call light. Resident #2 stated she needed her brief changed. CNA A washed her hands and put on gloves. Upon uncovering the resident, it was revealed Resident #2 had a peritoneal dialysis catheter which was unsecured. CNA A pushed the soiled brief down and cleaned the resident from front to back. CNA A then reached up and repositioned the peritoneal catheter while wearing soiled gloves. CNA A assisted the resident onto her side revealing the Resident had loose bowel movement. CNA A cleaned from front to back, removed gloves and sanitized hands and put on clean gloves and then applied a clean brief. In an interview with CNA A on 01/07/25 at 11:15 a.m. she stated she was working as a float and was not certain if Resident #2 was on enhanced barrier precautions or not. She stated there were not a sign indicating enhanced barrier precautions and there were no supplies in the room. She stated when someone was on enhanced barrier precautions the facility placed a kit on the wall which contained gloves and gowns. She stated she knew anyone with a G-tube, catheter or wounds were supposed to be on enhanced barrier precautions. She stated she did not realize she had touched the peritoneal catheter with dirty gloves and stated that would have cross contaminated the catheter. In an interview on 01/07/25 at 11:55 a.m. with the DON she stated a sign should be outside of the door of any resident who required enhanced barrier precautions and the required supplies of gloves and gowns should be available. She stated Nurse management and Charge nurses were responsible for ensuring Residents who had significant wound, central lines, catheter, and G-tubes were in enhanced barrier precautions. She stated she did not consider the peritoneal dialysis catheter, or her dialysis access site would require enhanced barrier precautions, since they were not accessing those sites. She stated the Peritoneal catheter was not in use but stated she had only been with the facility for a few weeks and would have to check the policies to determine if the resident should be in enhanced barrier precautions. She stated when the CNA touched the peritoneal catheter with dirty gloves, she had cross contaminated it. She stated the catheter should be secured and she was on her way to secure the catheter. In an interview on 01/08/25 at 04:30 p.m. with the Corporate Nurse she stated any resident with an indwelling medical device should be placed in Enhanced Barrier Precautions. She stated even though the peritoneal dialysis catheter was not in use it was still indwelling which would quality for Enhanced Barrier Precautions. She stated dialysis fistula alone would not put them in isolation, but if a resident had a central hemodialysis line, which Resident # 2 had, then that would also require them to be in Enhanced Barrier Precautions. She stated they had reviewed all the residents in the facility and made sure signage was posted and supplies were in the rooms for those residents who required Enhanced Barrier Precautions and would be doing further training and education to the staff. In an interview on 01/13/25 at 11:03 a.m. with ADON C he stated he was aware upon the Resident #2's admission she had a peritoneal dialysis catheter but stated it was not in use. He stated she had a central venous catheter for her hemodialysis. He stated at the time they did not think it was necessary to place her in Enhance Barrier Precautions. He stated Enhanced Barrier Precautions were new to the facility and they were still learning. He stated he knew residents with catheters, G-tubes, central lines, and wounds had to be in enhanced barrier precautions, but it just did not register that this resident needed it. He stated they had since been educated and had a better understanding of who needed that type of precautions. ADON C stated the risk of not placing someone who needed Enhanced Barrier Precautions were predisposing them to infections. Record review of an E-mail provided by the facility's Director of Corporate Compliance dated 01/08/24, reflected, Residents Requiring EBP, Indwelling Medical Devices (regardless of MDRO) central lines, urinary catheters, feeding tubes, tracheostomies,Duration .discontinuation of indwelling devices .Required PPE (gown/gloves) during High-Contact Resident care .Dressing, Bathing/showering, Transferring, Providing Hygiene, Changing linens, Toileting/Changing Brief, Device Care/Use, Wounds/Skin care & treatment .Implementation .Staff awareness .Update Care profile .Update POC,EBP Signage, PPE set up-Gloves, Gown, Hand Sanitizer Record Review of the facilities undated policy titled, Hand Washing, reflected, Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with any wastes or contaminated materials .or at any time the hands are soiled .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for two (Resident #90, and Resident #92) of 25 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #90 had her fingernails cleaned and trimmed and her facial hair on her chin trimmed. 2. Resident #92 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: 1. Record review of Resident #90's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and heart failure. Resident #90 had a BIMS of 12 which indicated she was moderately cognitively impaired. She required extensive assistance with transfers, dressing, and personal hygiene. Record review of Resident #90's Comprehensive Care Plan, revised 03/13/23, reflected .Resident requires assist with ADL's related to weakness .Interventions .Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift .The resident only wants showers on Saturdays, resident does not wants showers 3 times a week .Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers, and routine as much as possible An observation and interview on 12/12/23 at 10:10 a.m. revealed Resident #90 lying in bed. The nails on both hands where approximately 0.5 centimeters in length but were jagged and uneven and had peeling nail polish and the underside had a dark brown colored residue. Resident #90 also had multiple long chin hairs, approximately 2 inches in length, covering an area approximately 1.5 x 2 inches. Resident #90 stated the staff did not have time to mess with her chin hairs. She stated she would like them shaved. She stated she needed to see the beautician to get her hair and nails done, but she stated she kept missing her when she was at the facility. She stated she was unaware the staff could trim her nails. She stated they did look bad and are very dirty. She stated she only wanted a shower on Saturdays. She stated they cleaned her up pretty good the rest of time when they changed her brief. An interview on 12/13/23 at 09:00 a.m., CNA E stated CNAs were allowed to cut the residents' nails if they were not diabetic. She stated nail care and grooming should be done on the resident's showers days. She stated she was to Resident #90 and stated she had not noticed her nails or chin hairs, but stated she would see if she would let her take care of it. She stated she only gets a shower on Saturday's which is when they would typically shave a resident. In an interview on 12/13/23 at 09:05 a.m. with LVN C, she stated she was not aware of Resident #90 refusing to have her nails trimmed or chin hair shaved. She stated the CNAs were responsible for nail care on any resident who was not a diabetic. She stated facial hair should be addressed during the shower. In an Interview with the DON on 12/13/23 at 11:15 a.m. he stated nail care should be completed as needed. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated he expected CNAs to offer to cut and clean nails if they were long and dirty. He stated Resident #90 should have been offered by the CNAs if she wanted her facial hair trimmed at least on shower days or when staff noticed facial hair on a resident. He stated not performing those tasks could be a dignity issue and cause poor hygiene. 2. A record review of Resident #92's Quarterly MDS assessment dated [DATE] reflected Resident #92 was an [AGE] year-old male admitted to facility on 02/05/2022 with diagnoses included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, and lack of coordination. He had a BIMS of 3 which indicated sever cognitive impairment and required limited assistance from one person for ADL's. A record review of Resident #92's Comprehensive Care Plan, revised 08/18/23, reflected Problem: [Resident #92] requires assist with ADLs. Goal: [Resident #92] is able to perform self-care to optimal level and maintains strength and endurance x 90 days. Approach Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift. An observation on 12/12/23 at 10:35 a.m. revealed Resident #92 was sitting in a chair in his room, clean and groomed, and wearing daytime attire. The fingernails on both hands were approximately 0.3 centimeters in length extending from the tip of his fingers, and dirty with brown matter underneath. Resident #92 stated would like his fingernails trimmed, but he needed to go to [city name] to do so. The resident stated he ate with his hands. Interview and observation on 12/14/23 at 09:16 a.m. revealed CNA I looked at Resident #92's fingernails and stated they needed to be trimmed and they were little dirty and needed to be cleaned. She stated the nail care for nondiabetic residents was done every Sunday of the week by the CNAs. She stated the residents' fingernails needed cleaning daily by the CNAs. CNA I stated the risk to the resident was the development of infection, and he was putting his hands on his mouth. Interview/observation on 12/14/23 at 09:25 a.m. RN H stated Resident #92's fingernails looked long and needed to be cut, and they were dirty. RN H stated the CNAs could trim the residents' fingernail whenever they give them shower. She stated it was the responsible of nurses, and the ADON to observe residents' fingernails, and make sure they were cleaned and trimmed. RN H stated the risk to residents was the development of infection, through the bacteria growth underneath their fingernails. She stated Resident #92's fingernail would get taken care of today 12/14/2023. Interview on 12/14/23 at 11:07 a.m. the DON stated it was the responsibility of the CNAs to clean, and trim Resident #92's fingernails during his shower days: Tuesdays', Thursdays, and Saturdays of the week. The DON stated it was the responsibility of the charge nurses, ADON, and DON to make sure residents' fingernail care was done on their shower days. He stated the risk to the Resident #92 was the development of infection. Review of facility's undated policy Activities of Daily Living, reflected, .The facility will provide care and services for the following activities .Hygiene .grooming .Based on each resident's comprehensive assessment, appropriate treatment and services are provided for all residents to help them maintain or improve their abilities to perform activities of daily living .If unable to carry out activities of daily living, he/she shall receive the necessary services to maintain good .grooming, and personal and oral hygiene 47690

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to cover and date food stored in the refrigerator that should no longer be consumed. 2. The facility failed to discard food stored in the kitchen that was past use by date and should no longer be consumed. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: 1. Observation in facility's kitchen on 12/12/2023 at 9:11 AM revealed Hamburger bun with use by date of 12/2/2023 seen on the kitchen counter. 2. Observation in facility's kitchen on 12/12/23 at 09:13 AM revealed Apple juice stored within reach-in refrigerator was unlabeled and undated. 3. Observation in facility's kitchen on 12/13/23 at 11:42 AM revealed Iced tea stored within reach-in refrigerator was unlabeled and undated. In an interview with dietary aide on 12/12/23 at 09:15 AM revealed that he worked in the facility for last two years. He reported he had received in-services regarding food storage that includes labeling and dating, hand hygiene, storage temperatures. He reported that usually diet aides were responsible for dating and labeling all drinks that will be served for meals that day . he reported that if food items are not labeled or dated it could pose the risk of exposing residents to food borne illness. He also reported that questionable food should be reported to Dietary Manager and should be thrown it out. In an interview with Dietary Manager on 12/12/23 at 09:19 AM revealed that she was not sure why the hamburger buns are on the counter. She added that hamburger buns are not on the menu today. She also reported that she will throw out the buns immediately since they have been past best by date. She also stated that the risk to residents of serving food that is past best by date was possible risk of food borne illness. She stated that dietary aides were responsible for labeling and dating all food items and added that they may have forgotten to date the juice since they were getting drinks ready for lunch. She also reported that per facility policy all foods should be labeled and dated especially drinks like tea and juice that was repackaged to a different container. The risk of not labeling and dating foods was serving foods that could have gone bad. She reported that she conducted in-services with the kitchen staff monthly; in-services include Hand hygiene, food storage, infection control , food borne illness, safe storage temperature. In an interview with Cook on 12/13/23 at 12:03 PM revealed she had been a cook in the facility for 4 months She reported she had received in-services that included hand washing, Food storage, chemical storage. She reported that risk of not labeling or dating foods or serving foods beyond-use date can lead to potential for residents being sick and possible food borne illness. She also stated that in-services are conducted by Dietary manager or Dietitian when she visited the facility. In an interview with Dietitian on 12/13/23 at 12:08 PM revealed that she was not sure why hamburger buns were left on the counter on since she did not see it on the menu for the day. She stated that any food item in the kitchen found beyond use-by date should be thrown away and not served to any resident. The risk of serving foods that are past due-by date or serving food that was not labeled or dated can cause food borne illness. She reported that she, along with Dietary Manager conducted monthly and as needed in-services with kitchen staff that included therapeutic diet, hand hygiene, food storage that includes labeling and dating, portion sizes. Record Review of facility's Food Safety in Receiving and Storage policy dated 1/1/2010 revealed that Receiving Guidelines 5. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. Record Review of facility's Food Safety in Receiving and Storage policy dated 1/1/2020 revealed that General Food Storage Guidelines 3. Food that is repackaged is placed in a leak-proof, pest-proof , in-absorbent sanitary container with a tight-fitting lid. The container/lid is labeled with name of contents and dated with the date it was transferred to the container. The U.S. Public Health Service, Food Code, dated 2022, reflected the following, .3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include .(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

Based on observation, interview and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #59) of 25 residents reviewed for comprehensive care plans. The facility failed to identify and implement person-centered interventions to prevent further decline of Resident #59's contracture to his left hand. This failure could place residents at risk for decline in range of motion, decreased mobility, pain, decreased quality of life and ability to maintain independence. Findings include: Record review of Resident #59's annual MDS assessment, dated 10/05/23, reflected a [AGE] year-old male with an admitted [DATE]. Resident #59 had a BIMs of 11 which indicated he was moderately cognitively impaired. The resident had upper and lower extremity impairment on one side and had not received OT or PT services in the seven days look back period. Resident #59 had not received restorative care, splints, or braces. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #59's comprehensive care plan initiated on 10/27/22, reflected, .At risk for contractures related to left sided hemiplegia .Interventions .Monitor for pain with activities of daily living and movement .Monitor for stiffness of joints .Reposition every two hours and prn . No other interventions were documented. An observation and interview with Resident #59 on 12/12/23 at 10:10 a.m. revealed Resident #59 was up in his wheelchair. The resident's left arm was tucked closely to his body and his left hand was noted with his Index finger pointing straight out and unable to uncurl the remaining fingers which were tightly curled toward the palm of his hand. Resident #59 stated he used to have a brace but he had not seen it in months. Resident #59 stated no one was doing anything for his hand. He stated his hand felt better when he had a brace on it . In an interview with CNA E on 12/13/23 at 9:00 a.m. revealed she had never seen Resident #59 with a hand splint. She stated they had not been instructed to perform any passive or active range of motion on the resident's left hand and arm. In an interview with the DOR on 12/13/23 at 9:15 a.m., she stated she had started about six weeks ago. She stated Resident #59 was on her list to be screened for therapy services. She revealed the last time the resident was on therapy was for physical therapy from 08/30/23 through 10/28/23. She stated she could not locate any recent occupational therapy evaluations for Resident #59. An observation made with the DOR on 12/13/23 at 10:05 a.m. of Resident #59 revealed with some stretching from the DOR Resident #59 was able to uncurl his fingers slightly. Resident #59 informed the DOR he used to have a hand splint, but he had not seen it for several months and had no idea what had happened to it. The DOR stated his hand was contracted and he could benefit from a resting hand splint. She stated they would pick him up on therapy today (12/13/23). Record Review of Resident #59's Occupational Therapy assessment completed by the DOR on 12/13/23 reflected, .Assessment Summary Functional Limitations as Result of Contractures(s): Functional mobility, propelling Wheelchair, Skin integrity, Upper body Dressing, Lower body Dressing. Hygiene/grooming. Bathing and Gathering .Splint/Orthotic Recommendations: It is recommended the patient wear a resting hand splint, a hand roll and to further and assess and order/fabricate on left hand during daily task to manage tone, improve Passive Range of motion for adequate hygiene, develop/establish wearing schedule and adapt/modify splint device In an interview with MDS G on 12/14/23 at 9:05 a.m. she stated she was responsible of for updating the care plans for the long-term residents. She stated they meet weekly with the team and review and update any changes to the care plan. She stated they relied on therapy for any specific interventions related to contractures, but stated they should at least have passive range of motion in place for someone with hemiplegia. She stated care plans needed to accurate to reflect the residents needs and preferences. In an interview with the DON on 12/14/23 at 9:35 a.m. he stated they had all residents screened by therapy upon admission and any time there was a functional decline. He stated he had not been informed about Resident #59's need for range of motion or splinting. He stated therapy just needed to let him know what the ongoing needs were going to be. He stated the care plan should address all the resident's needs. He stated failing to have interventions in place for residents with limited range of motion could lead to worsening of a resident's contractures and decline in function. Review of the facility's undated policy titled, Comprehensive Person-Centered Resident Care Planning reflected, A comprehensive person-centered care plan is developed and implement for each resident, consistent with the resident's rights and will incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following .the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #59) of three residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #59's contracture to his left hand. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings include: Record review of Resident #59's annual MDS assessment, dated [DATE], reflected a [AGE] year-old male with an admitted [DATE]. Resident #59 had a BIMs of 11 which indicated he was moderately cognitively impaired. The resident had upper and lower extremity impairment on one side and had not received OT or PT services in the seven days look back period. Resident #59 had not received restorative care, splints, or braces. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #59's comprehensive care plan initiated on [DATE], reflected, .At risk for contractures related to left sided hemiplegia .Interventions .Monitor for pain with activities of daily living and movement .Monitor for stiffness of joints .Reposition every two hours and prn . No other interventions were documented. An observation and interview with Resident #59 on [DATE] at 10:10 a.m. revealed Resident #59 up in his wheelchair. The resident's left arm was tucked closely to his body and his left hand was noted with his Index finger pointing straight out and unable to uncurl the remaining fingers which were tightly curled toward the palm of his hand. Resident #59 stated he used to have a brace but he had not seen it in months. Resident #59 stated no one was doing anything for his hand. He stated his hand felt better when he had a brace on it . In an interview with CNA E on [DATE] at 9:00 a.m. revealed she had never seen Resident #59 with a hand splint. She stated they had not been instructed to perform any passive or active range of motion on the resident's left hand and arm. In an interview with the DOR on [DATE] at 9:15 a.m., she stated she had started about six weeks ago. She stated Resident #59 was on her list to be screened for therapy services. She revealed the last time the resident was on therapy was for physical therapy from [DATE] through [DATE]. She stated she could not locate any recent occupational therapy evaluations for Resident #59. An observation made with the DOR on [DATE] at 10:05 a.m. of Resident #59 revealed with some stretching from the DOR Resident #59 was able to uncurl his fingers slightly. Resident #59 informed the DOR he used to have a hand splint, but he had not seen it for several months and had no idea what had happened to it. The DOR stated his hand was contracted and he could benefit from a resting hand splint. She stated they would pick him up on therapy today ([DATE]). Record Review of Resident #59's Occupational Therapy assessment completed by the DOR on [DATE] reflected, .Assessment Summary Functional Limitations as Result of Contractures(s): Functional mobility, propelling Wheelchair, Skin integrity, Upper body Dressing, Lower body Dressing. Hygiene/grooming. Bathing and Gathering .Splint/Orthotic Recommendations: It is recommended the patient wear a resting hand splint, a hand roll and to further and assess and order/fabricate on left hand during daily task to manage tone, improve Passive Range of motion for adequate hygiene, develop/establish wearing schedule and adapt/modify splint device In an interview with MDS G on [DATE] at 9:05 a.m. she stated she was responsible of for updating the care plans for the long-term residents. She stated they meet weekly with the team and review and update any changes to the care plan. She stated they relied on therapy for any specific interventions related to contractures, but stated they should at least have passive range of motion in place for someone with hemiplegia. She stated care plans needed to accurate to reflect the residents needs and preferences. In an interview with the DON on [DATE] at 9:35 a.m. he stated they had all residents screened by therapy upon admission and any time there was a functional decline. He stated they did not have a restorative program , but range of motion and splinting could be carried out by the nursing staff and the CNAs once therapy determined the need. He stated he had not been informed about Resident #59's need for Range of motion or splinting. He stated therapy just needs to let him know what the ongoing needs were going to be. He stated failing to have interventions in place for residents with limited Range of motion could lead to worsening of a resident's contractures and decline in function. Review of the facility's undated policy titled, Mobility/Range of Motion, reflected, Based on the resident's comprehensive assessment, the resident will receive appropriate treatment and services to increase or maintain range of motion and prevent further decease in function. A resident with limited range of motion will receive appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion .Routine range of motion exercises will be provided according to the resident's plan of care. Resident shall receive proper and assistive devices to maintain or improve range of motion

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure grease trap in oven was not full of food debris and grease buildup. 2. The facility failed to ensure the fryer with grease was covered and clean when not in use. 3. Dietary Aides K and L failed to wash hands during lunch preparation of meal trays. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation on 10/18/22 at 9:42 AM of grease trap on stove top was difficult to open but Dietary Manager was able to open it after forcing it open. The grease trap was covered on outside sides with sticky and hard brownish and black buildup. The inside bottom of grease trap about 1 inch of yellowish, brownish and blackish buildup of grease and food buildup. There was 2 fries along with 1 inch white plastic piece on top of hard blackish buildup at least 1/2 inch. Interview on 10/18/22 at 9:43 AM, Dietary Cook M revealed she last cleaned the grease trap about 3 weeks ago. Interview on 10/18/22 at 9:44 AM, the Dietary Manger revealed the Dietary Cooks were responsible for cleaning the grease trap. She further stated she did not have it listed on the cleaning schedule and thought it was getting done. She moved the grease trap to 3 compartment sink to be cleaned. She stated the grease trap needed to be cleaned up with that much buildup. Review of the facility's policy on Cleaning Ranges/Grills revised 01/01/2010 reflected Ranges/grills will be kept clean and free of spills and grease. Under procedure for each shift about range reflected .4. Remove grease trap and wash in hot detergent water. Use a stiff bristle brush to remove hard to remove spills. Rinse in fresh, hot water. 2. Observations on 10/18/22 at 9:37 AM revealed 2 fryer basket had food and grease particles on the inside of them and on the handles. The fryer had uncovered dark oil with sediment particles on top of the oil. Particles of grease were above the oil on the edges. The top front of fryer had food particles and grease particles on it. There were food particles and stains covering the bottom door of the fryer which was sitting on the ground. Interview on 10/18/22 from 9:39 AM and 9:48 AM with Dietary Manager revealed she did not have a lid for fryer grease to cover it but stated it should be covered by a flat pan when not in use. Observation revealed Dietary Manager moved a flat pan and covered the grease. She stated it was due to be cleaned today and expected it to be cleaned weekly as part of deep cleaning. She stated the fryer baskets should have been cleaned after last use. She stated she did not have a deep cleaning schedule for the kitchen. Review of the facility's policy on Cleaning the Fryer revised 05/15/2015 reflected The fryer will be maintained clean and in good repair. The oil in fryer should be kept cool and covered when not in use. When oil darkens in color or changes viscosity .it is time to thoroughly clean the fryer and change the oil .Procedure: after each use: .2. Remove any food particles using filter tool. 3.Wipe down front, sides, back and cover with warm soapy water. 3. Observations of Dietary aide L on 10/19/22 revealed the following: * At 11:32 AM, Dietary Aide L took his gloves off, put new gloves on and did not wash his hands. He then put lunch plates on trays along with drinks on hall trays. * At 11:51 AM, Dietary Aide L changed gloves but did not wash hands. He continued putting completed lunch plates on meal tray along with drinks and silverware on tray. * At 11:55 AM he took his gloves off and did not wash hands. Dietary Aide L put one glove on right hand and left hand no glove. He put drink on lunch meal trays and put the tray in hall cart. Interview on 10/19/22 at 11:58 AM, Dietary Aide L stated he did take his gloves off and should have washed his hands prior to putting on new gloves. He stated he usually put two gloves on his hands and not just the one glove . Observations of Dietary aide K on 10/19/22 revealed the following: * At 11:50 AM Dietary Aide K came in from dining room and did not wash hands. She put gloves on and put lunch plates on trays. She placed the lunch trays on hall cart. *At 11:52 AM she went to freezer to get a magic cup and placed on meal tray. She took her gloves off and put new gloves on without washing her hands. Interview on 10/19/22 at 11:56 AM, Dietary Aide K stated she should have washed hands when changing gloves before putting on new gloves. She stated she was supposed to wash hands when she entered the kitchen before doing any tasks . Interview on 10/19/22 at 11:59 AM, the Dietary Manager stated Dietary Aides K and L should have washed hands when they take gloves off and before putting on new gloves. She stated they were nervous. She stated they should wash hands when entering kitchen before starting any tasks . She stated they should have washed their hands to prevent cross contamination. Review of the facility's policy Hand Washing revised 01/01/2010 reflected hand hygiene is the most import component for preventing the spread of infection. Proper hand washing technique will be used at all times that hand washing is indicated. Employees will keep their hands and exposed portions of their arms clean. Procedure: 1. Employees are to wash hands .g. prior to returning to food production areas .j. Before putting on gloves, when changing into fresh pair of gloves and immediately after removing gloves. The US Public Health Service, Food Code, dated 2017, retrieved on 10/25/22, reflected the following regarding Equipment, Food-Contact Surfaces and Nonfood-Contact Surfaces, equipment food-contact surfaces and utensils shall be clean to sight and touch .the nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. 36 opportunities were observed with a total of four errors, resulting in a 11 percent medication error rate. Two (MA B and MA C) of four staff observed administering medication made errors. Two (Residents #76 and Resident # 16) of four residents observed during the medication pass was affected. 1. MA C administered Zinc 50 mg instead of Zinc 100 mg and failed to administer [MEDICATION(S)] 1000 units 2 tablets per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. MA B administered Zinc 50 mg instead of Zinc 100 mg and administered Calcium 500mg +D 1 tab, instead of administering Calcium 500 mg per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] These failures residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Review of Resident #76's Face sheet dated 10/20/22 reflected a [AGE] year-old female with an admitted [DATE]. Residents #76's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of the medication pass on 10/19/22 at 08:50 a.m., revealed MA C administered 1 tablet of Zinc 50 mg, (mineral used for immune health) along with nine additional medications to Resident #76. MA C did not administer [MEDICATION(S)] (Vitamin D for bone strength) 1000 units 2 tablets. Review of Resident #76's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with MA C on 10/19/22 at 8:30 a.m., when asked to review Resident #76's medications orders for Zinc she pulled up the Medication orders and stated she should have given 2 tablets of the Zinc 50 mg since the order was for Zinc 100 mg. She stated she saw the 1 tablet on the administration record and failed to check the dosage of the bottle. When asked why she had not given the [MEDICATION(S)] 1000 units 2 tablets, she stated it had not popped up on the computer for her to administer it. She stated it showed up on the computer screen with the Resident's other medication but did not indicate she was supposed to administered it. She stated she had not asked anyone why the medication was showing up like this. Review of Resident #76's MAR for October 2022 reflected, [MEDICATION(S)] tablet 1000 unit Give 2 tablet by mouth start date 10/13/22 It was coded with U-SA on all days from 10/13/22 to 10/19/22. Review of the reference codes on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with ADON C on 10/19/22 at 1:30 p.m. revealed she was unsure what U-SA code on Resident #76's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would have to research to determine why U-SA was populating on the MAR. Interview with the Corporate Nurse on 10/19/22 at 3:30 p.m. revealed when the order for [MEDICATION(S)] 1000 units 2 tablets had been put into the system, the staff had inadvertently checked Unsupervised -Self-administered, which would cause it to show up on the Mediation Administration but would not let the staff sign it out as administered. She stated it was a data entry error, which then led to the medication error. She stated MA C should have alerted the nurse or the ADON when she was not sure about the medication. She stated the error in the system had been corrected. 2. Record Review of Resident #16's Face Sheet dated 10/20/22 reflected a [AGE] year-old female with an admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of the medication pass on 10/19/22 at 09:50 a.m., revealed MA B administered 1 tablet of Zinc 50 mg, (mineral used for immune health) and Calcium (Mineral for bone health) 500 mg +D 1 tablet along with 14 additional medications to Resident #16. Record Review of Resident #16's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oyster Shell Calcium 500 mg q tablet by mouth with a start date of 07/19/22 In an interview with MA B on 10/19/22 at 12:35 p.m. revealed her checking the bottle of Zinc in her medication cart, revealing it was only 50 mg. She stated she should have given 2 tablets of the Zinc 50 mg and had the nurse correct the order. She stated she saw the 1 tablet on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she only had Calcium 500 mg with D on her medication cart. She stated she had asked the Central Supply clerk for plain calcium and was told this was all they had, so that was what she had been giving to Resident #16. She stated she should have clarified it with the nurse, since it did not match the Medication administration order. In an interview with the Central Supply Clerk on 10/19/22 at 1:45 p.m. revealed the staff were supposed to clarify any discrepancy with the nurse on medication orders. She stated if the nurse determined they needed a specific over the counter medication after clarifying it with the physician, then they were to place it on a log sheet in central supply. She stated if it was not in their pharmacy formulary then she would go to the local pharmacy and pick up whatever was needed. She stated Oyster Shell Calcium 500 mg was never placed on her log sheet for her to request. She stated the only 500 mg Calcium she had in stock was Calcium 500 mg with D. In an interview with the DON on 10/20/22 at 09:35 a.m., He stated he expected the staff to follow the 5 rights of medication administration which are right drug, right dose, right route, right patient, and right time. He stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to drug interactions if the correct medication or dosage was not given. He stated the MAs should always go to the Charge nurse, the ADON or himself if there were any question about a medication and they should clarify with the physician if they did not have a prescribed over the counter medication in stock. Review of the facility's undated policy titled, Medication Cart, Administration of Drugs, reflected, .Read medication orders on medication sheet and have medication cup ready .Remove mediation container (blister pack or bottle) and compare label and medication sheet. Place appropriate dosage into souffle 'cup. Re-Read label and medication sheet and return drug to its proper location .Administer medication to resident .Make appropriate entry on E-MAR .

Based on observation, interview, and record review the facility failed to provide food that was palatable, served at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one (Lunch 10/19/22) of one meals observed for food texture and palatability. The facility failed to provide lunch hall trays with bread that was palpable and in a form to meet the needs of individual residents on 10/19/22. This failure placed residents at risk of possibly choking and create a potential for weight loss and a decline in their quality of life. Findings included: In an interview on 10/18/22 at 11:05 a.m. Resident #64 was in his room and stated, The food is over cooked. The resident showed the surveyor the bacon from breakfast. Observation revealed the bacon was hard. Interview on 10/18/22 at 10:28 a.m. , Resident # 55 revealed food was overcooked and can be tough to eat. Observation on 10/19/22 at 12:50 p.m revealed the last hall and meal tray for residents was served on 100 hall. In an observation on 10/19/22 at 12:58 p.m. revealed a regular lunch test tray with bread that was extremely hard. It would break and crumble. Surveyor was unable to bite into the bread. Interview on 10/19/22 at 1:28 PM, the Dietary Manager revealed the garlic bread toast served for lunch today could be more difficult on residents to swallow and chew since the bread was hard. She stated she would have to look into cooking temperature times of the garlic bread toast to ensure it is not overcooked. In an interview on 10/19/22 at 01:05 p.m. the ADON revealed the bread was hard. She stated the bread would be hard and difficult to eat. She stated the residents could choke or maybe cause teeth pain. Review of the facility's policy, Preparation of Foods, revised 4/9/19, reflected, .all food will be prepared by methods In a form to meet the individual needs of the resident .food is not overcooked .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #59 and Resident #76) of six residents observed for infection control in that: 1. Facility staff failed to place Resident #59 in isolation after the resident was diagnosed with parainfluenza virus on 10/13/22. 2. MA C failed to handle Resident # 76's medication in a manner to prevent cross contamination. Theses failure could place residents at risk for infection and cross contamination. Findings included: 1. Review of the Facilities undated Emergency Guidance plan for the management of Seasonal Influenza(flu) and/or Pandemic Viruses reflected, .If a Resident Develops Influenza-Like Illness (ILI) .In the absence of definitive diagnosis, influenza-like illness (ILI) is often used as an indicator of flu activity. ILI is defined as having a fever (temperature >100 degrees F) .AND either cough or sore throat or both with no other known cause for these symptoms .All ill resident should be separate from other in a single room until asymptomatic, if possible .Facilities should have signage at entry points instructing residents and visitors about facility policies including the need to notify staff immediately if they have signs and symptoms of influenza-like or other illness .Employees should wear N-95 respirators when in direct or close contact (within 6 feet) with ill individuals. Physical contact with the individual should be avoided, but if contact must be made, the employee should follow standard and contact precautions (including gown and gloves) and eye protection. Visitors may be offered N95 respirators for director or close contact with ill individuals. Physical contact should be avoided, but if contact must be made, the visitor may be offered respirators, gowns, gloves, and eye protection, and if used, should be instructed on their use . Review of Resident #59's Face Sheet dated 10/19/22 reflected a [AGE] year-old female with an admitted [DATE]. Resident #59's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #59's hospital discharge record dated 10/13/22 reflected, .Admit 10/12/22 .Chief Complaint Shortness of breath Fever .Patient is noted to have some cough and wheezing. She is also febrile in ER with fever of 101. Her COVID is negative .Lab results .10/13/22 .Parainfluenza (virus that causes respiratory symptoms) detected . Review of Resident #59's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #59's Admission Nursing Entry dated 10/14/22, reflected, .A [AGE] year-old Female is readmitted back to this facility . Went to the hospital with a DX: [CONDITION(S)] and was admitted for flu and [CONDITION(S)]. Pt is on isolation for FLU X 5 days . In an observation 10/18/22 at 1:30 p.m. revealed Resident #59 in her room. There was no signage posted outside her room indicating the resident was in any form of isolation. In an interview with RN F on 10/18/22 at 1:35 p.m. stated he was unsure if Resident #59 was supposed to be in isolation or not. He stated the resident had tested positive for flu at the hospital. He stated he would have to follow up with the physician. He stated Resident #59 had been on antibiotics and had not had any fever since her return to the facility. In an interview with ADON D on 10/18/22 at 1:40 p.m. stated any resident who was diagnosed with the flu was supposed to be in isolation. She stated she had done the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON D stated the resident should have been placed in isolation when she readmitted on [DATE]. She stated since the facility was already in outbreak mode due to COVID all staff were wearing N95's but stated they should have been wearing full PPE (gown, N95, goggles and gloves) when caring for Resident #59 when she had returned from the hospital. She stated they just missed it. She stated failing to place her in isolation could pose the risk of spreading infection to staff and other residents. She stated at this time there were no other residents in the facility who had tested positive for flu. 2. Review of Resident #76's Face sheet dated 10/20/22 reflected a [AGE] year-old female with an admitted [DATE]. Residents #76's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MA C's undated skills checks reflected she had been skills checked on medication proficiency, which included Proper hand washing techniques/gloves at appropriate times. During a medication pass observation on 10/19/22 at 8:50 revealed MA C pulling medications for Resident #76. Resident #76 had six over the counter medications; Acidophilus (probiotic to promote growth of good bacteria), Vitamin C ( antioxidant) 500 mg, [MEDICATION(S)] ([MEDICATION(S)]) 100 mg, [MEDICATION(S)] Sulfate ( iron supplement) 325mg, [MEDICATION(S)] (reduces gas) 80 mg and Zinc ( mineral for immune health) 50 mg; which were utilized for multiple residents. MA C was observed holding her un-gloved finger over the top of the open bottle of each of the over-the-counter medication bottles to prevent more than one pill from coming out of the bottle. While pouring one of the over-the-counter medications into the medication cup, the pill bounced out of the cup and fell on top of the medication cart. MA C proceeded to pick up the pill with her bare hands and placed it back into the medication cup with the remainder of Resident #79's morning medications and then entered the Resident's room and administered her medications. In an interview with MA C on 10/19/22 at 9:00 a.m. revealed she was not supposed to touch medications with her bare hands. She stated she should wear gloves when pouring medications from over-the-counter medication bottles to prevent from touching the remaining medication in the bottle. She stated she should have thrown the pill away that fell on to the medication cart and gotten another pill. She stated by touching the medications with her bare hands she could spread germs to the resident. In an interview with the DON on 10/20/22 at 09:30 a.m. he stated staff were never supposed to touch a resident's medication with their bare hands. He stated if they had to touch a medication, they were performed hand hygiene and put on gloves. He stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. Review of the facility's guidelines titled, Your 5 moments for hand hygiene, obtained from the World Health Organization, dated October 2006, reflected, 1. Before patient contact .Clean your hands before touching a patient when approaching him or her .2. Before an aseptic task .Clean your hands immediately before any aseptic task to protect the patient against harmful germs, including the patients' own germs, entering his or her body .3. After body fluid exposure risk .Clean your hands immediately after an exposure risk to body fluids (and glove removal .4. After patient contact .Clean your hands after touching a patient and his or her immediate surroundings when leaving .5. After Contact with Patient surroundings .Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving-even without touching the patient Review of the facility's undated policy titled, Medication Cart, Administration of Drugs, reflected, .Properly wash hands if contact has been made with the resident or any procedure that would cause infected hands .

Resident #56 FTag Initiation Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #56) of four residents reviewed for falls. The facility failed to ensure adequate supervision on 07/17/21 when Resident #56 was left alone in the bathroom and fell resulting in a fractured foot, Resident fell on [DATE], 07/31/21, 08/03/21, she fell two separate times on 08/03/21 and on 08/17/21 she fell with a likely fracture to her wrist. This failure could place residents at risk for injuries, pain and hospitalization . Record review of Resident #56's Face Sheet, dated 07/16/21 reflected an [AGE] year -old female admitted to the facility on [DATE] with diagnosis of Malignant Neoplasm (cancer), Traumatic Subdural hemorrhage (bleeding in the brain related to trauma), other disorder of the brain, Altered Mental status, Expressive language Disorder (inability to communicate through words, writing or gestures). Record review of Resident #56's Admission MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility 07/16/21 with a BIMs of 3 which indicated serve cognitive loss. Resident required extensive assistance with two-person physical assist with bed mobility and transfers. Extensive assistance with one-person physical assist for toileting. Balance during transition and walking: moving on and off toilet not steady, only able to stabilize with staff assistance. Surface to surface (transfer between bed and chair or wheelchair only able to stabilize with staff assistance. She was Occasionally incontinent of urinary and bowel. In an interview on 08/29/21 at 1:44 PM with POA for Resident #56 revealed the day resident was admitted to the facility she informed the facility resident had a history of falls and must be watched extremely close. The next day she arrived at the facility and resident was not in her room. She went to the nurse's station asked where resident #56 was at that she was not in her room. She stated the nurse said maybe she is in the restroom, at that time she stated I don't think she would be in the restroom room she can't walk. They went to residents' room and the nurse opened bathroom door and she seen resident on the bathroom floor crying. They got her up and put her to bed. She later was informed a CNA had taken her to the bathroom and left her alone. She fell resulting in fracture to her foot. She has been notified of multiply fall since she has been admitted . Record review of Resident #56's Nursing Admission /Readmission assessment dated [DATE] reflected resident had a medical condition that could increase fall risk. She had a history of falls and resident is not able to bear full weight due to pain, fear, cognitive deficit or weakness. Risk areas /intervention implemented: at risk for falls, night light in bathroom and bedside commode. Resident requires one person assist for ambulation to wheelchair or bathroom. Observation 0n 08/29/21 at 9:55 AM resident was lying in bed with both legs and with socks on feet hanging off the side of the bed. Resident was alert with confusion. She was unable to follow instruction when encouraged to put her legs on the bed. There was not a fall mat, or scoop mattress in place. Observation on 08/30/21 at 10:00 AM revealed no fall mat or scoop mattress in place. Observation on 08/30/21 at 11:45 AM after surveyor intervened the staff placed a fall mat against the wall, but no scoop mattress in place. Observation on 08/31/21 at 12:45 PM revealed a scoop mattress on bed and fall mat against the wall. Record review of Resident #56's Care Plan dated 07/19/21 and revision on 08/18/21, reflected on the Focus area: the resident has had an actual fall, on 07/17/21 with fracture of the right foot, Fall on 07/23/21, no injuries, fall on 07/31/21 ambulating in hallway no injuries, fall on 08/03/21 no injuries, fall on 08/17/ 21, no injuries, slide out of bed. Goal: the resident will resume usual activities without further incident through next review. Interventions: Call light education for assistance date initiated 07/27/21. Continue intervention on the at-risk plan, for no apparent acute injury, determine and address causative factors of the fall, date initiated 07/19/21 Monitor and document, report as needed for 72 hours to medical doctor for sign and symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, and agitation, date initiated 07/19/21 Physical Therapy consult for strength and mobility, date initiated 07/19/21. Call light education for assistance date initiated 07/19/21. In an interview on 08/30/21 at 1:37 PM with DON revealed the at-risk plan is the intervention addressed in the care plan. In an interview on 08/31/1:00 pm with the DON revealed the facility has a stand up meeting every morning to discuss issues that happened over night. The department heads meet and discuss falls, hospitalization , admissions, discharges etc. He stated safety measures can be put in place to reduce the risk for falls for residents such as refer to Physical Therapy, education, fall mats, non-slip sole, bed in low position with bolster mattress. He stated the care plan team discusses each resident, evaluate the situation then interventions are added or updated to the care plan. The MDS nurse then the adds the interventions to the care plan. The CNAs tablets will be up-dated, as the care plans is up-dated in the nurse's computers. It is the DON's responsibility to ensure the interventions have been implemented. Record review of Resident #56's Incident report date 07/17/21 reflected resident was found on the restroom floor, on her right side. Resident was taken to the restroom by CNA. Resident complained of pain to her right foot with swelling. X-rays were ordered. Record review of Resident #56's progress notes dated 0717/21 reflected resident was found on the restroom floor, on her right side. Resident was taken to the restroom by CNA. X-ray results showed fracture to right foot transport to hospital for further evaluation and treatment. Resident returned to facility with a hard shoe on the right foot. Record review of Resident #56's X-Ray report dated 07/17/21 reflected acute fracture to fifth digit. Record review of Resident # 56's BIMs dated 07/17 /2 reflected a score of three which indicated severe cognitive impairment. Record review of Resident #56's Incident Report dated 07/23/21 reflected resident was on the floor by the bathroom setting on her buttock. She was ambulating without assistance, oriented to person, place and time and saturation with impaired memory and she refuses to use call light. No injuries noted. Record review of Resident #56's progress notes dated 0723/21 reflected resident had fallen on the floor outside of bathroom floor. No injuries noted. Record review of Resident #56's Incident Report dated 07/31/21 reflected resident was walking in the hallway and sat on the floor she was unable to state what happened or where she was going due to cognitive impairment. Resident oriented to person she has impaired memory and gait imbalance. Record review of Resident #56's progress notes dated 07/31/21 reflected resident was walking in the hallway resident sat on the floor. Resident was assisted into her wheelchair and brought to nurses' station for close monitoring. Record review of Resident #56's Incident Report dated 08/03/21 reflected resident was found sitting on her right leg on the floor, close to her bed. Resident is confused and orientated to person, ambulating without assistance No injuries were noted. Record review of Resident #56's progress notes dated 08/03/21 resident was found sitting on her right leg on the floor, close to her bed. X-rays were ordered of the right leg. Resident educated to always use call light. Record review of Resident #56's, second Incident Report dated 08/03/21 reflected residents second fall. Resident was found sitting on the floor. No injuries noted. Record review of Resident #56's progress notes dated 08/03/21reflected Resident was found sitting on the floor No injuries noted resident was taken to the bathroom and was showered. Resident was confused with impaired memory. Weakness with gait imbalance and incontinent.no injuries noted. Record review of Resident #56's Incident Report dated 08/17/21 reflected, resident was trying to get out of bed when she fell . Resident was found on the floor. She complained of pain to her left wrist with swelling noted. X-rays were ordered. Record review of Resident #56's X-Ray report dated 08/17/21 reflected the distal diametaphyseal dorsal slanting and distal ulnar styloid irregularity is present, likely a fracture, however age is indeterminate. Record review of Resident #56 progress note dated 08/17/21 reflected, question if there is a fracture. Likely represents old fracture. Place arm in sling and refer to Orthopedic surgeon. Record review of the Provider Investigation Report dated 07/17/221 revealed Resident #56 was taken to the bathroom to toilet by CNA. She was assessed and returned to bed. Resident complained of pain on her right foot and ankle with some swelling. The physician Assistant order x-rays. Neurovascular checks started. CNA was educated not to leave residents untended in any circumstances, and to call ask for help from other CNAs, or charge nurse. Resident was transferred to hospital for further assessment and treatment. Facility in-serviced staff on abuse/neglect policy, toileting confused residents, residents' rights, falls, and fall preventions. In an interview on 08/30/21 at 2:30 PM with LVN A revealed when she entered the bathroom Resident #56 was lying on the floor on her side with the brief pulled down to her knees. RN C brought a wheelchair to transfer her into to get her out of the bathroom. LVN A and RN C lifted her into the wheelchair. LVN A stated CNA B took resident to the bathroom and left her alone. She stated resident should not be left along in the bathroom. In an interview on 08/30/21 at 6:10 PM with RN C reveal, she was called to Resident #56's bathroom by LVN A when the resident fell . She was on her side with the brief pulled down. She and LVN A lifted her into a wheelchair then laid her down on the bed. She done a head to toes assessment noted swelling to her foot and ankle. The doctor was notified with new orders to get an X-ray. The X-ray came back showed fracture of the right foot toe. She was transferred out to the hospital for evaluation and treatment. Resident returned with a hard shoe in place. She educated CNA not to leave residents untended no matter what was happening. In an Interview on 08/29/21 at 12:42 PM with Administrator revealed residents are to be assisted to the bathroom and someone stay with the resident. He would not expect for resident to be left alone relate to the risk of falls with possible injuries. In an interview on 08/29/21 at 1:37 PM with DON revealed resident should not be left unattended, the CNA must stay with the resident related to the risk of falling with possible injuries. In an interview on 08/30/21 at 4:46 PM with PCA B revealed she took Resident #56 to the bathroom and put her on the commode and told her to pull the light when she was finished. She never pulled the light. It was lunch time and the she was passing out lunch trays and forgot that she had left her in the restroom, and she fell . She continued to state there was nothing on the resident's care plan on her tablet that gave any information on her cognitive or ambulatory status. In an interview on 08/31/21 at 1:00 pm with CNA G the resident care and treatment in in the care plan on our tablets. Review of a facility policy, titled Fall Investigation and Intervention Policy and Procedure undated revealed, Fall Investigations .Care Plan the fall and all interventions specific to the fall. First Fall: .Care plan the fall and interventions .if the resident is going to the restroom can you include CNA interventions such as a toileting schedule . Second Fall: .decide what new interventions and update the CNAs .low bed and landing mat .if the fall is related to going to the bathroom, do you need to adjust the scheduling toileting time? Multiple Falls: .make sure you include all the interventions you have attempted with prior falls.