Every finding on record at Rambling Oaks Courtyard Extensive Care Community

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 5 of 8 room (Rooms# 109;111; 206; 208; 210) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 08/05/26, 08/07/26; 08/08/26.1-Resident #1 had multiple ants' bites over her body per ER doctor's note on 08/05/26.2-Resident #2 had two ants' bites over her left elbow per the Resident on 08/08/26.3-Resident #3 had three ants' bites over her left elbow per the Resident on 08/08/26.4-Resident #5 reported seen ants in her room on 08/06/26.5-Resident #6 reported seen ants in his room on 08/07/266-There were life ants and a brownish, granular or soil-like substance in Resident#4's room on 08/08/2026. This failure places residents at risk of serious physical harm from ants or other pest bites. Findings included: 1-Record review of Resident #1's face sheet dated 08/07/26 reflected the resident was aa [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (elevated blood sugar), fistula of vagina to large intestine (A fistula connecting the vagina to the large intestine usually requires surgical repair), and ileostomy (a surgical procedure that diverts stool from the small intestine (ileum) to an opening in the abdominal wall called a stoma, bypassing the colon and rectum). Record review of Resident #1's MDS dated [DATE] reflected Resident#1 had BIMS score of 14/15 indicating intact cognition. Record review of Resident #1's base line care plan signed on 08/04/26 reflected the resident had skin integrity issue stage 3 right buttocks, stage 2 left buttock, middle head scrap wound status post craniotomy and excoriation right abdomen. Functional abilities and goals-self-care.2. Personal hygiene: support provided: two+ persons physical assist.urinary continence: frequently incontinent. Bowel incontinence: occasionally incontinent. ADL self-care performance related to bed mobility was coded as: ADL activity itself did not occur. The care plan further reflected that the resident can easily communicate with staff and understand the staff. Record review of Resident #1's wound care Doctor skin assessment dated [DATE] reflected Resident presents with wounds on her right buttock; scalp; left buttock and rashes. Other diagnosis: Candidiasis rush left leg. Record review of Resident #1's wound care Doctor progress notes dated 08/06/26 reflected the following: Resident was sent to the ED yesterday due to elevated WBC with concerns for possible sepsis. I was able to view updated photos of the rash to her left lateral hip/buttock/thigh region today. There is noticeable improvement in the appearance of the lesions since my evaluation on 08/04. The rash does remain consistent with candidal intertrigo with satellite pustulosis, and the history of high output ileotomy with associated MASD (Moisture-Associated Skin Damage), location and distribution of the rash in addition to improvement with antifungal, supports this as well. I would not suspect candidal intertrigo to explain the leukocytosis. Record review of Resident #1's ED's Doctor progress notes dated 08/05/26 reflected the following: Resident stated that she was laying in the bed of ants so she called her niece today. She had multiple ant bites all over. Record review on 08/08/26 of Pest Control service report dated 08/05/26 revealed Technician Comments Today I checked in with staff I inspected and treated for crawling insects I also treated ants in room [ROOM NUMBER]-208-210 there was soda in the floor and snacks. Observation and interview with Resident #1 on 08/07/26 at 2:08 PM at the hospital revealed Resident#1 was lying in bed alert, awake, there were numerous small red-to-dark papules/sports scattered over her left thigh, left forearm, the back of her right upper arm, and right shoulder, some lesions look raised and inflamed full of pus, while others appear crusted or scratched/open. The distribution was multiple and scattered and not continuous rash. Resident#1 stated she was lying in the bed in the nursing home, and there were ants crawling over her body and biting her. She stated she called the staff and did do anything about it; she called her niece and asked her to take her to hospital. Resident#1 described her pain level at 8/10 all over the areas described above on the morning of Wednesday (08/05/2026). Interview on 08/08/26 at 6:25 AM with RN A revealed CNA E alerted her that she saw ants in Resident#1's room on the floor by the end of the shift on 08/05/26. RN A stated she did not check the room or Resident#1 herself, and she only reported to the incoming nurse (LVN E) for the day shift. RN A stated she had an encounter with Resident#1 during her 6 pm to 6 am shift at 1 AM when she changed her ileotomy bag. RN A stated since Resident#1 did not call for anything during the rest of the shift RN A was only doing round on the Resident to make sure she was [NAME]. Interview on 08/08/26 at 07:09 AM LVN D stated she was the nurse who admitted the Resident#1 on Saturday 08/01/2026. She stated she had to change Resident#1's ileostomy bag three time during her shift, because it was leaking, related to the stoma been created in the lower part of the abdomen, and flat. She stated Resident#1 skin assessment on admission showed that the Resident had two pressure sores in both side of her buttocks area, scalp old wound, and excoriating rash starting at the stoma exit in the right lower abdomen going toward her back. She denied seen ants in the Resident#1 room. She stated staff reported seen ants in Resident#1 in 200 Hall, or in the Resident#1's room [ROOM NUMBER]. Attempted interview on 08/08/26 at 08:56 AM with MD G: call placed no answer. Interview on 08/08/26 at 09:02 AM over the phone The Wound Care Doctor stated she performed Resident#1 skin/wound assessment on 08/04/2026. She stated Resident#1 had rash in 3 places on her body: pustular rash on her left buttocks, left hip, left forearm. She stated Resident#1 had some MSD (moist skin damage) on her right side from the ileostomy site going toward the back.She stated the rash was related to the moisture from the leak of gastric acid content, or disseminated Zoster virus vs. moisture from candidiasis infection, not from ants' bites. She stated the rash was monophone and located in the area, and she was not a Dermatologist, and it did not look like ants' bites, for her and it would need culture to figure out exactly what it was. She stated her progress note on 08/06/26 was based on a picture the facility's Administrator sent to her via test message from a hard copy of the affected area on Resident#1's body that her family gave him. Interview on 08/08/26 at 1:08 PM over the phone LVN E stated she work day's shifts (6 am to 6 pm). She stated she was assigned to Resident#1 on Wednesday 08/05/2026 morning. She stated she received report from the previous nurse (RN A) that notified her of presence of ants in Resident#1's room. She stated she moved Resident#1 to another room in wheelchair, between 6:30 am and 7:00 am during her first round. She stated she saw ants on the floor toward the window, but not on the Resident. She stated she assessed Resident#1, and she only noticed the old scar on the Resident#1 scalp, right lower abdomen toward the back and two pressure sores covered with dressing on both side of her buttocks area. She stated she did not document the assessment. LVN E stated Resident#1 niece came in and wanted the Resident to be transferred to hospital. She Stated MD G coming assessed Resident#1 and order to send her to hospital. She stated EMS called and took Resident#1 to hospital. 2-Record Review of Resident#2's Quarterly MDS assessment dated [DATE] reflected, Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] and readmitted [DATE].Her relevant diagnoses included: Type 2 diabetes mellitus (elevated blood sugar), UTI (urinary tract infection), morbid (severe) obesity due to excess calories, and muscle weakness.Resident #2 had BIMS of 15, which indicated she had intact cognition. Observation on 08/08/26 at 10:35 AM revealed Resident#2 was lying in bed, awake and alert. She stated she had seeing ants in her bed last night and had 2 bites with pus in her left elbow. She stated they (facility staff) came in and sprayed her table couple of weeks ago. 3-Record Review of Resident#3's Quarterly MDS assessment dated [DATE] reflected, Resident #3 was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted [DATE].Her relevant diagnoses included: Hypertension (elevated blood pressure),Type 2 diabetes mellitus (elevated blood sugar), cerebrovascular accident (happens when blood flow to a part of the brain stops), difficulty in walking, and muscle weakness. Resident #4 had BIMS of 04/15, which indicated sever cognition impairment. Observation on 08/08/26 at 11:07 AM revealed Resident#3 was lying in bed, awake alert. She stated she knew there were ants in her room but did not see any. She started she had couple of ants' bites in her left elbow (3 bites), and they started fading away. She stated they were itching for one day or two. She stated they (staff)came in and sprayed outside her room. Observation on 08/08/26 at 10:05 AM during a walk with the Administrator around the outside of the facility and the enclosed courtyard located behind the residents and number rooms in 100 Hall, Residents' with even number rooms in 200 Hall revealed multiple mounds of ants, in the ground, and against the wall of 100 Hall, with large amount of active ants crawling in the areas. Interview on 08/08/26 at 09:49 AM over the phone the Maintenance Supervisor stated he saw ants in Resident#1's room in 200 Hall may be 1-2 by the window. He stated he called Pest Control services and he requested the Technician to treat the rooms 206, 208 and 210 inside and outside. He stated he asked housekeeper if they see ants to clean the room and he will call the pest control to spray it. He stated there were ants in another room a week before and he called pest control, and they sprayed it. He stated during the Pest Control monthly services they treat all around the building. He stated during the month of July he called pest control once. He stated the Pest control Services were scheduled for the first week of each month for treatment of the building. When asked if the Pest Control company treated the courtyard on 08/05/2026 he replied not sure. He denied visiting and checking the courtyard on 08/06/2026. He stated the administrator got some chemicals and gave them to housekeeping to spray them outside. Interview on 08/08/26 at 08:26 AM Administrator denied seeing ants in the facility before the walk around the facility this morning. He stated staff reported seen ants in Resident#1's room on 08/05/2026 between 7:00 am and 7:30 AM and moved Resident#1 to another room. Administrator stated he did not hear about the ants' bites on Resident#1 until her family told him that the rash she had over parts of her body, they thought was related to ants' bites after Resident#1 went to emergency room. He stated Resident#1's family member showed and gave him the pictures of the body area with rash. He stated what he saw in the pictures could not be ants' bites, because those areas had already been recorded by the Wound Care Doctor during her skin assessment on 08/04/2026 as a rash related to fungal candidiasis. He stated the Maintenance Supervisor called the Pest control service on 08/05/2026 they came and sprayed Resident#1's room and the two adjusting rooms to it. He stated he bought some pest control chemicals and sprayed them himself in the courtyard. He stated he reported the incident to HHSC, and he was in the process of finishing his investigation including in serving the staff on ants' activities in the facility and to report it immediately to him or the DON Interview on 08/08/26 at 08:35 AM the DON stated she performed Resident#1's skin assessment on the morning of 08/05/2026 and she did no see ants bites. She stated she saw rash on the left arm, right abdominal side lateral cavity, the inflammation was going to the back and groin area. She stated Resident#1 had two wound dressing on the buttocks area. She stated the rash on Resident#1 skin for her looked like shingles with purulent pockets. The DON denied seen ants in Resident#1's room or in the facility, but she let the Maintenance Director know about what was reported to her so he could treat Resident#1's room. The DON stated she in serviced staff on ants' activities in the facility. Record review of the undated facility's General Pest Control Policy, reflected the following: Policy Statement: The facility shall maintain an effective pest management program to prevent infestations of insects, rodents, birds, and other pests that may pose a risk to resident health, food safety, infection prevention, property, or operations. Policy Interpretation and Implementation . Monitor their assigned areas for pest activity. Ensure staff follow sanitation and storage practices. Report pest sightings immediately. All pest sightings or evidence of pests shall be reported immediately to the supervisor, Environmental Services Director, or Maintenance Director.

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 one (Resident #5) of six residents observed for infection control. RN B failed to perform hand hygiene between glove changes, and when she went from dirty to clean during incontinence care for Resident #5. These failures placed residents at risk for spread of infection through cross-contamination.Findings included: Record review of Resident #5's MDS date assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] her relevant diagnoses included: Peripheral Vascular Disease, multiple fracture of the pelvis, and right leg above knee amputation, Resident#5 BIMS score was 15/15 indicating intact cognition. Further review revealed she was always incontinent of bowel and bladder and was dependent for toileting hygiene. Review of Resident #5's Care Plan revised on 07/20/26 reflected no ADLs activities were care planed for Resident#5. In an observation 08/08/26 at 06:45 AM RN B answered Resident # 5's call light. RN B closed the door and got gloves from the box inside the room by the left side of the entrance. She got clean brief, and a box of wipes from a storage ban in the resident bathroom. She uncovered Resident#5, unfastened the brief. RN B cleaned Resident#5 front area, pushed the brief between her leg. She helped Resident#5 turn to her left side, cleaned her buttocks area, folded the dirty brief, removed it and put it by the foot of the bed. Resident#5 was incontinent of urine. RN B put the clean brief on Resident#5 without changing gloves or performing any form of hands hygiene (washing hands with soap and water or sanitizing hands with hands sanitizer). RN B helped Resident#5 on to her back, finished putting the brief on her. RN B took the dirty brief disposed of it in a trash can in the bathroom, changed gloves, without performing any form of hands hygiene. She covered Resident#5, she removed the gloves, sanitized her hands and exited the room. Interview with RN B on 08 /08/26 at 06:54 AM revealed she was supposed to perform hands hygiene each time she removed the gloves before putting on clean gloves. She stated she was supposed to change the gloves with hands hygiene; before getting the clean brief to put it on the Resident. She did not answer why she was not following proper hands hygiene and gloves use. She stated the risk to Resident cross contamination and development of infection. Interview with the DON on 08/08/26 at 1:19 PM revealed she expected staff to wash their hands before care, when they went from dirty to clean, and after care was completed. The DON stated the dirt brief should be removed off, change gloves with hands hygiene before proceeding to put a clean one. She stated the risk to residents' developing infection. Review of the facility's policy titled Hand washing/Hand Hygiene revised October 2023, reflected, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. hand hygiene is indicated: . before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal .

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 20 resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8) observed for cleanliness. The facility failed to ensure Rooms #1, #2, #3, #4, #5, #6, #7, and #8 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 01/06/26 at 10:58 AM, in room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor under the sink and grayish and brownish stains around the toilet area. An observation on 01/06/26 at 11:01 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor under the sink and thick black dirt stains around the toilet area. An observation on 01/06/26 at 11:05 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor under the sink and thick black dirt stains around the toilet area. The air conditioning unit had dirt in the vents. An observation on 01/06/26 at 11:13 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish and brown dirt stains on the floor, especially around the toilet area. In an interview on 1/06/26 at 11:14 AM, the resident in room [ROOM NUMBER] stated they mopped the bathroom floor, but she had to scrub the floor around the toilet area because it grossed her out. An observation on 01/06/26 at 11:20 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor around the toilet area. An observation on 01/06/26 at 11:23 AM, of room [ROOM NUMBER] reflected the bathroom floor had brown and grayish dirt stains on the floor around the toilet area. An observation on 01/06/26 at 11:36 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor around the toilet area. An observation on 01/06/26 at 11:39 AM, of room [ROOM NUMBER] reflected the bathroom floor had grayish dirt stains on the floor around the toilet area. In an interview on 1/08/26 at 12:02 PM, Housekeeper M stated he had been at the facility for about 4 months, and he was assigned to clean the 200 Hall. He stated they were trained to clean the room from the back of the room to the front of the room. He stated they were to clean the bathrooms and the air condition units in the rooms. He stated they were to clean the resident rooms daily. He was shown photos of the concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, and #8, and he stated he tried to clean the stains in the bathroom floors but they had never attempted to deep clean the floors. He stated the bathroom floors being in the condition observed was not appealing to the residents who resided in the rooms. In an interview on 1/08/26 at 12:11 PM, Housekeeping Supervisor stated she had been at the facility since July 2025. She stated they trained staff to clean the facility by doing 1 on 1 training and showing them a video of how to properly clean the rooms. She was shown pictures of the concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, and #8 and she stated the bathroom floors needed to be scrubbed with a machine, and all the areas were fixable. She stated the concerns observed did not have a good impact on the residents. In an interview on 1/08/26 at 12:15 PM, the Administrator stated he was told by his Housekeeping Supervisor of the concerns observed in the resident rooms, He was shown pictures of concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, and #8, especially the bathroom floors. He stated he would work with Housekeeping to deep clean the floors. He stated the impact these concerns had on the resident was it did not present a homelike environment for them. Review of the facility's policy on Housekeeping Cleaning & Disinfecting (2021) revealed Purpose: To keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for six (Residents #9, #11, #12, #25, #36, and #40) of eighteen residents reviewed for privacy and confidentiality.The facility failed to ensure LVN C secured Residents #9, #11, #12, #25, #36, and #40's medical information before leaving his nurse's cart on [DATE]. This failure could place the residents at risk of not having their private and medical information exposed to unauthorized individuals.Findings included:Resident #9Record review of Resident #9's Face Sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with tachycardia (fast heart rate) and intracranial hemorrhage (bleeding inside the skull).Record review of Resident #9's advance directive on [DATE] reflected that the resident was a full code (life-saving measures would be provide if the heart stops).Record review of Resident #9's Comprehensive Care Plan, dated [DATE], reflected that the resident wished to be a full code and one of the interventions was that the request for CPR (Cardiopulmonary Resuscitation: an emergency life-saving procedure) to be initiated would be followed.Resident #11Record review of Resident #11's Face Sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with upper respiratory disease and fracture (broken bone) of left fibula.Record review of Resident #11's advance directive on [DATE] reflected that the resident was a DNR (Do Not Resuscitate: refuse CPR if the heart or breathing stops).Record review of Resident #11's Comprehensive MDS Assessment, dated [DATE], reflected the resident had moderate impairment in cognition with a BIMS score of 11.Record review of Resident #11's Comprehensive Care Plan, dated [DATE], reflected the resident had an order for Do Not Resuscitate and one of the interventions was in the absence of b/p, pulse, and respiration, CPR would not be initiated.Record review of Resident #11's Progress Notes, dated [DATE], reflected Answered . had chest x-ray done .Resident #12Record review of Resident #12's Face Sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with atrial fibrillation (an irregular, rapid heartbeat).Record review of Resident #12's advance directive on [DATE] reflected that the resident was a full code.Record review of Resident #12's Comprehensive MDS Assessment, dated [DATE], reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. Record review of Resident #12's Comprehensive Care Plan, dated [DATE], reflected that the resident was on full code and one of the interventions was that the request for CPR to be initiated would be followed.Resident #25Record review of Resident #25's Face Sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture to left humerus.Record review of Resident #25's advance directive on [DATE] reflected that the resident was a full code.Record review of Resident #25's Comprehensive MDS Assessment, dated [DATE], reflected the resident was cognitively intact with a BIMS score of 15. Record review of Resident #25's Comprehensive Care Plan, dated [DATE], reflected that the resident was on full code and one of the interventions was that the request for CPR to be initiated would be followed.Resident #36Record review of Resident #36's Face Sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with atrial fibrillation.Record review of Resident #36's advance directive on [DATE] reflected that the resident was a DNR.Record review of Resident #36's Comprehensive MDS Assessment, dated [DATE], reflected the resident was cognitively intact with a BIMS score of 14. Record review of Resident #36's Comprehensive Care Plan, dated [DATE], reflected the resident had an order for Do Not Resuscitate and one of the interventions was in the absence of b/p, pulse, and respiration, CPR would not be initiated.Resident #40Record review of Resident #40's Face Sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with atrial fibrillation.Record review of Resident #40's advance directive on [DATE] reflected that the resident was a DNR.Record review of Resident #40's Comprehensive MDS Assessment, dated [DATE], reflected the resident was cognitively intact with a BIMS score of 15. Record review of Resident #40's Comprehensive Care Plan, dated [DATE], reflected the resident had an order for Do Not Resuscitate and one of the interventions was in the absence of b/p, pulse, and respiration, CPR would not be initiated.An observation on [DATE] at 11:41 AM, revealed a piece of paper was on top of the cart that was parked in front of the nurses' station and the cart was facing the hallway. On the piece of paper were some of Residents #9, #11, #12, #25, #36, and #40's medical information. The piece of paper revealed that Residents #9, #12, and #25 were a full code and Residents #11, #36, and #40 were a DNR. The piece of paper also showed that Resident #11 needed a chest X-ray and Resident #40 was on oral ABT. During an observation and interview on [DATE] at 11:25 AM, revealed LVN A saw the piece of paper on top of the cart that showed medical information for some of the residents. She flipped the paper and stated the paper should have been turned upside down because medical information would be a HIPAA violation if exposed to unauthorized individuals. LVN A said she would let LVN C know that he needed to make sure no information was exposed.In an interview on [DATE] at 11:27 AM, LVN C stated he left his cart because he attended to someone. He said he thought he covered the paper, which was their shift report, but did not make sure it was fully covered. He said he was in a hurry and just turned away from his cart. He said he would be mindful the next time he would leave his cart because the information written on the piece of paper was medical information and was confidential.In an interview on [DATE] at 6:41 AM, the ADON stated the medical information of any resident should not be left unattended because it was confidential and could be a HIPAA violation. She said, before leaving the cart, the staff should have secured it somewhere so unauthorized individuals would not see them. She said the expectation was for the staff to secure or flip any paper that had medical information in it. She said it would be better if they would lock it inside their carts because somebody might flip it and read it. She said the expectation was for the staff to be mindful every time they leave their carts to secure any paper with medical information. She said the DON already started an in-service about privacy and confidentiality.In an interview on [DATE] at 7:40 AM, the DON stated if what was written on the piece of paper was medical information of the residents, then it should not be left unattended because unauthorized individuals might see it. She said medical information about a resident should be protected and not be visible for everybody to see because that was confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said if the confidential information was exposed, non-nursing staff, other residents, and visitors would be able to see it. She said all staff, including her, was expected to provide confidentiality of all the residents' personal and medical information. The DON stated she already started an in-service about confidentiality of medical records.In an interview on [DATE] at 8:36 AM, the Administrator stated the expectation was for the staff to have turned the paper upside down before leaving the cart because what was written on the paper was supposed to be confidential because it was medical information. He said he would coordinate with the DON regarding closely monitoring the staff regarding confidentiality of medical records.Record review of the facility's policy entitled, Confidentiality of Information and Personal Privacy 2001 MED-PASS, Inc., revised [DATE] reflected Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . Policy Interpretation and Implementation . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 4. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #8 and Resident #26) of eighteen residents, for two (LVN C and LVN B) of three LVNs, for two (CNA D and CNA E) of six CNAs reviewed for infection control. 1. The facility failed to ensure LVN C would not walk the hallway with a glove to one hand after coming out of Resident #11's room on 01/06/2026. 2. The facility failed to ensure LVN B wore a gown when connecting Resident #8's IV on 01/06/2026. 3. The facility failed to ensure LVN B wore a gown while emptying Resident #8's catheter bag on 01/06/2026. 4. The facility failed to ensure CNA D and CNA E did not use the gloves inside their pockets during Resident #26's incontinent care on 01/07/2026.These failures could place residents at risk of cross-contamination and development of infections.Findings include:1. Record review of Resident #11's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with depression. Record review of Resident #11's Comprehensive MDS Assessment, dated 11/27/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had depression.Record review of Resident #11's Comprehensive Care Plan, dated 11/10/2025, reflected that the resident required antidepressant medication and one of the interventions was to monitor any signs and symptoms of depression.An observation on 01/06/2026 at 11:14 AM, revealed LVN C exited Resident #11's room with his left hand holding a disposable cup and with his right hand with glove on. LVN C went to the sink at the nurse's station and washed the disposable cup.In an interview on 01/06/2026 at 11:19 AM, LVN C stated he was just getting Resident #11 some water. He said he should have disposed of his gloves first before going out of the resident's room to get her some water. He said, even though he did not touch the resident, the rule of the thumb was to dispose of the gloves before leaving the room to prevent spread of infection. He said the resident did not have any infection, but he still should have taken off his glove before going to the nurse's station.2. Record review of Resident #8's Face Sheet, dated 01/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urine retention. Record review of Resident #8's Comprehensive MDS Assessment, dated 12/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had urine retention.Record review of Resident #8's Comprehensive Care Plan, dated 11/10/2025, reflected the resident had UTI and one of the interventions was to administer antibiotic as ordered.Record review of Resident #8's Physician Order, dated 01/06/2025, reflected Imipenem 1-gram IVPB every 8 hours X days every 8 hours for 7 Days.Record review of Resident #8's Physician Order, dated 04/28/2025, reflected ENHANCED BARRIER PRECAUTIONS AS NEEDED.An observation on 01/06/2026 at 2:06 PM, revealed LVN B was about to connect Resident #8's antibiotics via IV. She washed her hands and put on a pair of gloves. She took the resident's antibiotics and the IV set from the top of her cart, placed them on the resident's overbed table, and closed the resident's door. She connected the IV set to the antibiotics and primed it. After priming the IV, she flushed the PICC line, and then connected the IV. She did not wear a gown while she was connecting the IV. It was observed that there was a sign outside the resident's room that PPE was required because the resident was on enhanced barrier precautions because she had a central line.3. Record review of Resident #8's Face Sheet, dated 01/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urine retention. Record review of Resident #8's Comprehensive MDS Assessment, dated 12/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag).Record review of Resident #8's Comprehensive Care Plan, dated 11/10/2025, reflected the resident had an indwelling catheter and one of the interventions was catheter care every shift.Record review of Resident #8's Physician Order, dated 04/28/2025, reflected Foley (device used to help drain urine from bladder) catheter every shift.Record review of Resident #8's Physician Order, dated 04/28/2025, reflected ENHANCED BARRIER PRECAUTIONS AS NEEDED.An observation on 01/06/2026 at 11:56 AM, revealed that Resident #8's catheter bag was full. The resident asked LVN B if she could empty it. LVN B put on a pair of gloves, went to the bathroom to get a basin, and then emptied the resident's catheter bag. She did not wear a gown when she emptied the resident's catheter bag. It was observed that there was a sign outside the resident's room that PPE was required because the resident was on enhanced barrier precautions because she had a catheter.In an interview on 01/06/2026 at 2:29 PM, LVN B stated Resident #8 was on EBP because the resident had an IV and a catheter. She said when a resident was on EBP, it meant that a gown was required when doing a treatment. She said she did not know why she forgot to wear a gown when she administered the resident's antibiotics via IV and when she emptied the resident's catheter bag. She said the gown was needed basically to prevent transmission of microorganisms from staff to resident, from resident to staff, and from staff to another resident. She said she would wear a gown the next time she would care for residents with an IV and a catheter.4. Record review of Resident #26's Face Sheet, dated 01/08/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with retention of urine and kidney failure.Record review of Resident #26's Comprehensive MDS Assessment, dated 10/16/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated that the resident was incontinent for bowel and bladder.Record review of Resident #26's Comprehensive Care Plan, dated 11/12/2025, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent care.An observation on 01/07/2026 at 9:54 AM, revealed that CNA D and CNA E was about to do Resident #26's incontinent care. Both CNAs washed their hands before putting on their gloves. It was observed that both CNAs had gloves inside their pockets. During the process of incontinent care, both CNAs used the gloves in their pockets when they changed their gloves. It was observed that a box of gloves was on top of the resident's bedside table, both CNAs only took gloves from the box of gloves when they were out gloves from their pockets.In an interview on 01/07/2026 at 10:18 AM, CNA D stated she put some gloves in her pockets, and she was not sure if her pocket was clean. She said she guessed her pocket was not clean because she would put her keys and cell phone in her pocket. She said she would not put gloves inside her pocket again and would just get them from the box to make sure she was using clean gloves.In an interview on 01/07/2026 at 10:21 AM, CNA E stated she would put gloves in her pockets for easy access. She said it did not dawn on her that her pockets might have dirt in them or was soiled making the gloves she used for incontinent care dirty.In an interview on 01/08/2026 at 6:41 AM, the ADON stated staff should not walk in the hallway with gloves on coming out of a resident's room. She said it did not matter if the staff touched the resident or not or that the resident did not have any infection at all but gloves should be disposed of inside the room before coming out of the room. She said if the staff needed to go back to the residents' room, then the staff needed to put on a new pair of gloves. She said if a resident had IV and had a catheter, then the staff should wear a gown because the resident was on EBP. She said gloves should not be in the pockets because the pockets were dirty rendering the gloves dirty when used. She said the issues discussed contributed to cross contamination and probable infection. She said the expectation was for the staff to be mindful of what they were doing to protect the residents. She said the DON already started an in-service about infection control.In an interview on 01/08/2026 at 7:40 AM, the DON stated gloves should be disposed of before leaving a resident's room. She said gloves in the hallways could contribute to spread of infection. She said if a resident was on EBP, then the staff doing care or treatment should wear a gown every time they had contact with the resident. She said residents with g-tube, catheter, tracheostomy, or an IV were on EBP and required PPE to prevent the spread of infection from one resident to another. She said there might be no policy that would say not to put the gloves in the pockets but the best practice was not to put gloves inside the pockets to make sure the gloves being used were clean. She said she already started an in-service about infection control.In an interview on 04/17/2026 at 8:36 AM, the Administrator stated that the expectation was for the staff to be mindful to dispose the gloves before coming out of a resident's room, to wear gowns in addition to the gloves if the residents were on EBP, and not to use dirty gloves. He said the concerns discussed would all contribute to the development and spread of infection. He said the DON already started an in-service about infection control but would closely coordinate with the DON if the staff were following the policy and procedure for infection control. Policy and procedure for Enhanced Barrier protection was requested via email to the Administrator on 01/07/2026 at 9:16 AM and on 01/08/2026 at 9:39 AM 09/19/202 but was not provided prior to exit.Record review of the facility's policy Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual 2010 revised October 21, 2022 reflected A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility . Gloving . Gloves are worn for three important reasons . 1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . 5. Gowns and protective apparel . Gowns are also worn . they are removed before the personnel leave the resident's environment.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for two (Resident #3 and Resident #15) of eighteen residents and one (LVN A) of three LVNs reviewed for pharmaceutical services.1. The facility failed to ensure LVN C did not leave Resident #3's medications inside the resident's room for the resident to administer unattended on 01/06/2026. 2. The facility failed to ensure Resident #15 was not self-administering her eye drops without an assessment on 01/06/2026.3. The facility failed to ensure LVN A did not put her personal beverage on top of the nurse's cart while passing medications on 01/06/2026.4. The facility failed to ensure that there was no expired medications inside the medication room on 01/07/2026.These failures could place residents at risk of not receiving medications as ordered, taking medications without a proper assessment, potential overdose, adverse effects, cross contamination, not receiving the medication's full therapeutic benefits, and potential interference with medication preparation.Findings include: 1. Record review of Resident #6's Face Sheet, dated 01/06/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason), anxiety (intense or excessive fear or worry), and depression (persistent feeling of sadness or loss of interest). Record review of Resident #3's Comprehensive MDS Assessment, dated 12/18/2025, reflected the resident had moderate impairment in cognition with a BIMS 07. The Comprehensive MDS Assessment indicated the resident had dementia, anxiety, and depression.Record review of Resident #3's Comprehensive Care Plan, dated 12/18/2025, reflected that the resident was taking an antidepressant and one of the interventions was to give medications as ordered. The Comprehensive Care Plan did not indicate that the resident could self-administer her medications.Record review of Resident #3's Physician's Order, dated 01/03/2026, reflected PreserVision AREDS 2 Oral Capsule (Multiple Vitamins w/ Minerals) Give 1 capsule orally two times a day for Supplement. Record review of Resident #3's Physician's Order, dated 10/06/2025, reflected Apixaban Oral Tablet 2.5 MG (Apixaban) Give 1 tablet orally two times a day for Stroke prevention.Record review of Resident #3's Physician's Order, dated 01/02/2025, reflected Ferrous Sulfate Oral Tablet 325 MG (Ferrous Sulfate) Give 1 tablet orally in the morning for Supplement.Record review of Resident #3's Physician's Order, dated 01/04/2025, reflected Levocetirizine Dihydrochloride Oral Tablet 5 MG (Levocetirizine Dihydrochloride) Give 1 tablet by mouth two times a day for Seasonal Allergies.Record review of Resident #3's Clinical Assessment Notes on 01/06/2026 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications.During an observation and interview on 01/06/2026 at 09:43 AM, revealed Resident #3 was in her bed, awake. It was observed that a small plastic cup, with four pills inside, was on top of the resident's overbed table. According to the resident, her nurse left the medications with her and she would take them after she was finished with his breakfast. The resident said it was not the first time that her medications were left with her. She said there was more than four pills, she already took some of them. She said she was not sure what the remaining pills was in the small cup. In an interview on 01/06/2026 at 10:12 AM, LVN C stated he left Resident #3's morning pills with her because the resident insisted. He said the resident was oriented to person, place, time, and event and could decide for herself. In an interview on 01/07/2026 at 8:12 AM, LVN C stated he should not have left Resident #3's medications and should have stayed with the resident until the resident had taken all the medications. He said the pills should not be left with the residents because the residents might not take them, throw them, or choke while taking them and no one would know. He said the resident was a nurse before but was diagnosed dementia.2. Record review of Resident #15's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #15's Comprehensive MDS Assessment, dated 10/30/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had dementia.Record review of Resident #15's Comprehensive Care Plan, dated 11/12/2025, reflected that the resident had dementia and one of the interventions was to administer medications as ordered.Record review of Resident #15's Physician's Order on 01/06/2025 reflected the resident did not have an order for eye drops. During an observation and interview on 01/06/2026 at 9:27 AM, revealed Resident #15 was in her bed, awake. It was observed that three vials were on top of the resident's side table. According to the resident, the vials were eyedrops that she used every morning because her eyes were itchy and dry every morning. She said she was the one putting it in her eyes every morning. She said the staff knew about her eyedrops.In an interview on 06/01/2026 at 9:43 AM, LVN B stated she did not notice the vials on the Resident #15's side table. She said, sometimes family members were the ones bringing the medications. She said, for the resident's safety, there should be no medications inside the rooms because the nurses were the ones giving the medications and doing the treatments as well. She said the residents had no reason to have medications inside the room. She said the resident was oriented and cognitive but unless she had an assessment indicating that she could self-medicate, there should be no medications inside her room. She said she would talk to the resident and the resident's family member about the medications inside the room. She would also see if the resident needed eye drops so she could request an order for the eye drops.3. During an observation and interview on 01/06/2026 at 9:08 AM, revealed a personal tumbler was on top of the nurse's car parked at the nurse's station. LVN A stated it was her cart and the tumbler was hers. She took the tumbler and put it inside the nurse's station. She said she could not have her personal tumblers on the cart when passing medications or doing treatments because it could cause cross contamination. She said it could create clutter on the medication cart and might accidentally be mixed with the medications she was preparing.4. Record review of Resident #10's Face Sheet, dated 01/07/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's disease (movement disorder) and pain.Record review of Resident #10's Quarterly MDS Assessment, dated 12/04/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated that the resident had Parkinson's disease and pain.Record review of Resident #10's Comprehensive Care Plan, dated 12/04/2025, reflected the resident had Parkinson's disease and pain and the interventions were to administer medications as ordered.Record review of Resident #10's Physician Order, dated 12/27/2025, reflected Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day related to PAIN.Record review of Resident #10's Physician Order, dated 12/27/2025, reflected Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 3 tablet by mouth three times a day related to PARKINSON'S DISEASE WITHOUTDYSKINESIA (involuntary muscle movements), WITHOUT MENTION OF FLUCTUATIONS.An observation on 01/07/2026 at 1:38 PM, revealed during medication cart inspection, it was observed that three bottles of medications inside Nurse's Cart #1 was expired. The bottles, one for gabapentin and two for carbidopa, had a use by date of 12/10/2025. The medications belonged to Resident #10.During an observation and interview on 01/07/2026 at 1:39 PM, revealed LVN B saw the three bottles and said the medications was expired as indicated by the bottle. She said she did not notice that the medications was expired. She said she did not know who put the medications inside the cart. She said she did not use them when she passed her morning medications because Resident #10 had blister packs for the said medications. She said the ADON checked the cart monthly, so she was not sure why there was expired medications in the cart. She said she was also responsible in checking any expired medications during her shift. She said expired medications should not be inside the cart so that staff administering the medication would not mistakenly use them. She said the effectiveness of expired medications could be lesser or could cause adverse reactions depending on the medications.In an interview on 01/08/2026 at 6:41 AM, the ADON stated staff should not leave any medications with the residents for the residents to take unsupervised. She said the staff administering the medications should stay with the resident until the resident was done with the medications. She said the resident might not take them or someone else might, like another resident or a visitor. She said the resident might aspirate or choke while taking the medications and nobody would know. She said the same rationale applied for the eyedrops. She said the resident should not be applying it by herself. She said the residents could not take medications by themselves except if they were assessed that they could self-administer. She said no personal beverages should be on the medication carts because aside from being a clutter that might contribute to medication error, staff might bring some microorganism from their home to the medication cart. She said she was responsible in auditing the carts to check for any expired medications. She said she did how the three expired medications was missed. She said aside from her, the staff passing the medications should also check the expiration date of the medications inside the carts so they would be disposed. She said expired medications lose their effectiveness and would not address the medical needs of the residents. She said the DON already started an in-service about not leaving the medications with the residents, no expired medication inside the carts, and no personal beverages in the carts.In an interview on 01/08/2026 at 7:40 AM, the DON stated staff should never leave the medications at the bedside for the resident to take later. She said the staff must ensure the resident took his medications before leaving the room. She said so much could go wrong like the resident could hoard or hide the pills to avoid taking them, could overdose on hoarded pills, and could choke without anybody to help the resident. She said the eyedrops should not be applied by the resident by herself. She said there was a breakroom where the staff could put their personal belongings as well as their drinks. She said aside from the risk of cross contamination, some residents might take it and drink its content. She said its content might also spill on the medications the staff were preparing. The DON said there should be no expired medications inside the carts. She said the carts were audited regularly so she was not sure why there was expired medications inside the cart. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects. She said the expectation was that no residents were administering their medications without proper assessment. The DON said she already started an in-service about medication administration.In an interview on 04/17/2026 at 8:36 AM, the Administrator stated the expectation was for the staff would not leave medications with the residents unattended because of the risk of the resident not taking them or the pills not taken on time. He said if personal beverages should not be on top of the cart, the staff should not put them there. He said another expectation was that expired medications should be disposed of so they would not be used for the residents. He said the staff should check for the expiration dates before administering the medications to prevent any reaction it might cause. He said he would coordinate with the clinicians on how to go forward to prevent untoward outcomes of leaving the medications with a resident.Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, undated reflected 1. All medications are administered by licensed medical or nursing personnel.Record review of the facility's policy entitled, Medication Labeling and Storage MED-PASS revised February 2023 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . Policy Interpretation and Implementation . Medication Storage . 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals . instructions regarding returning or destroying these items.Policy for not leaving personal beverages requested on 01/08/2026 at 9:39 AM but was not provided prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #7, Resident #15, and Resident #27) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #7, Resident #15, and Resident #27's rooms was in a position that was accessible to the resident on 01/06/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #7 Record review of Resident #7's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with ataxic gait (a person walking with uncoordinated movements) and difficulty in walking.Record review of Resident #7's Quarterly MDS Assessment, dated 12/05/2025, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident was dependent for transfer, toileting hygiene, shower, dressing, and personal hygiene.Record review of Resident #7's Comprehensive Care Plan, dated 12/16/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach.Observation and interview on 01/06/2026 at 9:23 AM, revealed Resident #7 was in her bed, awake. It was observed that the resident's call light was on the floor at the head of the bed. When asked where her call light was, the resident said her call light was nowhere to be found. Observation and interview on 01/06/2026 at 9:45 AM, CNA F stated call lights should always be within reach of the residents because that was how they called the staff if they needed something. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She went inside Resident's #7's room and saw the call light on the floor. She pulled the call light from the floor and put it where the resident could reach it. She said, maybe, the call light fell when the resident was repositioned. She said the staff who repositioned her should have made sure the call light was with the resident before leaving the resident's room. Resident #15 Record review of Resident #15's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness and difficulty in walking.Record review of Resident #15's Quarterly MDS Assessment, dated 10/30/2025, reflected the resident had a moderate (resident may need additional support and monitoring) impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident needed supervision for shower and dressing. Record review of Resident #15's Comprehensive Care Plan, dated 02/27/2025, reflected the resident had limited physical mobility and one of the goals was that the resident would be free from complications including falls.Observation and interview on 01/06/2026 at 9:27 AM revealed Resident #15 was in her bed, awake. It was observed that the resident's call light was on the floor and was on the resident's roommate's side. When asked where her call light was, the resident just shrugged her shoulders.Observation and interview on 01/06/2026 at 9:43 AM, CNA F stated call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. She said the residents might fall trying to get the call light or trying to do some activities that needed assistance. She went inside Resident #15's room and saw the call light on the floor. She said she did not notice the call light was on the floor when she did her morning round. Resident #27Record review of Resident #27's Face Sheet, dated 01/06/2026, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #27's Quarterly MDS Assessment, dated 01/05/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 01. The Quarterly MDS Assessment indicated the resident was dependent for shower, dressing, personal hygiene, toileting, and transfer. Record review of Resident #27's Comprehensive Care Plan, dated 01/06/2025, reflected the resident was a high risk for falls and one of the interventions was to be sure the resident's call light was within reach.Observation and interview on 01/06/2026 at 9:20 AM, revealed Resident #27 was in her bed, awake. It was observed that the resident's call light was on the floor at the head of the bed. When asked where her call light was, the resident looked at her side and said Oh, it might be hanging or was on the floor. The resident said she could get up and pull her call light.Observation and interview on 01/06/2026 at 9:47 AM, LVN B stated call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. She went inside Resident #27's room and saw the call light on the floor. She picked-up the call light and placed it where the resident could reach it. She said she did not notice the call light was on the floor when she administered the resident's medication. She said she should have made sure the call light was with the resident before leaving the room, because even though the resident could stand up and walk. She said the resident might be having a heart attack or shortness of breath and could not get up to pick-up the call light. In an interview on 01/08/2026 at 6:41 AM, the ADON stated the call lights should always be with the residents or within reach of the residents. She said the staff should make sure that the call lights were with the residents before they left the room. She said the call lights were for all residents, regardless they were dependent or independent. She said independent residents might be dizzy or was not feeling well and could not call the staff because their call lights were not with them. She said everybody was responsible in making sure the call lights were with the residents. She said the expectation was for the staff to make sure that all the call lights were within reach of the residents. She said she the DON already initiated an in-service regarding the call light. In an interview on 01/08/2026 at 7:40 AM, the DON stated call lights were inside the residents' rooms so they can call the staff for assistance, a glass of water, pain medication, or because they needed to be changed. The DON said if the call lights were not within reach, their needs would not be met. The DON said the call lights were for all residents and all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the residents' room when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said she already started an in-service about call light placement and would continually educate the staff about the importance of call lights for the residents. In an interview on 04/17/2026 at 8:36 AM, the Administrator stated call lights should be within the reach of the residents at all times. He said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. The Administrator said the residents might fall trying to get up to get what they needed. He said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. He said he would collaborate with the DON and the ADON about the issue regarding call lights.Record review of facility's policy Answering the Call Light 2018 MED-PASS, Inc. revised September 2022 reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs . General Guidelines . 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #37) reviewed for care plan revisions. The facility failed to ensure Resident #37's care plan reflected the use of her BiPAP device. This failure could place residents at risk of their needs not being met.Findings include:Record review of Resident #37's Face Sheet, dated 01/08/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37 had acute respiratory failure with hypoxia (low oxygen intake). Record review of Resident #37's Quarterly MDS Assessment, dated 12/02/25, reflected Resident #37 had a severe cognitive impairment response. The Quarterly MDS Assessment reflected the resident had an active diagnosis of respiratory failure. Record review of Resident #37's Physician Orders, dated 01/07/26, reflected BiPAP on at night per home settings at bedtime for sleep apnea. Record review #37's Comprehensive Care Plan, dated 11/17/25, reflected no plan of care for the resident's use of the BiPAP device. In an interview on 01/07/26 at 1:10 PM, the MDS nurse stated Resident #37 should have been care planned for the BIPAP device because it is important to her care. She stated it was the MDS nurse's responsibility to ensure the resident's use of the device was care planned. She stated she was responsible for care planning the resident's long term care and the DON and ADON were responsible for care planning acute care. In an interview on 01/07/26 at 1:55 PM, the DON and ADON stated they thought there was a care plan for Resident #37's BiPAP device. The DON stated it was everyone's responsibility to ensure the resident's care plans were updated with the appropriate plan of care for the resident to ensure they received the right care. They both stated the resident's use of the device should have been care planned. Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for one of five residents (Resident #36) reviewed for accident prevention. The facility failed to ensure Residents #36's bed was lowered to the lowest position possible while he was lying in the bed. This failure could result in the resident falling from his bed and sustaining an injury. Findings include: Record review of Resident #36's Face Sheet, dated 01/07/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and he had a moderate cognitive impairment response. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #36's Quarterly MDS assessment, dated 10/24/25, reflected he had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis of muscle weakness and muscle weakness and difficulty walking. Record review of Resident #36's Comprehensive Care Plan, dated 11/17/25, reflected the resident was a fall risk, with recent falls occurring on 12/29/25 (with injury) and 11/26/25 (no injury). Intervention included the resident's bed being in the lowest position possible. In an observation on 01/07/26 at 9:07 AM, Resident #36 was observed lying in his bed sleeping and his bed was not placed in the lowest position possible. In an interview and observation on 01/07/26 at 9:09 AM, LVN C stated Resident #36 was a fall risk and one of the interventions was for his bed to be at the lowest position. LVN C and Surveyor observed the resident's bed not in the lowest position possible and LVN C lowered the bed. He stated the bed should be in the lowest position in case the resident had a fall. He stated the resident had just finished breakfast, but no food was observed on the resident's bedside table. He stated it was his and the CNA's responsibility to lower the bed once the resident had finished his meal. In an interview on 01/07/26 at 1:00 PM, CNA E stated Resident #36 was a fall risk and his bed was to be in the lowest position possible and fall mats placed on both sides of the bed. She was told by the surveyor of Resident #36 being observed lying in bed, and it was not in the lowest position possible. She stated the resident needed his bed in a low position to assist in preventing the resident from injury if he fell out of bed. In an interview on 01/07/26 at 1:55 PM, the DON and ADON were told by the Surveyor of Resident #36's bed being observed not in the lowest position possible while he was lying in his bed. The DON stated the resident had a history of changing the height of his bed, The DON was told the resident was sleeping in his bed and the CNA admitted to not lowering his bed after he had finished eating breakfast. They stated the resident had recent falls and his bed should be in the lowest position possible, so if he fell out of the bed, there was less chance of injury. Record review of the policy Falls and Fall Risk, Managing (03/2018) reflected Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two (Resident #13 and Resident #39) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach) management.1. The facility failed to ensure LVN A checked Resident #13's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering medication on 01/07/2026. 2. The facility failed to ensure Resident #39 had orders to flush the g-tube before, during, and after medication administration on 01/07/2026.These failures could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included:1. Record review of Resident #13's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing).Record review of Resident #13's Comprehensive MDS Assessment, dated 11/14/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube.Record review of Resident #13's Quarterly Care Plan, dated 11/30/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement.Record review of Resident #13's Physician Order, dated 10/04/2023, reflected Check placement of G-Tube prior to medication administration every shift.An observation on 01/07/2026 at 9:03 AM, revealed LVN A was about to give Resident #13's medication via g-tube. She sanitized her hands, put the medications in a small plastic cup one by one, crushed them, returned the crushed medications to the small plastic cup, and dissolved them. She put the cups of crushed medications in a tray along with 60 cc of water and another 120 cc of water. She then went inside the resident's room and placed the tray on top of the resident's overbed table. She took a 60 ml piston syringe from the resident's cabinet and placed it on the overbed table. She put on a gown and a pair of gloves, raised the bed, elevated the head of the bed, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, she pulled the plunger out of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, she poured the dissolved medications one by one and flushed in between medications. She did not check for placement of the resident's g-tube before flushing and administering the medication. After she was done administering the medications, she flushed the g-tube, detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe.In an interview on 01/07/2026 at 9:19 AM, LVN A stated she forgot to check the placement before flushing the g-tube. She said the placement should be checked to make sure that the g-tube was not dislodged. She said the dislodged g-tube could cause aspiration. 2. Record review of Resident #39's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (presence of surgical opening in the stomach to support nutrition).Record review of Resident #39's Comprehensive MDS Assessment, dated 12/29/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had a feeding tube.Record review of Resident #39's Quarterly Care Plan, dated 01/02/2026, reflected the resident had a feeding tube and one of the goals was the peg tube (a flexible feeding tube inserted directly to the stomach) would be patent throughout facility stay.Record review of Resident #39's Physician Order on 01/07/2026 reflected no orders to check for residuals, check for tube placement, and to flush before, during, and after medication administration.An observation on 01/07/2026 at 10:19 AM, revealed LVN B was about to administer Resident #39's medication via g-tube. She flushed the resident's g-tube with 30 ml of water and proceeded to administer the medications one-by-one, flushing in between medications with 5 ml water. After she was done administering the medications, she flushed the g-tube with 30 ml of water.Observation and interview on 01/07/2026 at 10:29 AM, LVN B stated g-tubes should be flushed before and after medication administration to maintain its patency, to make sure all the medications went through, and nothing was left in the tube. She said placement and residual should also be checked to see if the tube was not dislodged and that the resident's stomach had no problem with absorption. When asked if the resident had an order for flushing the g-tube, checking for placement, and checking for the residual. LVN B checked her computer for the order and said there was no orders for flushing the g-tube, checking for placement, and checking for the residual. She said she knew what to do but there should be an order for flushing the g-tube, checking for placement, and checking for the residual. She said this should have been caught earlier by whoever was administering the resident's medications, so an order was put in place. She said she was partly at fault because she did not check if the resident had appropriate orders. She said there should be an order for everything done for the resident to ensure continuity of care. She said she would just finish what she was doing and then would transcribe the orders.In an interview on 01/08/2026 at 6:41 AM, the ADON stated the g-tube placement should be checked before giving the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place and would not cause aspiration. She said even though the residents were on continuous feeding, the placement should still be checked. She said there should be orders for everything done for the residents. She said even though the nurses knew what to do, there should be an order in the resident's profile. She said the resident had been in the facility for almost two weeks and nobody noticed that there was no order pertaining to the flushing, checking for placement, and checking for residual. She said it was an oversight for those administering the resident's medication. She said it was also an oversight on her part because she was supposed to check the orders as well. She said the expectation was for the staff to check for g-tube placement and to check if appropriate orders were in place. She said the DON already started an in-service about enteral feeding.In an interview on 01/08/2026 at 7:40 AM, the DON stated the placement of the g-tube should be checked before flushing it and before medication administration to ensure the medications and the fluid would enter the stomach and not the lungs. She said even though the staff did the right procedure and knew that the g-tube needed flushing before and after administering medications via g-tube, there should still be an order for flushing before and after and how much should be used for flushing. She said, new nurses might not be familiar with how to administer medications via g-tube and end up not flushing the g-tube before and after, and then they would wonder why the g-tube was clogged. She said the expectation was for the nurses to check for g-tube placement and check if the orders for g-tubes were complete. She said she already started an in-service about g-tube and physician order as soon as she learned about the issue.In an interview on 04/17/2026 at 8:36 AM, the Administrator stated the expectation was for the staff to check the g-tube placement as per order and there were appropriate orders for the g-tube. He said the DON already started an in-service about g-tube and physician orders but would closely coordinate with the DON to monitor the adherence of the staff to the policies.Record review of the facility's policy Administering Medications through an Enteral Tube 2001 MED-PASS, Inc., revised November 2018 reflected Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Preparation . 1. Verify that there is a physician's medication order for this procedure . Steps in the Procedure . 6. Verify placement of feeding tube.Record review of the facility's policy Medication and Treatment Orders 2001 MED-PASS, Inc., revised July 2016 reflected Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing . Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance to physician orders for one (Resident #8) of eight residents reviewed for parenteral (delivery of medications through injection)/IV (intravenous: administering fluids or medications directly into a vein) fluids. The facility failed to ensure Resident #8 had orders to flush the IV before medication administration, to monitor for infiltration (fluid leaks from a vein to the surrounding tissues) and infections, and when to change the IV site dressing.This failure could place residents receiving IV medications at risk for injury, infections, IV infiltration, clogging, pain, which may result in required replacement of IV.Findings included:Record review of Resident #8's Face Sheet, dated 01/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urine retention. Record review of Resident #8's Comprehensive MDS Assessment, dated 12/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had urine retention.Record review of Resident #8's Comprehensive Care Plan, dated 11/10/2025, reflected the resident had a UTI and one of the interventions was to administer antibiotic as ordered.Review of Resident #8's Physician Order, dated 01/06/2025, reflected Imipenem (medication used for bacterial infection) 1-gram IVPB every 8 hours X days every 8 hours for 7 Days.An observation on 01/07/2026 at 2:06 PM, revealed LVN B was about to connect Resident #8's antibiotics via IV. She washed her hands and put on a pair of gloves. She prepared the antibiotics and connected it to the resident's PICC line. Before, connecting the antibiotics, LVN B flushed the PICC line.During an observation and interview on 01/07/2026 at 2:29 PM, LVN B stated before connecting the IV, the PICC line should be flushed to ensure the line was patent and would not get clogged. She said the dressing should be changed every seven days. When asked if the resident had orders for flushing and dressing changes, LVN B checked the resident's profile and said there were no orders for flushing and dressing changes and there should be an order.In an interview on 01/08/2026 at 6:41 AM, the ADON stated there should be an order on the Resident #8's chart about flushing the PICC line before connecting the IV bag with antibiotics. She said there should also be orders on when to change the dressing and what to assess, like check for signs and symptoms of infections. She said LVN B told her about the issue and they already entered the appropriate orders pertaining to the resident's IV on the resident's physician orders. She said, for example, there was no order when to change the dressing, the staff would not be able to change the dressing because it would not be on the resident's eTAR.In an interview on 01/08/2026 at 7:23 AM, LVN G stated he was the one that put in Resident #8's order for the antibiotics. He said aside from the order for the antibiotics, he did not put any order to flush the IV every shift or before medication administration, and when to change the dressing. He said the orders should be in place to ensure continuity of IV care. He said there was standard orders pertaining to IVs but those orders should still be in the resident's profile.In an interview on 01/08/2026 at 7:40 AM, the DON stated there should be orders to flush the PICC line, when to change the dressing, and what to assess. She said everything done for the resident should have orders. She said the nurses might know what to do but there should be orders so the staff would be in synched with the residents' care. She said she already started an in-service.In an interview on 04/17/2026 at 8:36 AM, the Administrator stated the expectation was orders would be in place to make sure the staff were doing the care correctly. He said the DON already started an in-service.Record review of the facility's policy Peripheral and Midline IV Catheter Flushing and Locking 2001 MED-PASS, Inc., revised March 2022 reflected Purpose: The purposes of this procedure are to maintain catheter patency and function.Record review of the facility's policy Medication and Treatment Orders 2001 MED-PASS, Inc., revised July 2016 reflected Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing . Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #37) reviewed for respiratory care. The facility failed to ensure Resident #37's BiPAP mask and nebulizer machine (breathing treatment device) was properly stored in a bag when not in use on 01/06/26. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings included: Record review of Resident #37's Face Sheet, dated 01/08/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37 had acute respiratory failure with hypoxia (low oxygen intake). Record review of Resident #37's Quarterly MDS Assessment, dated 12/02/25, reflected Resident #37 had a severe cognitive impairment response. The Quarterly MDS Assessment reflected the resident had an active diagnosis of respiratory failure. Record review of Resident #37's Physician Orders, dated 01/07/26, reflected BiPAP on at night per home settings at bedtime for sleep apnea and Albuterol Sulfate inhalation solution, 2 puff inhale orally every 4 hours for shortness of breath. In an observation on 01/06/26 at 11:05 AM, Resident #37's BiPAP mask was observed sitting on top of a stand unbagged and a nebulizer machine was sitting on a nightstand unbagged. In an interview and observation on 1/06/26 at 11:07 AM, LVN A was shown Resident #37's BiPAP mask and breathing treatment device unbagged and she stated they should both be bagged to avoid any bacteria from getting on them. She stated it was the nurse's responsibility to ensure the items were bagged when not in use. In an interview on 01/08/26 at 11:10 AM, the DON and ADON stated they were told by LVN A about Resident #37's BiPAP mask and breathing treatment device not being bagged. The DON stated the nurse stated she had bagged the items previously, but the resident may have unbagged them. They stated it was the nurse's responsibility to ensure both devices were bagged when not in use to avoid the resident getting an infection. Review of the facility's policy Oxygen Administration, 10/2010, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four (Residents #2, #10, #15, #25) of eighteen residents and one (Nurse's Cart #1) of three nurses' carts reviewed for medication storage. 1. The facility failed to ensure that Resident #2's nystatin powder, antifungal powder, and zinc oxide were not on top of the resident's side table on 01/06/2026.2. The facility failed to ensure that a skin barrier was not left on top of Resident #25's overbed table on 01/07/2026.These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible adverse reactions.Findings include: 1. Record review of Resident #2's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with neoplasm (abnormal growth of tissue in the body) of the breast. Record review of Resident #2's Comprehensive MDS Assessment, dated 12/23/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident had neoplasm of the breast.Record review of Resident #2's Comprehensive Care Plan, dated 11/13/2025, reflected that the resident had potentials for alteration of skin integrity related to fungal or yeast infections under the breasts and one of the interventions was to apply medications as ordered. Record review of Resident #2's Physician's Order, dated 09/21/2025, reflected Nystatin Cream 100000 UNIT/GM Apply to under bilateral breast topically every 8 hours as needed for Skin Irritation.During an observation and interview on 01/06/2026 at 9:13 AM, revealed Resident #2 was in her bed, awake. Containers of nystatin powder, antifungal powder, and zinc oxide were on top of the resident's side table. The resident the medications on top of the side table were hers. In an interview on 01/06/2026 at 11:23 AM, LVN C stated the nystatin powder, antifungal powder, and zinc oxide should not be inside Resident #2's room. He said it should be inside the nurses' carts because the nurses were supposed to be the ones administering the nystatin and the fungal powder and the CNAs were supposed to apply the zinc oxide. He said he did not know who left the nystatin powder, antifungal powder, and zinc oxide inside the resident's room and said he did not notice them when he gave the resident's morning medications. He said the resident might use it more than the recommended and could result in skin redness or dryness. He said confused residents might consume them as well that could result to upset stomach and nausea. LVN C said he would go to the resident's room and would get the medications.2. Record review of Resident #25's Face Sheet, dated 01/06/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture to left humerus.Record review of Resident #25's Comprehensive MDS Assessment, dated 12/29/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder.Record review of Resident #25's Comprehensive Care Plan, dated 01/06/2025, reflected that the resident was incontinent and one of the interventions was to apply skin barrier after incontinent care.During an observation and interview on 01/07/2026 at 6:50 AM, revealed that a tube of skin barrier was on Resident #25's overbed table. Resident #25 said the staff would use it every time they changed her. She said she was not sure who left the skin barrier on her table.During an observation and interview on 01/07/2026 at 7:02 AM, revealed LVN C took the tube of skin barrier from Resident #25's overbed table. He said he took the tube of skin barrier because it should not be inside the room. He said the resident might have mistook it as toothpaste or might mistakenly consumed it. He said the skin barrier should be in the cart.In an interview on 01/08/2026 at 6:41 AM, the ADON stated medicated creams and medicated powders. She said the nystatin powder, antifungal powder, and zinc oxide should not be inside the residents' rooms and should be in the carts and should be secured so the residents, especially the confused resident, would not get a hold of them. She said residents with poor eyesight could mistakenly thought that zinc oxide was sauce and put on their food. She said the DON already started an in-service about medication storage.In an interview on 01/08/2026 at 7:11 AM, CNA E stated zinc oxides should not be inside the resident's rooms or somewhere they could access them. She said the zinc oxides should be in the cart and just ask for it when needed. She said the zinc oxide could be placed in a small cup so that the tube would stay in the cart. She said they should not be left inside the room where the resident or other residents could reach it and accidentally put it in their mouth. She said she was not sure what could happen, but she was sure zinc oxides was not for consumption. In an interview on 01/08/2026 at 7:40 AM, the DON stated medications should not be stored inside the resident's room. She said nystatin powder, antifungal powder, and zinc oxide should be inside the carts to secure them. She said the residents might use them inappropriately that could result in adverse reactions. She said zinc oxide was applied topically and could be harmful when ingested. She said the same rationale applied to the medicated powders. She said she already started an in-service about medication storage.In an interview on 04/17/2026 at 8:36 AM, the Administrator stated the expectation was for the staff to make sure there was no medications inside the resident's rooms because the residents might consume the medications or use them inappropriately. He said another expectation was that expired medications should be disposed of so they would not be used for the residents. He said the DON already started an in-service about medication storage but closely coordinated with the DON so the issue would not happen again.Record review of the facility's policy entitled, Medication Labeling and Storage MED-PASS revised February 2023 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . Policy Interpretation and Implementation . Medication Storage . 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals . instructions regarding returning or destroying these items.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one (Resident #1) of eight residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 was not self-administering his nasal spray without an assessment and an order for nasal spray on 09/02/2025. This failure could place residents at risk for potential overdose and adverse effects. Findings include: Record review of Resident #1's Face Sheet, dated 09/02/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 08/13/2025, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/08/2025, reflected the resident had asthma (lung disorder caused by narrowing of the airways) and one of the interventions was to assist the resident in identifying asthma triggers (things, activities, or conditions that could lead to asthma attack). Record review of Resident #1's Physician's Order on 09/02/2025 reflected no order for nasal spray. Record review of Resident #1's Assessment Notes on 09/02/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 09/02/2025 at 8:28 AM revealed Resident #1 was in his recliner, awake. A container of nasal spray was observed on top of the resident's side table. He said he was the one administering his nasal spray and he had been doing it for some time. He said he was not sure if the staff knew he was doing it and nobody talked to him that the nurse was supposed to administer his nasal spray. He said his nasal spray had been always in his table where he could easily see it. He said he would not call nor tell the nurse everytime he used the nasal spray. He said he would do it every morning and sometimes if his nose were getting itchy. The resident took the nasal spray from the side table and sprayed once on each nostril (opening of the nose). Observation on 09/02/2025 at 8:32 AM revealed LVN A went inside Resident #1's room to administer his medications. She did not notice the nasal spray on the resident's side table was in plain view. Observation and interview on 09/02/2025 at 8:38 AM, LVN A stated she did not notice the nasal spray on top of Resident #1' side table when she administered his morning medications. She said she was not aware the resident was doing it by himself. She said the nasal spray should not be inside the room because they were medications and she was not sure if the resident could self-administer any medication. She said the resident might use them every hour and no one would know until adverse reactions such as nasal irritation and nasal dryness. She went inside the room and talked to the resident that she would get his nasal spray and would place them inside the cart. She also told the resident that she would request an order for his nasal spray. In an interview on 09/02/2025 at 11:08 AM, LVN A stated she already took Resident #1's nasal spray and had placed an order for it. She said the nasal spray should be inside the nurses' cart and should be administered by nurses. She said the resident might be confused and took the medication using a different route. She said other residents, that were allergic to the content of the medication, might access the medication and consume it leading to allergic reactions. She said she also checked the rooms of other residents if there were medications inside the room. She said she would also coordinate with the family members to let the nursing staff know if they were bringing any medication. In an interview on 09/02/2025 at 11:50 AM, the DON stated Resident #1's nasal spray should be administered by nurses and there should be a physician's order for it. She said the expectation was for the staff to check if there were any medications inside the residents' room. She said if a resident was administering medications unsupervised, for this incident a nasal spray, there could be adverse effects if the nasal spray was overused such as nose irritation or allergic reactions. She said if the resident was the one administering the nasal spray, there should be an assessment that the resident was able to do so. She said if the resident was deemed able to administer his nasal spray, the nasal spray should still not be on top of the side table were other confused residents could assess it and consume it. The DON said that since the resident was using it, she would check if a physician order was already in place. The DON said she would do an in-service about not leaving any medication inside the residents' room and scanning the room if there were any medications accessible to the residents. In an interview on 09/02/2025 at 12:39 PM, the Administrator stated residents could not administer their own medications unless there was an assessment that the residents were competent enough to do it. She said the resident might overuse the medication resulting to the resident being overmedicated. She said the expectation was for the staff to scan the room if there were any medications at bedside. She said there would be some family members that would bring medications, but still, those medications should not be inside the room and the facility should be aware. She said she would coordinate with the DON on how to make sure that there were no medications inside the residents' room and that no resident was administering any medication by himself. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17 reflected, 1. All medications are administered by licensed medical or nursing personnel . 14. A specific order must be obtained from the Physician Record review of the facility's policy, Medication and Treatment Orders 2001 MED-PASS, Inc revised July 2016 reflected Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on observations, interviews, and record review, the facility failed to ensure the medications were stored properly in locked compartments or provided a safe and secured storage with limited access for three (Residents #1, #2, and #3) of eight residents reviewed for medication storage. 1. The facility failed to ensure Resident #1's nasal spray was not left inside the resident's room on 09/02/2025. 2. The facility failed to ensure Resident #2's zinc oxide (medicated cream used to prevent skin irritation) was not left on top of the resident's side table on 09/02/2025. 3. The facility failed to ensure Resident #3's zinc oxide was not left on top of the resident's side table on 09/02/2025. These failures could place residents at risk to have access to medications that could result to accidental ingestion and misuse of medications. Findings include: 1. Record review of Resident #1's Face Sheet, dated 09/02/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive MDS Assessment, dated 08/13/2025, reflected the resident had a moderated impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/08/2025, reflected the resident had asthma and one of the interventions was to assist the resident in identifying asthma triggers. The care plan did not indicate that the resident could administer his nasal spray. Record review of Resident #1's Physician's Order on 09/02/2025 reflected no order for nasal spray. Record review of Resident #1's Assessment Notes on 09/02/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. Observation and interview on 09/02/2025 at 8:28 AM revealed Resident #1 was in his recliner, awake. A container of nasal spray was observed on top of the resident's side table. He said the nasal spray had been with him for a while. Observation on 09/02/2025 at 8:32 AM revealed LVN A went inside Resident #1's room to administer his medications. She did not notice the nasal spray on the resident's side table that was on plain view. Observation and interview on 09/02/2025 at 8:38 AM, LVN A stated she did not notice the nasal spray on top of Resident #1' side table when she administered his morning medications. She said the nasal spray should not be inside the room because the nasal spray was considered as a medication. She went inside the room and talked to the resident that she would get his nasal spray and would place them inside the cart. In an interview on 09/02/2025 at 11:08 AM, LVN A stated she already took Resident #1's nasal spray and placed it inside the nurses' cart. She said the resident might be confused and took the medication using a different route. She said other residents, that were allergic to the content of the medication, might access the medication and consume it leading to allergic reactions. 2. Record review of Resident #2's Face Sheet, dated 09/02/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with protein-calorie malnutrition (a form of malnutrition that could impact the skin causing dryness, roughness, and flakiness). Record review of Resident #2's Comprehensive MDS Assessment, dated 08/01/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had protein-calorie malnutrition and was incontinent for bladder and bowel. Record review of Resident #2's Comprehensive Care Plan, dated 09/02/2025, reflected the resident had incontinence and one of the interventions was to apply barrier cream after each episode if needed. Record review of Resident #2' Physician Order, dated 08/19/2024, reflected May apply barrier cream as needed. Observation and interview on 09/02/2025 at 8:41 AM revealed Resident #2 in her wheelchair eating breakfast. It was observed that a tube of zinc oxide was on the resident's side table. When asked if the staff left the zinc oxide on her side table after using it, the resident replied with uncomprehensible words. In an interview on 09/02/2025 at 10:26, CNA B stated she was assigned on Resident #2 and did not notice the zinc oxide on the resident's side table. She said the zinc oxide should be inside the nurse's cart and not at bedside because the resident might eat it. She said she would check Resident #2's room if the zinc oxide was still there and would also check the other rooms of the residents on her hall. 3. Record review of Resident #3's Face Sheet, dated 09/02/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with age-related debility (general decline in physical and mental function due to aging). Record review of Resident #3's Quarterly MDS Assessment, dated 07/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident was incontinent for bladder. Record review of Resident #3's Care Plan, dated 08/15/2024, reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per physician order. Record review of Resident #3's Physician Order, dated 09/20/2024, reflected May apply barrier cream as needed. Observation on 09/02/2025 at 8:51 AM revealed Resident #3 was in his bed with eyes closed. It was observed that a tube of zinc oxide was on top of the resident's side table. In an interview on 09/02/2025 at 10:31 AM, CNA C stated she was assigned on Resident #3' hall for the day. She said she did not notice the zinc oxide on Resident #3's side table. She said it should not be accessible to the residents because they might confuse it as food and put it in his mouth. She said she would check if the zinc oxide was still inside the resident's room. She said she would also check the residents' rooms on her assigned hall. She said she did change the resident and applied some barrier cream, but she could not remember if she put it inside the drawer or not. In an interview on 09/02/2025 at 11:08 AM, LVN A stated zinc oxide was a form of medication because it was used to prevent skin issues such as rashes, irritations, and minor burns. She said it should not be left inside the rooms of the residents as confused residents might consume it. She said the cream should be stored in the cart and just put some in a cup for use or place it somewhere not accessible to the residents. She said she would go to Resident #2 and Resident #3's rooms to get the zinc oxide. She said she would also check the rooms of the other residents to see if there were zinc oxides inside the room In an interview on 09/02/2025 at 11:50 AM, the DON stated zinc oxides should not be left or stored inside the resident's room because some residents might be able to get hold of the zinc oxide because the tubes were in plain view. She said the CNAs and the nurses were responsible in checking if there were zinc oxides were inside the residents' rooms. She said she already made her round when she was made aware about the zinc oxides being inside the rooms of the residents. She said zinc oxide was applied topically and could be harmful when ingested. She said, when ingested, some of its ingredient might cause allergic reactions or some adverse reactions such as stomach upset, nausea, and vomiting. She said the expectations were for the staff to always scan the residents' rooms to make sure they were not leaving the tubes of zinc oxide inside the room, putting them where the resident could not access them, or just put them in the cart. She said she would do an in-service about storing the zinc oxide accordingly. In an interview on 09/02/2025 at 12:39 PM, the Administrator stated the expectation was for the staff not to leave the zinc oxides inside the room of the residents after use. She said the residents, confused or not, could access and consume them and could result to untoward outcomes such as allergy or interaction with other oral medications. She said she would coordinate with the DON about storing the tubes of zinc oxide inside the carts or somewhere not accessible to the residents. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17, revealed, 8. After the medication administration process is completed . stored in a locked medication room, or otherwise secured.

Based on interview and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for respiratory care.Based on interview and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for respiratory care.The facility failed to ensure Resident #1 had an order for oxygen administration when she was a resident at the facility from 07/10/2025 to 07/12/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 07/30/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure (the body doesn't get enough oxygen), thrombocytopenia (low platelet count which can increase the risk of bleeding) and chronic atrial fibrillation (irregular heart rhythm). Resident #1 discharged from the facility on 07/12/2025. Record review of Resident #1's MDS (tool used to measure health status) admission Assessment, dated 07/12/2025, reflected moderate impaired cognition with a BIMS (tool used to assess cognitive function) score of 10. Section I (active diagnoses) reflected Resident #1 was treated for pneumonia (infection of the lungs) and respiratory failure. Record review of Resident #1's Baseline Care Plan, dated 07/14/2025, reflected Resident #1 received oxygen therapy while a resident. The Baseline Care Plan indicated Resident #1 was confused, removed the nasal cannula, and required frequent redirection related to the administration of oxygen therapy. Record review of Resident #1's Physician's Order, dated 07/10/2023, reflected to administer oxygen via nasal cannula 2-4 liters LPM (flow rate of oxygen) PRN to keep oxygen saturation above 92%. The end date for this order was 09/07/2023. Resident #1 did not have a current order for oxygen administration. Record review of Resident #1's hospital transfer orders, dated 07/10/2025, reflected an order to titrate oxygen delivered to keep oxygen saturation percentage above: 88-94%. The hospital transfer order reflected the resident was on supplemental oxygen at 4 LPM. Record review of Resident #1's vital signs, dated 7/10/2025, 07/11/2025, and 07/12/2025, reflected oxygen was administered via nasal cannula at 4 LPM. During a telephone interview on 07/30/2025 at 2:54 PM, LVN A stated Resident #1 had an order to receive continuous oxygen at 2-4 LPM and it was in her chart. She stated Resident #1 was administered oxygen at 4 LPM. When LVN A was asked about the date of the order, LVN A stated she had not noticed the order was for a previous admission. LVN A stated it was important to ensure, and clarify when needed, the resident had a current physician's orders for oxygen prior to administering oxygen. She stated administering less than or more than the prescribed order could have effects on the resident. She stated if not given the correct dose, a resident could have dizziness, headaches, or a nosebleed if the nasal passage became dry. She stated if orders were not followed, a resident might not receive sufficient oxygen. During an interview on 07/30/2025 at 3:08 PM, the DON stated her expectation was for nurses to check and verify that orders in the resident's chart corresponded with the resident's admission orders. She stated the DON and ADON checked to ensure orders were transcribed properly. She stated the pharmacy representative also looked at admission orders. The DON stated it was important to follow the physician's orders. She stated there was no question about that. She stated Resident #1 had an order but it was from 07/10/2023. She stated she missed it because it was the same date the resident admitted for her most recent admission. She stated it could potentially cause respiratory distress if orders were not followed. During an interview on 07/30/2025 at 3:15 PM, the [NAME] President of Clinical Services stated he when he looked at Resident #1's orders from 07/10/2023, he saw the date but did not notice the year was different. He stated other staff members probably did the same thing. He stated his expectation was for staff to follow discharge orders from whatever entity sent the resident to the facility. He stated orders were given for a reason and it was important to follow them. He stated it was important to ensure physician's orders were followed to avoid a potential negative outcome. Record review of the facility's policy Administering Medications, revised April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #25) of 6 residents reviewed for (ADL) care provided to dependent residents. The facility failed to ensure Resident #25 received scheduled bed baths according to reviews from October 1, 2024 - October 16, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem. Findings included: Record review of Resident #25's Face Sheet, dated 10/17/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Parkinson's disease (memory loss) and bed confinement. Record review of Resident #25's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 12 (moderate impairment) and fo,r ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Record review of the facility's shower sheet for Resident #25 from 10/01/24 to 10/16/24 reflected a single shower sheet for the resident dated 10/16/2024. In an interview on 10/15/24 at 11:01 AM, Resident #25 complained of not getting her bed baths when scheduled. She stated she was scheduled for her bed baths on Monday, Wednesday, and Friday, but she had not received any so far that month. She stated she preferred bed baths because she does not like the mechanical lift and was happy with her bed baths. She stated she had told a CNA, but they advised her that they were busy and would get back with her, but they never returned. She stated she would like her bed baths because she does not like being dirty. In an interview on 10/17/24 at 12:45 PM, LVN S stated that she knew, for sure, that Resident #25 had received her bed baths when she was scheduled on Monday, Wednesday, and Friday, but she was not sure why there was only one shower sheet recorded for the resident, including the bed bath she had received on 10/16/24. She was advised that the resident stated she had not received her bed baths this month. She stated the risk of the resident not getting her bed baths could result in the resident having skin breakdown, and it was a dignity issue. In an interview on 10/17/24 at 12:45 PM, the ADON stated she was made aware of Resident #25 not having but one shower sheet on file, as of 10/16/24. She stated she was sure that she had received her scheduled bed baths and the CNA probably forgot to complete the shower sheets. She confirmed that CNAs were required to complete shower sheets for all residents, regardless of whether a shower was provided or refused. She stated the risk of the resident not receiving her bed baths could result in skin breakdown, she could have a bad smell, and it was a dignity concern. In an interview on 10/17/24 at 12:54 PM, CNA S stated she had been at the facility a year. She stated she normally did not provide Resident # 25 her scheduled bed baths, but she did provide them at times. She stated she did provide the resident bed baths on Fridays, but she did not know the exact dates. She stated she forgot to complete the shower forms for the resident. She stated staff were supposed to complete showers sheets on every resident, whether they had refused a shower or not. She stated if the resident did not get their showers or bed baths when scheduled, she could have skin breakdown and they could get a fungus. The facility's policy Bath, Shower/Tub (dated February 2018), reflected The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 (Resident #12 and #30) of 4 residents reviewed for accident prevention. The facility failed to obtain physician orders or a physician assessment as of 10/15/24 for Residents #12 and #30, for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #12's Face Sheet, dated 10/16/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included difficulty walking, lack of coordination, and history of falling. Record review of Resident #12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it reflected assistance was required for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #12's physician orders dated 10/16/24 reflected no orders for a scoop mattress and no physician assessment was observed in the facility system records. An observation on 10/15/24 at 11:40 AM of Resident #12's bed revealed she was sleeping on a scoop mattress. The upper and lower sides of the mattress had raised sides of at least 6 inches. Record review of Resident #30's Face Sheet, dated 10/16/2024, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and moderate risk of falling. Record review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired cognition), and for ADL care, it reflected assistance was required for transfers, toileting, and bathing. The resident was totally dependent for assistance. Record review of Resident #30's physician orders dated 10/16/24 reflected no orders for a scoop mattress and no physician assessment was observed in the facility system records. An observation on 10/15/24 at 11:25 AM of Resident #30's bed revealed she was sleeping on a scoop mattress. The upper and lower sides of the mattress had raised sides of at least 6 inches. In an interview and observation on 10/15/24 at 1:00 PM, LVN S was shown Resident #12 and #30's scoop mattresses and she stated that she thought the residents had orders for the scoop mattress, but she was not sure. She stated if the resident did not have physician orders or an assessment for the scoop mattress, they could injure themselves if they tried to get out of the bed. In an interview and observation on 10/15/24 at 1:00 PM, the ADON was shown resident #12 and #30's scoop mattresses and she stated that the mattresses were considered therapeutic, and she did not think that it required physician orders and a physician assessment. She confirmed that there were no physician assessments completed by the residents' physician. She stated that the risk of the residents' not having their physician assess the risk of using the scoop mattress, could result in the resident's injuring themselves if they attempted to get out of the bed. In an interview on 10/16/24 at 1:00 PM, the DON and Corporate Compliance Nurse was advised of Resident #12 and #30's scoop mattresses and they stated that they thought that the since the mattresses were considered therapeutic, no physician orders or a physician assessment was required. They were advised that the scoop mattress had raised sides on the upper and lower sides of the residents' beds, which was a risk for the residents. The DON confirmed that there were no physician assessments completed by the residents' physician and she stated that the risk of the residents' not having neither could result in the resident's injuring themselves if they attempt to get out of the bed. Review of the facility's policy Medication and Treatment Orders (dated July 2016), reflected Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #2, Resident #5, and Resident #15) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #2's breathing mask for nebulization was properly stored and his humidifier had water in it. 2. The facility failed to ensure that Resident #5's yankauer suction tip (a firm plastic suction tip used to suction secretions in the mouth) was properly stored. 3. The facility failed to ensure that Resident #15's nasal canula was properly stored in a sanitized container. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #2's Face Sheet, dated 10/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #2 was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #2's Comprehensive MDS Assessment, dated 09/20/2024, reflected the resident was cognitively intact with a BIMS score of 13. Resident #2's Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #2's Comprehensive Care Plan, dated 09/17/2024, reflected the resident had COPD r/t smoking and one of the interventions was give aerosol (medications given through an inhaler) or bronchodilators (medications that dilate the airways) as ordered. Review of Resident #2's Comprehensive Care Plan, dated 09/17/2024, reflected the resident was on oxygen therapy r/t respiratory illness and one of the interventions was to monitor for signs and symptoms of respiratory distress. Review of Resident #2's Physician Order, dated 10/10/2024, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally one time a day for Shortness of Breath. Review of Resident #2's Physician Order, dated 10/10/2024, reflected Oxygen at 2 l/m to 4 l/m per nasal cannula as needed for SOB/Respiratory Compromise O2 sats less than _90__% (add percentage). Observation and interview on 10/15/2024 at 9:38 AM revealed Resident #2 was in his bed, awake. The resident was on oxygen therapy via nasal cannula at 3 liters per minute and was connected to an oxygen concentrator. The humidifier bottle on his oxygen concentrator was empty. It was observed that there was tube hanging out on the drawer of the resident's left-side table. The resident said it was okay to open his drawer. Inside the drawer, was a nebulizer with a breathing mask connected to it. The breathing mask was not bagged. The resident said he was given a breathing treatment every morning. He said the nurse would put it on and the nurse would take it off when it was done. He said he was not aware where the nurse would put it after the breathing treatment. He said he did not notice there was no water in his bottle. He said he will tell the nurse to put some water in the bottle. Observation and interview with LVN A on 10/15/2024 at 11:43 AM, LVN A stated she administered Resident #2's breathing treatment every morning. She said after the breathing treatment was done, she should clean it and put it inside a plastic bag to keep it safe. LVN A went inside the room, opened the resident's drawer and saw the breathing mask inside the drawer. LVN A disconnected the breathing mask and said she was going to change it because she was not able to bag it when she took it off the resident. She said the breathing mask should be bagged to prevent cross contamination and respiratory infection. LVN A threw the breathing mask, went out of the room, and returned with a new breathing mask. She said she noticed the resident's humidifier had little water when she gave the resident's medications and planned to come back to fill it up. She said she should have put water in it because it was already low. She said the humidifier would keep the nasal pathway moist to prevent irritation. LVN A took plastic container of distilled water and filled the humidifier halfway. 2. Review of Resident #5's Face Sheet, dated 10/16/2024, revealed the resident was an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with encephalopathy (a disease that affects brain structure or function and usually cause confusion, disorientation, memory loss, and agitation). Review of Resident #5's Comprehensive MDS Assessment, dated 08/16/2024, revealed the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was receiving hospice care. Review of Resident #5's Comprehensive Care Plan, dated 09/23/2024, reflected the resident was receiving hospice services and one of the interventions was to provide maximum comfort for the resident. Review of Resident #5's Physician's Order, dated 10/29/2021, reflected Admit to hospice DX: Senile degeneration of the brain. Review of Resident #5's Physician's Order, dated 10/26/2021, reflected May suction as needed. Review of Resident #5's agreement with hospice, dated 11/09/2021, reflected Hospice Responsibilities: . 2. Durable Medical Equipment . suction pump. Observation on 10/15/2024 at 10:16 AM revealed the resident was in her bed, sleeping. It was observed that the resident had a suction machine on top of her right-side table. A yankauer was connected to the suction machine. The yankauer was observed sitting on top of the table and was beneath a plastic container (the yankauer was not properly stored). Observation and interview with LVN B on 10/15/2024 at 12:51 PM, LVN B stated Resident #5 had a suction machine in case she had a lot of secretions and was unable to spit it out. She said the suction machine was provided by hospice and the main purpose was to maintain the airway patent. She said the resident rarely used it. She went inside the resident's room and saw the yankauer connected to the suction machine was on top of the table. She disconnected the yankauer and threw it on the waste basket. She said she would get a new one because the yankauer was already considered dirty. She said she did not notice the yankauer was just on the table when she was providing care. She said it should be stored properly to avoid germs from going inside the body if it was used. She said she would put it inside a bag while not in use. 3. Review of Resident #15's Face Sheet, dated 10/17/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #15 was diagnosed with acute respiratory failure with hypoxia. Review of Resident #15's Comprehensive MDS Assessment, dated 09/23/2024, reflected the resident was moderately impaired with a BIMS score of 11. Resident #15's Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #15's Comprehensive Care Plan, dated 09/17/2024, reflected the resident was on oxygen therapy r/t respiratory illness and one of the interventions was to monitor for signs and symptoms of respiratory distress. Review of Resident #15's Physician Order, dated 10/17/2024, reflected no physician orders for the oxygen concentrator. An observation on 10/15/24 at 09:36 AM revealed Resident #15's nasal cannula was coiled up on top of the resident's bed and not in a sealed container. An interview and observation on 10/15/24 at 09:40 AM, LVN S was shown Resident #15's nasal cannula coiled up on the resident's bed and not in a sealed container. She stated that the resident used the oxygen concentrator on an as needed basis, and she was not sure why it was sitting on the resident's bed and not placed in a sealed container. She stated the risk of not placing the nasal cannula in a bag when not in use, could result in the resident getting an infection. In an interview with the DON on 10/17/2024 at 8:24 AM, the DON stated the nasal cannula, breathing mask, and the yankauer should be stored properly when not in use to keep them clean. She said if those breathing apparatuses were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. She said the expectation was for the staff to be mindful in making sure that the nasal cannula, breathing mask, and the yankauer were properly stored. She said the nasal cannula, breathing mask, and the yankauer should be cleaned before storing them. She said the humidifier should always have water in it to prevent drying of the nose and the throat. She said the staff should refill it as soon as they saw it because they never knew when they could come back to the resident's room to put water in the humidifier. She said moving forward, she would make an in-service and re-educate the staff about storing the breathing mask and the yankauer properly to provide a quality and professional care. She said she would follow-up with that issue personally. In an interview with the ADON on 10/17/2024 at 8:33 AM, the ADON stated the nasal cannula, breathing mask, and the yankauer should be bagged when not in use. She said not bagging them could result in cross contamination and respiratory infection. She said even though the policy would only say to bag the nasal cannula, the policy also applies to the breathing mask and the yankauer. She said the purpose of the humidifier was to moisten the nasal pathway to improve comfort and prevent irritation. She said the expectation was for the staff to bag all the respiratory apparatuses used by the residents when not in use. She said she would coordinate with the DON pertaining to education and in-services about respiratory care. She said she would include checking on the respiratory apparatuses being bagged during her walk around. In an interview with the Administrator on 10/17/2024 at 8:55 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. He said he was not a clinician but would coordinate with the DON on how to go forward about the issue of respiratory care. He said the expectation was for the staff to be trained proficiently, follow basic protocols, and ask if something needed clarification. He said they would monitor the staff and discuss the issue. Record review of facility's policy, Oxygen Administration 2001 MED-PASS, Inc. revised October 2010 revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . 12 . Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Record review of facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection MED-PASS, Inc. revised November 2011 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy . Steps . 8. Keep the oxygen cannula and tubing . in a plastic bag when not in use.

Based on observations, interviews, and record review, the facility failed to ensure the medications for four (Resident #1, Resident #13, Resident #14, and Resident #35) of fifteen residents were provided a safe and secured storage with limited access. 1. The facility failed to ensure Resident 1's zinc oxide (ointment used to prevent skin irritation), Miralax, eye drops , and a nasal spray were not left on top of the resident's left side table. 2. The facility failed to ensure Resident 13's stoma powder was not left on top of the resident's left side table. 3. The facility failed to ensure Resident 14's zinc oxide was not left on top of the resident's left side table. 4. The facility failed to ensure Resident 35's zinc oxide was not left on top of the resident's TV stand. These failures could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications. Findings included: 1. Review of Resident #1's Face Sheet, dated 10/16/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1 was diagnosed with metabolic encephalopathy (a disease that affects brain structure or function and usually cause confusion, disorientation, memory loss, and agitation). Review of Resident #1's Comprehensive MDS Assessment, dated 09/05/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment also indicated the resident had medically complex conditions. Review of Resident #1's Comprehensive Care Plan, dated 09/23/2024, reflected the resident had impaired cognitive function or impaired thought processes noted due to her metabolic encephalopathy and the intervention was to report any changes in cognitive function. Observation on 10/15/2024 at 11:40 AM revealed the resident was in her bed, sleeping. There were several medications on the resident left side table. The medication were zinc oxide (ointment used to prevent skin irritation), Miralax, refresh eye drops, and fluticasone nasal spray. Observation and interview with LVN B on 10/16/2024 at 9:51 AM, LVN B said medications should not be left on top of the resident's side table because somebody could accidently ingest it. She said somebody confused or allergic to the said medications might use it. She said those medications were brought by one of resident's family member. She said she would tell the resident's family member that she would put the medications somewhere with limited access. LVN B took the medications and placed them inside the drawer of the resident's left side table. 2. Review of Resident #13's Face Sheet, dated 10/16/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13 was diagnosed with glomerular disease in systemic lupus erythematous (chronic disease that could cause inflammation and pain). Review of Resident #13's Comprehensive MDS Assessment, dated 09/20/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. Resident #13's Comprehensive MDS Assessment indicated the resident had an ostomy (opening in the abdomen). Review of Resident #13's Comprehensive Care Plan on 09/04/2024 reflected no care plan for colostomy care. Review of Resident #13's Physician Order, dated 12/17/2024, reflected change ostomy bag 2 x weekly on Mondays and Thursdays and prn. Observation and interview with Resident #13 on 10/15/2024 at 9:10 AM, Resident #13 was in her bed, awake. She said she had a colostomy bag and the nurse would change it periodically. Resident #13 raised her hospital gown to show her colostomy bag. It was observed that there was plastic container of stoma powder on the resident's left side table. Observation and interview with LVN A on 10/15/2024 at 12:11 PM, LVN A stated Resident #13 had a colostomy bag and it was changed weekly. She said the stoma powder was used as a skin protector to prevent stoma-related complications. She said it should not be left on the table or anywhere accessible to other residents and visitors. She said it could be accidently ingested and children could mistake it for candies. LVN A took the stoma powder and placed it in the resident's drawer along with the other paraphernalia for colostomy care. 3. Review of Resident #14's Face Sheet, dated 10/17/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #14 was diagnosed with ulcerative proctitis (inflammation of the lining of the rectum) and altered mental status. Review of Resident #14's Comprehensive MDS Assessment, dated 09/06/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment also indicated the resident was always incontinent for bladder and bowel. Review of Resident #14's Comprehensive Care Plan, dated 09/23/2024, reflected the resident had alteration of bladder and bowel function R/T incontinence and the intervention was use a barrier cream during incontinent care. Review of Resident #14's Physician Order dated 10/11/2021, reflected Apply zinc ointment to buttocks QS and prn. Observation and interview with Resident #14 on 10/15/2024 at 9:26 AM revealed the resident was in her bed, awake. A container of zinc oxide was observed on top of the resident's left side table. She said the ointment was used every time the staff cleaned her and changed her brief. 4. Review of Resident #35's Face Sheet, dated 10/17/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #35 was diagnosed with irritable bowel syndrome (intestinal disorder that cause diarrhea) and hemorrhoids (swollen veins in the rectum). Review of Resident #35's Comprehensive MDS Assessment, dated 09/24/2024, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment also indicated the resident was always incontinent for bladder and bowel. Review of Resident #35's Comprehensive Care Plan, dated 09/24/2024, reflected the resident had potential/actual impairment to skin integrity and the goal was the resident would be free from injury. Review of Resident #35's Physician Order dated 09/18/2024, reflected May apply barrier cream as needed. Observation and interview with Resident #35 on 10/15/2024 at 10:58 AM revealed a container of zinc oxide was noted on top of the TV stand. The medication was visible from the hallway. Resident #35 said the ointment was used every time she was cleaned. She said it was used to prevent irritation of her buttocks. Observation on 10/16/2024 at 7:35 AM revealed CNA C was providing incontinent care for Resident #35. When CNA C was done cleaning the resident, she took the zinc oxide from the TV stand, took a handful, and applied it to the resident's bottom while the resident was in a side-lying position. After the zinc oxide was applied, she placed the zinc oxide on the resident's overbed table, rolled the resident back, and fixed the brief. CNA C then transferred Resident #35 to her wheelchair and helped the resident with personal hygiene. After providing assistance for Resident #35, CNA C went out of the room. The zinc oxide was left on the overbed table beside the resident's bed. In an interview with CNA C on 10/16/2024 at 11:46 AM, CNA C stated the zinc oxide should not be left on the side table or on the overbed table. she said the resident might be confused and mistakenly swallowed the ointment. She said they might be harmed if the ointment was ingested. CNA went inside Resident #35's room and put the zinc oxide inside the resident's drawer. She then went inside Resident #14's room and also put the resident's zinc oxide inside the resident's drawer. She said she checked the other rooms and made sure the skin protection ointment was inside the drawers and with limited access to other residents and visitors. In an interview with the DON on 10/17/2024 at 8:24 AM, the DON stated all the medications should be inside the medication carts. She said if a family member was the one bringing the medications, the family member should be educated of the harm if the medications were accessible to others. She said the Miralax, eye drops, and the nasal spray should be inside the cart. She said the zinc oxide, used during incontinent care, should be placed inside the drawer of the side tables after using it. She said the stoma powder should be stored along with the things used for colostomy care inside the drawer of the side table. She said if the resident or a visitor ingested it, there could be adverse reactions especially if somebody who accidentally ingested the medications were allergic to the medications. A child who accidentally swallowed the medication could choke from it. She said the expectation was no medication would be left inside the room and the ointment used for incontinent care be placed inside the drawer to secure it. She said she would do an in-service about medication administration and making sure no medications were left inside the room. In an interview with the ADON on 10/17/2024 at 8:33 AM, the ADON stated medications, whether oral, nasal, eye drops, or topical should be in the medication carts. If those medications were left inside the room, several unsafe outcomes could happen. She said if someone accidently ingested the medication, it could result in nausea, vomiting, or abdominal pain. She said the zinc oxide was used after incontinent care. She said it should be placed inside the drawer or somewhere not accessible after use. She said if a family member was the one bringing the medication and did not want them placed in the medication cart, the medications should be in a plastic bag inside the drawer. She said the expectation was for the staff to make sure there were no medications easily accessible to confused residents and visitors. In an interview with the Administrator on 10/17/2024 at 8:55 AM, the Administrator stated all medications should be in the cart and not inside the residents' room. He said the ointment used for incontinent care should be in the drawer or somewhere secured. He said leaving medications inside the resident's room could result to accidental ingestion. He said the expectation was for the staff to make sure no medications were inside the room or were easily accessible to other residents and visitors. He said he would coordinate with the DON so the issue would not happen again. Record review of facility policy, Medication Labeling and Storage 2001 MED-PASS, Inc. revised February 2023 revealed Policy Statement: The facility stores all medications and biologicals in locked compartments . Medication Storage . 4. Compartments (including . drawers . cabinets . rooms, and boxes) . not left unattended if open or otherwise potentially available to others.

Based on observation, interview and record review, the facility failed to immediately inform the resident's physician and notify, consistent with his or her authority, notify a resident's representative when there was an accident involving the resident and/or when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: The facility failed to promptly notify Resident #1's physician and responsible party when Resident #1 exhibited cries of pain on 6/8/24 and verbally stated ow, my leg while crying in pain again on 6/9/24 after falling and suffering from a fracture of the right femoral/femur neck on the right hip on 6/07/24. She did not receive an X-ray until 06/10/2024 when Resident #1's responsible party sent a video recording of her crying in pain to the hospice provider. She was not sent out to be admitted to the hospital for treatment for over 65 hours although she was crying out in pain until 06/10/2024 at approximately 3:29 PM. An immediate Jeopardy (IJ) situation was identified on 06/13/2024 at 12:59 PM. While the IJ was removed on 06/14/2024 at 12:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy because all staff had to be trained on who to notify if they were to discover a resident crying out in pain and a change in behavior. This deficient practice could place residents at risk of not having their RP or physician informed when there is a change in condition resulting in a delay in medical intervention and decline in health. Findings included: Record review of Resident #1's face sheet dated 06/10/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral/psychotic/mood/anxiety. Other prior diagnosis consist of person history of transient ischemic attack (a stroke that lasts only a few minutes), and cerebral infarction without residual deficit, dysphagia (difficulty swallowing), unspecified gastritis (Inflammation of the lining of the stomach), unspecified, without bleeding, gastro-esophageal reflux disease without esophagitis (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), nontraumatic intracerebral hemorrhage (a common subtype of stroke with a poor prognosis), unspecified, hyperlipidemia (an elevated level of lipids), unspecified hypertensive chronic kidney disease with state 1 through stage 4 chronic kidney disease (Stage 4 CKD means you have severe loss of kidney function), or unspecified systolic heart failure, age related physical debility, pain, unspecified, major depressive disorder, single episode, unspecified, constipation, unspecified, heart failure, unspecified, chronic kidney disease, unspecified, essential hypertension, cerebral infarction (stroke), unspecified, aphasia following cerebral infarction, expressive language disorder (lower than normal ability in vocabulary), dysuria (sensation of pain and/or burning, stinging, or itching of the urethra or urethral meatus associated with urination), weakness, localized edema (when tiny blood vessels in the body, also known as capillaries, leak fluid), chronic atrial fibrillation (heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly), unspecified, other chronic pain, shortness of breath, chronic kidney disease, stage 3 unspecified, unspecified sequelae of cerebral infarction, unspecified macular degeneration (a disease that affects a person's central vision), anemia, unspecified, cardiomegaly (umbrella designation for various conditions leading to enlargement of the heart), unspecified abnormalities of gait and mobility, contact with and suspected exposure to covid-19. Family Member A was listed as the power of attorney. Record review of Resident #1's Annual MDS Assessment, dated 04/3/2024, reflected Resident #1 had a BIMS score of 3. Resident #1 was assessed to require assistance with ADL's including the following: transfers, eating, personal hygiene, showers, and dressing. Resident is on hospice and has an active PRN order of Morphine for pain management. Record review of Resident #1's Comprehensive Care Plan revised on 06/10/2024 reflected Resident #1 had sustained a right hip fracture. Intervention: For no apparent acute injury, determine and address causative factors of the fall. Monitory/document/report PRN x 72 h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro checks. Provide activities that promote exercise and strength building where possible. PT consult for strength and mobility. Pharmacy consult to evaluate medications. The resident did not have a history of falls so there were no preventions in place. Record review of Resident #1's Incident Report completed by RN N, dated on 06/07/24, reflected Resident #1 was found by RN N. RN N stated in the incident report Heard someone yelling down 300 hall. Went immediately down to check to see who it was. Found resident lying on her back beside the bed. Had rolled out of the bed on the side by the window. Bed had been in the lowest position. Call light had been within reach, but resident really doesn't use it due to dementia. She was awake and alert. When first walking into the room she was noted to be moving all extremities on her own and on further assessment would move them on command or with checking of ROM. No skin tears or bruises noted at this time upon assessment. Neuro checks initiated. WNL. Notified DON, Dr, Hospice, and responsible party. Record review of Resident #1's electronic medical records date 6/10/2024 reflected Resident #1 did have a pain assessment note that was entered by LVN R. It reflected, Pain assessment q shift using PAINAD/ Dementia Scale 0-10 Pain Intensity Goal 0-2 every shift. Record review of Resident #1's Hospice Nurses revealed a hospice note dated, 06/09/2024 revealed, Facility staff called stating that pt has a decline in condition stating that 02 sat had dropped to 89 and pt was given oxygen nc 2l and 02 sat increased to 94. Pt also did not eat breakfast upon my arrival to facility, facility staff said pts responsible party just left the facility from visiting with pt. pt is lying in bed in a supine position (lying horizontally with the face and torso facing up). Pt has oxygen nc running at 2l with 02sat of 94. Vs wnl but facility staff report was in pain earlier and was given morphine for pain management as ordered. Pt was sleeping when I arrived and did not wakeup during assessment. Facility staff reported that pt has been having difficulty swallowing solids and liquids, so she did not take her medications today nor eat or drink. Pt is in deep sleep all through assessment. Teaching done with facility staff to hold on liquids and food if pt is unable to swallow for aspiration precaution (inhaling some kind of foreign object or substance into your airway). Pt is not in pain at time of evaluation. Facility staff advised to contact hospice with any concerns or change in condition. Responsible party was called for update and no answer. Record review of a hospice note created by HSP T dated, 06/10/2024 reflected Resident #1 is a [AGE] year-old female. admitted to hospice with diagnosis Senile degeneration of brain. Seen for skilled nurse visit LVN. Patient lying in bed for assessment. Patient lethargic this am. Unable to verbalize needs. Skin warm and moist to touch. 02 via nasal cannula at 3 liters. Noted nonverbal signs of pain with assessment and care. [NAME] [sic] motions with hands. Facial grimace and agitation in the am. Nebulizer given. Record review of Resident #1's Medication Record dated 06/01/2024 to 06/10/2024, reflected Resident #1 was not given morphine for pain on Saturday, Sunday, Monday, Tuesday, Wednesday, and Thursday leading up to the fall that she had on Friday. However, she did receive morphine on Friday before the fall at 7:44 AM pain scale 7 and again at 10:22 PM pain scale 3, Saturday at 7:37 AM pain scale 7, Sunday at 3:39 AM pain scale 5 and 3:08 PM pain scale 7 and Monday at 7:44 AM pain scale 7 and 12:12 PM pain scale 9. Each of the times Resident #1 received Morphine it was documented as being Effective. The resident does have an active PRN order for Morphine. Record review of Resident #1's Hospital Records dated 06/10/2024 reflected a Right Femoral Neck Fracture, Acute Kidney Injury, Altered Mental Status, Hypernatremia, Hypoxic Respiratory Failure (don't have enough oxygen in your blood), and Sepsis (serious condition in which the body responds improperly to an infection). The hospital record reflect that the resident was brought by EMS from the nursing home where she was found to be altered from baseline with decreased responsiveness and incomprehensible speech, also having fallen from a bed to floor with a right hip deformity and a pain film that showed a hip fracture at the nursing home. Record review of LVN A's signed facility statement dated 06/13/2024 reflected that on Saturday 6/8/2024 LVN A was notified of Resident #1's pain by CNA S. LVN A performed an assessment which showed there was no indication of a fracture. LVN A administered pain medication. Record review of LVN A's signed facility statement dated 06/13/2024 reflected that on Sunday 06/09/2024 LVN A was notified of Resident #1's leg pain by CNA B. LVN A performed an assessment which showed that she was aligned, no bruising, no swelling, her skin and right hip appeared normal in temperature. LVN A administered pain medication. Record review of LVN A's signed facility statement dated 06/13/2024 reflected that on Sunday 06/09/2024 the Hospice Nurse assessed Resident #1 and found no concerns or brought forth that there was a right hip fracture. Record review of RN O's signed facility statement dated 06/13/2024 reflected that on Sunday 06/09/2024 RN O was making rounds on the residents and observed Resident #1 lying in bed with her eyes closed. She stated that Resident #1 was calm, not tearful or frowning. She performed a head-to-toe skin assessment and did not find any visual indications of swelling, bruising, or changes in skin appearance or temperature during her assessment. She stated that Resident #1 made no verbal complaints or facial indicators that she was experiencing pain during her assessment. Her body was aligned. She then stated that she received a call from the Hospice Clinical Director stating that an x-ray was ordered on 06/10/2024 which revealed findings of the bones being osteoporotic. It also revealed an acute right intertrochanteric femoral neck fracture. Record review of a recorded video dated Sunday 06/09/2024 revealed CNA C performing a cleaning and changing on Resident #1 while Resident #1 was crying out in pain and verbally saying ow, my leg. In an interview on 06/11/2024 at 9:00 AM, the DON stated Resident #1 had a fall with a right hip fracture on Friday 06/07/24. She stated that her bed was in the lowest place and that there was no bruising, redness, or swelling. She stated that it was discovered that she had a trochaic femoral neck fracture (hip fracture). She stated that this was confirmed by an x-ray that was taken on Monday 06/10/2024. She stated that Resident #1 has osteoporosis and was on hospice. She stated that her bed was always in the lowest position. Her bed was in the lowest position for her safety. Her physician decided that as an intervention. She stated that Resident #1 was not paralyzed. She doesn't have a ton of mobility. She stated that RN N was working on the night of the fall and that she assisted with getting Resident #1 off the floor. She stated that RN N asked what happened, ad Resident #1 stated that she was looking for her family member. She was not on any restraints. The facility is a restraint free facility. There are bed rails, but they are not a restraint. They are a turn assist only. She stated that Resident #1 does have a behavior of crying out in pain. She has a history of intermittent lower back pain. She will cry out during repositioning, but she will calm back down. She does have thin skin on her arms and legs. If it's easily bumped, it will bruise. She does not have any blood disorders. She stated that the Physician, Hospice, and Responsible Party were notified of the fall. In an interview on 06/11/2024 at 10:10 AM, LVN R stated that she worked Monday-Wednesday 6AM-6PM. She stated that on 6/11/24 Resident #1 was still sleeping at 6 AM. She stated that she went in her room and tried to wake her up, but she looked different. She couldn't respond to what she was being asked. Her temperature was elevated. She stated that she gave her morphine for pain because she was told that she had fallen and that she did not see any bruising on her when she changed her. She stated that she notified hospice of a change in condition at around 8 AM. Hospice returned the call and then the nurse showed up before lunch. There were no injuries to her head that she know of. She stated that she checked her and didn't see any more bruising than normal. She stated that Resident #1 does have bruising or skin tears on her arms. She stated that Resident # 1 does cry out a lot in pain because her stomach and back hurts. She stated that the resident has cancer in the abdomen area, and that is why she was on hospice and had pain. She stated that every time she changed her, she screamed. She stated that it was a little bit more than normal. She stated that she does not know of any blood disorders. She does bruise very easily. She is on a fluid restriction and has very thin skin. In an interview on 06/11/2024 at 11:50 AM, RN N stated that she was working on the night Resident #1 fell , 6/07/24. She stated that she was at the desk charting and heard somebody yelling from down the hall, so she went to check the rooms. She stated that she immediately went down the hall once she heard the screaming coming from Resident #1's room. She stated that it occurred around midnight. She stated that she did not know where the CNA was at. She stated that Resident #1 had fallen off the side of the bed by the window. It was the right side. The bed was in the lowest position which was unusual for her. She stated that Resident #1 was moving her arms and legs when she got into the room and stated that it seemed like she was trying to get back into bed. She stated that Resident #1 was squirming but that she was able to check for her range of motion. She checked her vitals and neural checks. It was all fine. She stated that she contacted the doctor, hospice, DON, family member, and just kind of went from there. She stated that Resident #1 had turned herself around; her head was at the foot of the bed. Her arms were reaching towards the bed. Her legs were moving. She was trying to get back onto the bed not realizing that she couldn't. He right side was weakened and that she assumed that she pushed with her stronger side, her left side until she managed to get turned around. She stated that she had never fallen before. She said that she was looking for her family member. She stated that she kept asking Resident #1 different questions, but she wasn't really responding to them. She just kept saying that she was looking for her family member. There was not a mat on the floor that night. She stated that she put in an order to get mats on the floor. She stated that she could not get the door open to where she thought the mats were. She stated that when she assessed her, she did not see any skins tear or bumps. In an interview on 06/11/2024 at 12:40 PM, LVN A stated he was informed on 6/8/2024 that Resident #1 had fallen on 6/7/2024 overnight. He stated that RN N told him that she had found her lying on the ground. He stated that her hospice doesn't come on Saturday. He stated that he had been giving her morphine over the weekend because she was in pain. He stated that he gave her morphine on Saturday 06/08/2024 and Sunday 06/09/2024 just to make sure she was comfortable. He stated that it is common to give her morphine because she is on hospice and has a history of pain. She was in bed, and nobody reported to him that she was in severe pain. He stated that her family came to visit her. Her responsible party stayed in the room with her while they did a breathing treatment for her. Her oxygen was 90. He stated that they raised her head up and she was unable to swallow. He stated she bruised easily and that he did not get a report on her being in pain during the routine changes. He stated that nobody told him about her crying out in pain. He stated that the morphine was effective at treating her pain. In an interview on 06/11/2024 at 3:00 PM, Resident #1's Family Member B stated that she had recorded a video while she was in Resident #1's room of the nurses changing her while she was crying out in pain. She stated that her leg was in pain and that she informed Resident #1's Responsible Party that something was wrong. She stated that she frequently visited Resident #1 and was aware of the fall that had recently occurred. She was under the impression that there were no injuries so she was shocked to see her screaming in pain and verbally saying ow, my leg when she was at the facility. She stated that she did not know the staff members by name but that it was obvious something was wrong and that they had to have known about it. In an interview on 06/12/2024 at 12:40 PM, the Physician stated he was not notified of any crying of pain or incident except when the facility contacted him about Resident #1's fall on 06/07/24. He stated he was not notified of Resident #1 being found crying out in pain or saying ow, my leg. He stated that had he had known that then it would have indicated that Resident #1 be further evaluated and received an x-ray sooner which would have revealed the fracture sooner. The Physician stated the Administrator, DON, ADON or a nurse should always contact him if there was a fall, pain, or any change of condition with a resident. The Physician stated Resident #1 could have fractured her hip falling from any height because of the osteoporosis diagnosis. He stated she did have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone falling from a low bed height or a normal bed height. He stated that Resident #1 required maximum activities of daily living and was on hospice with chronic pain. He stated that she had pain issues in the past and had behavior issues in the past. He stated it would be hard to know without there being a visual indicator that something was wrong because the resident could be having a normal behavior. However, because Resident #1 verbally said ow, my leg there should have been attention brought to the leg. In an interview on 06/12/2024 at 1:20 PM, HSP Q stated that he was the Clinical Director of the hospice company. He stated that Resident #1 had a hip fracture and that her Responsible Party was upset. He stated that the hospice company could only do a mobile x-ray. It's not as good as the one they can do in the hospital. He stated that the only notes that the hospice agency received from the facility was when the facility called the answering service about the fall that occurred on Friday 06/07/2024. He stated that the facility had sent out a brief message saying that the patient had fallen or something like that. He stated that it was his understanding that there was no injury. He said that he didn't even know about the pain or anything that Resident #1 was having until Sunday 06/09/2024. He found out about the leg pain because the Responsible Party sent him the video of Resident #1 crying out in pain. He stated that is when the hospice nurse went out to check on Resident #1. Another nurse went back on Monday 06/10/2024 to check on her again and that's the day that she was sent to the hospital. He stated that he chose to do the x-ray because there must be something more wrong with her if she was in pain. He stated that she had back pain for a while and that's normal for her to complain of that but not about her leg. He stated that some fractures are small enough that they don't show up until there has been some movement and stuff. He stated that the nurse that performed the assessment after the fall stated that the resident wasn't crying and that there was no indication of any fracture, so they put her back in bed. He stated that if Resident #1 started showing signs of changes or complaining about her leg hurting then the facility should have done something. He stated that the facility should have called the hospice company to tell them what was going on. He stated that she can communicate pain. Once the facility started noticing that there was pain, they should have or could have called the hospice company. He stated that he saw the video of Resident #1 crying out in pain on Monday 06/10/2024 and ordered the x-ray. He stated that the hospice nurse that performed the assessment on Sunday 06/09/2024 did not mention anything about Resident #1 being in pain at that time. He stated at the end of every on-call section, hospice will write a synopsis usually saying something like not eating much or something like that. There was no mention of pain. He stated that the LVN had administered pain medication and that could have masked her symptoms. He stated that Resident #1 has a history of chronic pain, and that morphine keeps her comfortable. When asked if the hospice nurse on Sunday should have discovered pain during the assessment from something like a test of Resident #1's range of motion he stated, You will certainly not want to be moving the leg around if you suspect a break. You should look to see if you could bend it without pain. But yeah, she could have done the assessment if she had any notion that there might have been an injury. He stated that the hospice agency was not aware of any injury at that time. He stated that the change in condition was initially because Resident #1 was not swallowing. It was not about pain. In an interview on 06/12/2024 at 1:50 PM, CNA C stated that she worked with Resident #1 on Friday 06/07/2024 before her fall occurred and again on Sunday 06/09/2024. She stated that when she arrived to work on Sunday morning, she noticed that Resident #1's bed was lowered which seemed off, that her leg was propped up with a pillow underneath it, and that Resident #1 seemed out of it. She stated that she went straight to LVN A and informed him that something was wrong. She stated that LVN A told her that Resident #1 had a fall. She stated that she changed Resident #1's gown and that's when Resident #1 began screaming saying my leg, my leg, my leg. She stated that Resident #1's leg wouldn't lay down straight. She stated that Resident #1 was having a change in condition from her previous shift that she had worked with her on Friday 2 days before. She stated that Resident #1 would not eat her food, she would just let it sit inside her mouth. She said that Resident #1 normally ate her food without problem and that she normally ate all of it. She stated that she could tell something was different immediately when she entered the room. She stated that she had never heard Resident #1 complain about leg pain before. She stated that the family was in the room with her when she did another changing and that they were very upset. She stated that as soon as she tried to do another changing Resident #1 immediately started complaining about her leg again saying ow, my leg. The family started asking what had happened to her, so she told them that she had fallen over the weekend and that she didn't know what was going on other than that. She stated that she did not know if LVN A knew about Resident #1's leg pain before her shift started but she believed that he did. She told him during her shift. She stated that the Weekend Supervisor had called hospice so that they could perform an assessment. She stated that when she had worked on Friday everything was normal. She stated that on Friday her oxygen was normal, and that Resident #1 had fed herself 3 meals. She knew something was wrong. She stated that Resident #1 wasn't even going to the bathroom like she normally would. She stated that the first time she heard Resident #1 say something verbally about her leg was at around 7:30 AM and that's when she told LVN A. She stated that the leg didn't look right and that it was turned. She stated someone had to have known because the leg was propped up on a pillow. She stated that her leg looked bruise with purple dots and that she has never seen that on her leg before. In an interview on 06/12/2024 at 2:03 PM, RN O stated that she was the Weekend Supervisor that worked with Resident #1 and LVN A on the weekend of 6/8/24-6/9/24. She stated that she spoke to the Responsible Party and that he was upset. She understood that he was upset and stated that anyone would be upset if their family member was in the same situation as Resident #1. She stated that the Responsible Party had told her that Resident #1 did not recognize him, so she called the hospice nurse who came and assessed her. She stated that Resident #1 was not the most verbal resident and that she was not in pain. She stated that she did not hear anything about her having leg pain. In an interview on 06/12/2024 at 2:30 PM, the Administrator stated he was not notified of Resident #1 being found crying with leg pain. He stated his expectations was for a nurse to assess a resident anytime a resident was found to be in pain or showing any signs of a change of condition. The Administrator stated that there were no nurses notes about Resident #1 complaining of leg pain on the assessments or incident /accident reports. In an interview with the DON on 06/12/2024 at 3:40 PM, when the Investigator asked if it would have changed the outcome if she had known earlier about the resident crying out in pain on Saturday and Sunday instead of waiting until Monday, she stated that I can't say that it would have changed the outcome or if getting an x-ray earlier would have changed the outcome. She stated that it would have brought a concern to her that Resident #1 was in pain and crying. If so, then the nurse staff would call hospice or call the physician again. She stated that the staff did not witness the resident crying out in pain saying ow, my leg on Saturday and Sunday. She stated that the staff had not had an indication that she was crying in pain. She stated that if the staff had heard Resident #1 crying out in pain, then they should have called hospice and told the physician about her complaining of pain. She stated that it would be the responsibility of the LVN or RN to notify. In an interview with LVN A on 06/12/2024 at 3:48 PM, when the Investigator asked if he had known about Resident #1 crying out in pain on Saturday and Sunday, he stated that he did not know about her leg pain during his shift and that nobody ever told him. He stated that Resident #1 was in her bed all day and that he gave her pain medicine because she was on hospice. He stated that she has a PRN order for the Morphine for pain management. In an interview with CNA B on 06/12/2024 at 4:54 PM, she stated that she had worked with Resident #1 on Saturday 06/08/2024 and that she had worked with her for 3-5 years. She stated that on that morning Resident #1 was different. She stated that Resident #1 was screaming while she was being changed. That occurred after breakfast between 8:30-9AM. She stated that she was not able to understand her. She stated that she did not even know that she had fallen. She went to ask LVN A and he told her that she had a fall. She stated that she noticed that she was screaming whenever she was being changed. She did not eat much. She stated that she did not remember her complaining about her leg. She just knew that she was in pain. She never said ow, ow my leg hurts. She stated that she asked Resident #1 questions, but she didn't speak. She stated that she told LVN A about her being in pain and that he just told her that she had fallen. She was only screaming in pain whenever she was being changed. She stated that Resident #1 would scream if there was any movement. If she moved at all then she was screaming. That was totally different than her normal. She stated that she had changed her many times and she had never screamed like that. She wasn't talking at all. She stated that she had to also feed her because she wasn't eating on her own. She stated that she told LVN A and that she believed he gave her medicine for pain. Record review of Resident #1's electronic medical records 06/07/2024- 06/10/2024 reflected Resident #1 did not have any pain assessment note entries that stated she was crying out in pain or complaining about her leg being in pain on 06/8/2024 or 06/9/2024. She did have a pain assessment on 06/8/2024 but it was checked 0 for no pain, and 0 for no injury. It was also checked that she was given morphine. Record review of Facility Policy on Change in a Resident's Condition or Status: 1. The nurse will notify the residents attending physician or physician on call when there has been a(an): a. Accident or incident involving the resident; b. Discovery of injuries of an unknown source; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times); g. Need to transfer the resident to a hospital/treatment center; h. Discharge without proper medical authority; and/or i. Specify instructions to notify the physician of changed in the residents condition. 2. A significant change of condition is a major decline or improvement in the residents status that; a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting'); b. Impacts more than one area of the residents health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the residents representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the residents physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residents medical/mental condition or status. The Administrator was notified on 06/13/2024 at 12:30 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided at 12:59 PM. The following POR was accepted on 06/14/2024 at 10:26 AM: Date 06/14/24 On 06/11/24 a facility investigation was initiated at the facility. 06/13/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Plan of Removal completion date is 06/13/24 with continuation of oncoming staff and follow-up. 1. Resident #1 is currently in the hospital. [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 5 residents observed for accident hazards. -On 2-4-2020 CNA A transferred Resident #1 without assistance resulting in a fall that fractured Resident #1's femur. The facility implemented corrective measures and training prior to entrance for this survey. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, suffocation, subdural hematomas, and death. Findings include: Record review of Resident #1's clinical record revealed a [AGE] year-old female resident originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's last MDS was a discharge return anticipated completed on 2-5-2020 with a BIMS that could not be conducted due to memory problems and a functionality of requiring extensive assistance with all activities. Record review or Resident #1's clinical record revealed a care plan with the following: Focus-Mobility Impairment R/T Weakness, date initiated 6-6-2017 Interventions/Task-Transfer: I require the Hoyer lift to transfer with x2 staff assistance, revision date 4-1-2019. Record review of Resident #1's clinical record revealed a Radiology Report: date 2-4-2020 with the following: Results: .There is acute fracture in distal femur with moderate angulation and displacement . Record review of Resident #1's clinical record revealed a Progress Note dated 2/5/2020 at 01:08 AM with the following: Health Status Note: Note Text-Resident was being helped by the aide using the device, and she slid, and aide helped resident to the floor mat. Got a call from the walkie talkie and rushed to the room. Put a pillow on her head, did an assessment on the resident. She denied pain initially and stated, put me back in bed. Pain meds administered on resident. MD, RP, and DON notified of incidence. X-ray of left femur and right foot done on resident and awaiting results . Record review of facility provided investigation revealed a statement from CNA A with the following: Summary of Incident: I took the resident from the nurse's station to the room and used sit to stand to transfer resident from wheelchair to bed, resident foot slipped off sit to stand and started to go down. I eased resident down to the floor and paged another CNA on the walkie talkie to come and help. I was trained to use sit to stand on resident. I also know about the daily care guide and failed to look and see that the resident is a Hoyer lift. Signed by CNA A on 2-4-2020 Record review of facility provided Orientation schedule completed by all new staff 1-30-2020, (CNA A was hired 1-14-2020 and completed this orientation) listed the following: Lift Training (Restorative Aide), Job Duties, . Record review of facility provided Provider Investigation Report revealed the following statement from CNA B, I trained CNA A for two days .I show her how to follow the daily care guide for each resident. Also, CNA A was present when we used the mechanical lift device (Hoyler) to transfer the patient from chair to bed. During an interview on 2-27-2020 at 10:36 AM CNA A reported that she did try to transfer Resident #1 by herself after the resident asked several times to be put to bed. CNA A confirmed that she was aware that Resident #1 was a two-person transfer and Resident #1 should have had two people for her transfer. CNA A reported she attempted to find assistance but it was her third night on evening duty and so she went ahead and transferred Resident #1. When asked if the facility had trained CNA A on the use of a lift CNA A stated, Yes they did. CNA A went on to state, When it happened I helped her slide to the floor and then I called for help on the walkie talkie and someone immediately came and helped me. During an interview on 2-27-2020 at 12:05 AM when asked about facility training on lift transfers and procedures the administrator stated, We have therapy do a training on the procedure then we have one of our restorative aides do a physical demonstration of the procedure. I have given you the forms we use during orientation to complete each employee's training. As far as Resident #1, when I interviewed CNA A she was very remorseful. CNA A admitted freely that she knew she wasn't supposed to do the transfer by herself. You will find in the PIR statements, three individuals that trained her on the use of the lift. CNA A admitted that she did not get denied help that evening. CNA A stated, basically I made a choice and it was a bad one. We also have daily care guides that are for each resident that make a specific point that if the resident is a lift transfer that two people must be present. These are available to each employee daily. During an interview on 2-27-2020 at 2:00 PM the DON reported that upon hire, new hire orientation includes mechanical lift training. The DON reported staff are informed not to use lifts without a second person. A return demonstration training is completed during orientation and annually. The DON reported training is also performed as needed too. Record review of facility provided policy titled Transfer Techniques-Mechanical Lift dated (MONTH) 2019, reveled the following: Procedure: Sit to Stand Lift 3.Ensure that the required number of staffs are present for a safe transfer. Record review of facility provided policy titled Lift Devices-Electric and Hydraulic Addendum dated (MONTH) 2012, reveled the following: 3. If a resident requires a two (2) person transfer a mechanical lift MUST be used by nursing staff. 4. Two (2) nursing staff members must be present during all mechanical lift transfer. Record review of facility provided policy titled Lifting Devices-Electric and Hydraulic dated (MONTH) 2019, reveled the following: Procedure: 1. Review proper use of equipment prior to initiating the procedure b. Review to include, but not be limited to: -Proper number of people required to perform lift. The facility implemented corrective measures and training prior to entrance for this survey. Record review of facility provided In-service Sign in Sheet for Proper Transfer Training Techniques and Lift Training completed 2-5-2020 through 2-7-2020 were completed by 25 staff members.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 5 Residents (Resident #1) reviewed for safety during procedures. - On 2-4-2020 CNA A transferred Resident #1 without assistance resulting in a fall that fractured Resident #1's femur. The facility implemented corrective measures and training prior to entrance for this survey. This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to injuries such as bruising, skin tears, fractures, suffocation, subdural hematomas, and death. Findings include: Record review of Resident #1's clinical record revealed a [AGE] year-old female resident originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's last MDS was a discharge return anticipated completed on 2-5-2020 with a BIMS that could not be conducted due to memory problems and a functionality of requiring extensive assistance with all activities. Record review or Resident #1's clinical record revealed a care plan with the following: Focus-Mobility Impairment R/T Weakness, date initiated 6-6-2017 Interventions/Task-Transfer: I require the Hoyer lift to transfer with x2 staff assistance, revision date 4-1-2019. Record review of Resident #1's clinical record revealed a Radiology Report: date 2-4-2020 with the following: Results: .There is acute fracture in distal femur with moderate angulation and displacement . Record review of Resident #1's clinical record revealed a Progress Note dated 2/5/2020 at 01:08 AM with the following: Health Status Note: Note Text-Resident was being helped by the aide using the device, and she slid, and aide helped resident to the floor mat. Got a call from the walkie talkie and rushed to the room. Put a pillow on her head, did an assessment on the resident. She denied pain initially and stated, put me back in bed. Pain meds administered on resident. MD, RP, and DON notified of incidence. X-ray of left femur and right foot done on resident and awaiting results . Record review of facility provided investigation revealed a statement from CNA A with the following: Summary of Incident: I took the resident from the nurse's station to the room and used sit to stand to transfer resident from wheelchair to bed, resident foot slipped off sit to stand and started to go down. I eased resident down to the floor and paged another CNA on the walkie talkie to come and help. I was trained to use sit to stand on resident. I also know about the daily care guide and failed to look and see that the resident is a Hoyer lift. Signed by CNA A on 2-4-2020 Record review of facility provided Orientation schedule completed by all new staff 1-30-2020, (CNA A was hired 1-14-2020 and completed this orientation) listed the following: Lift Training (Restorative Aide), Job Duties, . Record review of facility provided Provider Investigation Report revealed the following statement from CNA B, I trained CNA A for two days .I show her how to follow the daily care guide for each resident. Also, CNA A was present when we used the mechanical lift device (Hoyler) to transfer the patient from chair to bed. During an interview on 2-27-2020 at 10:36 AM CNA A reported that she did try to transfer Resident #1 by herself after the resident asked several times to be put to bed. CNA A confirmed that she was aware that Resident #1 was a two-person transfer and Resident #1 should have had two people for her transfer. CNA A reported she attempted to find assistance but it was her third night on evening duty and so she went ahead and transferred Resident #1. When asked if the facility had trained CNA A on the use of a lift CNA A stated, Yes they did. CNA A went on to state, When it happened I helped her slide to the floor and then I called for help on the walkie talkie and someone immediately came and helped me. During an interview on 2-27-2020 at 12:05 AM when asked about facility training on lift transfers and procedures the administrator stated, We have therapy do a training on the procedure then we have one of our restorative aides do a physical demonstration of the procedure. I have given you the forms we use during orientation to complete each employee's training. As far as Resident #1, when I interviewed CNA A she was very remorseful. CNA A admitted freely that she knew she wasn't supposed to do the transfer by herself. You will find in the PIR statements, three individuals that trained her on the use of the lift. CNA A admitted that she did not get denied help that evening. CNA A stated, basically I made a choice and it was a bad one. We also have daily care guides that are for each resident that make a specific point that if the resident is a lift transfer that two people must be present. These are available to each employee daily. During an interview on 2-27-2020 at 2:00 PM the DON reported that upon hire, new hire orientation includes mechanical lift training. The DON reported staff are informed not to use lifts without a second person. A return demonstration training is completed during orientation and annually. The DON reported training is also performed as needed too. Record review of facility provided policy titled Transfer Techniques-Mechanical Lift dated (MONTH) 2019, reveled the following: Procedure: Sit to Stand Lift 3.Ensure that the required number of staffs are present for a safe transfer. Record review of facility provided policy titled Lift Devices-Electric and Hydraulic Addendum dated (MONTH) 2012, reveled the following: 3. If a resident requires a two (2) person transfer a mechanical lift MUST be used by nursing staff. 4. Two (2) nursing staff members must be present during all mechanical lift transfer. Record review of facility provided policy titled Lifting Devices-Electric and Hydraulic dated (MONTH) 2019, reveled the following: Procedure: 1. Review proper use of equipment prior to initiating the procedure b. Review to include, but not be limited to: -Proper number of people required to perform lift. The facility implemented corrective measures and training prior to entrance for this survey. Record review of facility provided In-service Sign in Sheet for Proper Transfer Training Techniques and Lift Training completed 2-5-2020 through 2-7-2020 were completed by 25 staff members.