Every finding on record at Remington Transitional Care of San Antonio

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for each resident in a manner and in an environment that promotes maintenances or enhancement of his or her quality of life for 2 of 10 residents (Resident #68 and Resident #92) reviewed for resident rights.1. LVN A referred to Resident #68 as Dear when requesting the resident's oxygen level.2. LVN A referred to Resident #92 as Baby, Sweetheart, and Dear.This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #68's face sheet dated 8/12/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, stage 4 pressure ulcer (injury that involves full-thickness skin and tissue loss), respiratory failure (lungs not able to provide enough oxygen to the body and/or are unable to remove enough carbon dioxide from the blood) and cardiomyopathies (disease of the heart muscle that makes it harder for the heart to pump blood effectively). Record review of Resident #68's most recent comprehensive MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills. During an observation on 8/11/26 at 12:22 p.m., LVN A entered Resident #68's room and asked the resident, Can I check your O2, dear? Resident #68 stated, Ok. LVN A stated to Resident #68 that the doctor had ordered the resident on fluid restriction and was going to prescribe a diuretic and then Resident #68 began to cry. During an interview on 8/11/26 at 12:33 p.m., Resident #68 was asked by the State Surveyor if she was offended when referred to as dear by LVN A. Resident #68 stated, Yes, sometimes it bothers me because she (LVN A) should know my name. Resident #68 stated LVN A should refer to her by her name, and How would she like it if I called her something else other than nurse, because that is her profession. 2. Record review of Resident #92's admission sheet dated 8/04/2026 with an original admission date of 12/23/2025 documented a [AGE] year-old female resident with diagnoses including COPD (an ongoing lung condition caused by damage to the lungs resulting in the obstruction of airflow), hypertension (high blood pressure), heart disease, type 2 diabetes mellitus, kidney disease, anxiety, depression, and insomnia. Record review of Resident #92's MDS assessment dated [DATE], documented a BIMS score of 11 indicating the resident was moderately cognitively impaired, and recorded the use of antianxiety, anticoagulant, diuretic, and anticonvulsant medications. During an observation on 8/11/2026 at 9:58 AM, LVN A walked into Resident #92's room and referred to the resident as Baby, Sweetheart, and Dear. During an interview with Resident #92 on 8/11/2026 at 10:14 AM, Resident #92 stated she preferred for staff to use her name instead of terms of endearment when addressing her. During an interview with LVN A on 8/14/26 at 11:02 AM, LVN A stated most residents did not want to be at the facility, and she tried to make them feel good about themselves when using a term of endearment. LVN A stated that dignity was important to the patient, and because they lose control in a medical facility, LVN A stated dignity was one of the things staff could keep intact for them. During an interview on 8/14/26 at 11:36 a.m., the DON stated his expectation when staff addressed a resident was to address them in a professional manner and not to assume the staff could address the resident using a term of endearment, unless the resident was ok with it. The DON stated, it was a dignity issue. Record review of the facility policy titled Statement of Resident Rights, undated, revealed You have a right to: (4) be treated with courtesy, consideration, and respect;

Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 2 of 15 residents (Resident #10 and #88) reviewed for advanced directives:The facility failed to determine upon admission whether Resident #10 and Resident #88 had an advanced directive, and if not, determined whether the resident or resident representative wished to formulate an advanced directive.This failure could place residents at risk of not having their wishes known, which could affect whether they receive medical treatment according to their rights.1. Record review of Resident #10's face sheet, dated [DATE] revealed a [AGE] year-old female with an admission on [DATE] and a readmission on [DATE] with diagnoses that include encephalopathy, unspecified (a group of conditions that cause brain dysfunction that can appear as confusion, memory loss, and personality changes). Record review of Resident #10's initial baseline/advanced care plan dated [DATE] indicated the resident's cognition was intact. Record review of Resident #10's care plan initiated on [DATE] revealed: Resident is a full code with interventions that included if resident has a cardiac arrest, initiate CPR and call 911, notify MD/RP and follow MD orders after notification initiated on [DATE]. Record review of Resident #10's order summary dated [DATE] revealed an order for: CPR (full code), with a start date [DATE] with no end date. Record review of Resident #10's clinical record reflected there was no Advance Directive Discussion form in the resident's record. Record review of Resident #10's forms under section Social services – Advanced Directive Discussion Form – V 1 revealed no form dated after Resident #10's admission on [DATE]. During an interview on [DATE] at 10:40 a.m., SW D stated advance directives were discussed with residents upon admission. SW D stated Resident #10's advanced directive discussion had not been completed yet. SW D stated they were unsure regarding the timeframe advanced directive discussions needed to be completed by. SW D stated they believed the advance directive discussion had to be done as soon as possible. SW D stated the advance directive discussion form was completed in order to show the discussion had been had. SW D stated there were no risks of not completing the advance directive discussion form because they had several cheeks to oversee a resident's advance directive. 2. Record review of Resident #88's face sheet dated [DATE] reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute kidney failure, chronic obstructive pulmonary disease, hypertension, diabetes, and heart disease. Record review of Resident #88's most current 5-day scheduled MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills. Record review of Resident #88's Physician Order Summary Report dated [DATE] reflected the following: - CPR (Full Code) with order date [DATE] and no end date Record review of Resident #88's comprehensive care plan dated [DATE] reflected the resident was a full code with interventions that included to mark the medical record and all pertinent documents with FULL CODE. Record review of Resident #88's clinical record reflected there was no Advance Directive Discussion form in the resident's record. Record review of Resident #88's clinical record under the FORMS section reflected in part: Next Form Due: SOCIAL SERVICES – Advanced Directive Discussion Form – 5 days overdue – [DATE] During an observation and interview on [DATE] at 10:09 a.m., SW E stated the Social Workers were responsible for completing the Advanced Directive Discussion form. SW E stated the Advanced Directive Discussion form should be completed anywhere from admission to the first five days the resident was admitted to the facility. SW E stated she met with Resident #88 and discussed advance directives with the resident. SW E showed the State Surveyor with a handwritten note she indicated was used to discuss the right for Resident #88 to formulate an advanced directive. The undated document provided by SW E indicated, Advanced Directives? FC, which indicated the resident was a full code. SW E stated she was holding on to (the handwritten note) to make sure that I did ask (about an advanced directive) and then I will upload it later. SW E could not elaborate on why the Advanced Directive Discussion form was not uploaded into Resident #88's clinical record. During an interview on [DATE] at 10:10 a.m., SW D stated the Social Workers were responsible for completing the Advanced Directive Discussion form but was not sure it had to be done within 5 days. During an interview on [DATE] at 3:44 p.m., the DON stated resident code status was determined on admission. The DON stated, the SW met with the resident within at least 72 hours to discuss the right to formulate an advanced directive. The DON stated the Advanced Directive Discussion form should be completed as soon as possible. During an interview on [DATE] at 8:01 a.m., the Administrator stated it was important to have the discussion and the proper forms for the discussion on the resident's right to formulate an advanced directive because that was how we know how to treat the patient if something happens. The Administrator stated, the Advanced Directive Discussion form should be done and uploaded on the day of admission or within 48 hours for those residents who admit during the weekend. We have to make sure we have a system in place. Record review of the facility document titled Residents' Rights Regarding Treatment and Advance Directives, dated [DATE] reflected in part, .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards for 2 of 10 residents (Resident #100 and Resident #110) reviewed for baseline care plans. 1. The facility failed to include Resident #100's use of anticoagulant medications in the baseline care plan. 2. The facility failed to include Resident #110's use of an antidepressant medication in the baseline care plan. These failures could place residents at risk of not receiving needed care and treatment. The findings included: 1. Record review of Resident #100's admission sheet dated 8/07/2026 with an original admission date of 12/12/2024 documented a [AGE] year-old female resident with diagnoses including cellulitis (a bacterial skin infection most commonly found in the lower legs), hypertension (high blood pressure), type 2 diabetes mellitus, and heart disease. Record review of Resident #100's MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition and recorded active diagnoses of coronary artery disease, hypertension, diabetes mellitus, and hyperlipidemia (high cholesterol). At the time of the survey, the assessment did not record the use of Resident #100's medications in section N0415 High-Risk Drug Classes: Use and Indication. Record review of Resident #100's order summary included an order for the antiplatelet medication Clopidogrel with an order date of 8/07/2026. Clopidogrel was ordered as Clopidogrel 75 mg, Give 1 tablet by mouth one time a day for Antiplatelet. Record review of Resident #100's August 2026 MAR documented the resident had been receiving Clopidogrel as prescribed. Record review of Resident #100's hospital discharge instructions dated 8/07/2026 included an order for Plavix (brand name of Clopidogrel) 75 mg daily. Record review of Resident #100's baseline care plan did not include the resident's use of antiplatelet medications. 2. Record review of Resident #110's face sheet, dated 08/12/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that include bipolar disorder, unspecified (significant mood swings) and anxiety disorder, unspecified (uncontrollable worry that affect daily functioning). Record review of Resident #110's initial baseline/advanced care plan dated 08/10/2026 revealed Resident #110's cognition was intact. Further review of the initial baseline/advanced care plan in section 2. Health conditions and orders under C. Orders, 2. Medications Ordered revealed the box labeled Problem: The resident uses antidepressant medication (specify medication) r/t) left unchecked. Record review of Resident #110's physician order summary dated 08/12/2026 revealed the following order: Trazodone HCI Oral Tablet 150 MG (Trazadone HCI), give 1 tablet by mouth at bedtime for sleep with a start date 08/08/2026 Record review of Resident #110's hospital records dated 08/07/2026 revealed the following medication order under Discharge Medications: Trazodone 150 MG, indication: for sleep, at bedtime During an interview with the ADON on 8/13/26 on 1:54 PM, the ADON stated she did the assessments for the initial baseline care plan which were used to populate the care plan. The ADON stated the baseline care plan should be accurate because if something is missed, there could be harm to a resident. During an interview on 08/13/32026 at 1:55 p.m., the ADON stated they were in charge of completing the initial baseline care plan. The ADON stated care plans should be accurate because that was how the facility plans the resident's care. The ADON confirmed that Trazodone was an antidepressant. The ADON stated because the order was indicated for sleep, they may have coded the medication as a sedative/hypnotic instead. The ADON stated they try to check off that both the resident was taking an antidepressant and sedative/hypnotic. During an interview with the DON on 8/13/26 at 3:58 PM, the DON stated his expectation for care plans was that the daily plan of care should be based on the documented interdisciplinary care plan. During an interview on 08/13/2026 at 3:59 p.m., the DON stated that care plans should reflect the daily plan of care the residents receive. Record review of the facility policy titled Baseline Care Plan, dated 6/06/2025, documented The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-entered care of the resident that meet professional standards of quality care ., .The baseline care plan will: b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: ii. Physician orders.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 for 2 of 10 residents (Resident #3 and Resident #103) reviewed for care plans. 1. The facility failed to ensure Residents #3's comprehensive care plan included the use of opioid medications. 2. The facility failed to ensure Resident #103's comprehensive care plan included the use of his TLSO back brace. These deficient practices could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: 1. Record review of Resident #3's admission sheet dated 7/13/2026 documented a [AGE] year-old female resident with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection causing the organs to work poorly), insomnia, depression, type 2 diabetes mellitus, hypertension (high blood pressure), and muscle wasting. Record review of Resident #3's MDS assessment, dated 7/16/2026 documented a BIMS score of 15 indicating cognition was intact and recorded the use of antidepressant, anticoagulant, antibiotic, opioid, and hypoglycemic medications. Record review of Resident #3's order summary included an order for the opioid medication Acetaminophen-Codeine. Acetaminophen-Codeine was ordered as Acetaminophen-Codeine 300-30 mg, Give 1 tablet by mouth every 6 hours for Pain. Record review of Resident #3's July 2026 and August 2026 MARs documented the resident had been receiving Acetaminophen-Codeine as prescribed. Record review of Resident #3's care plan with an initiation date of 7/15/2026 did not include the resident's use of opioid medications. 2. Record review of Resident #103's face sheet dated 08/12/2026, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that include wedge compression fracture of the first lumbar vertebra, subsequent encounter for fracture with routine healing (fracture often due to trauma). Record review of Resident #103's initial baseline/advanced care plan dated 08/04/2026 revealed the resident's cognition was intact. Record review Resident #103's care plan last revised on 08/06/2026 revealed no mention of Resident #103's TLSO back brace. Record review of Resident #103's order summary dated 08/11/2026 revealed an order for: Patient to have back brace on when out of bed, every shift with start date 08/04/3036. Record review of Resident #103's hospital record Discharge summary dated [DATE] revealed: TLSO brace when out of bed only. Does not need it when laying down. No heavy lifting/bending/twisting for 8 weeks. During a joint interview on 08/13/2026 at 2:21 p.m., with LVN F and LVN G, LVN F stated the care plan was used in order to evaluate residents' problems and figure out goals and interventions for each problem. LVN F stated she reviewed Resident #103's hospital records which indicated an order for a back brace. LVN F stated the back brace should have been on Resident #103's care plan. LVN G stated care plans were used to help dictate care and if staff had questions regarding plan of care they could refer to the resident's care plan. During an interview on 8/13/26 on 1:54 PM, the ADON stated she did the assessments for the initial baseline care plan, and the nurses go in and update the care plan when new orders are added. The ADON stated upper nursing and the MDS staff all take part in ensuring the accuracy of the care plan. The ADON stated the care plan should be accurate, because if it was not complete, something could be missed and cause harm to a resident. During an interview with the DON on 8/13/26 at 3:58 PM, the DON stated his expectation for care plans was that the daily plan of care should be based on the documented interdisciplinary care plan. Record review of the facility policy titled Comprehensive Care Plans, dated 10/24/22, noted It is the policy of this facility to develop and implement a comprehensive person-entered care plan for each resident, consistent with 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 resident's comprehensive assessment ., and The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 2 carts (the two west cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: During an observation of the two west cart on 8/13/2026 at 2:58 PM, eight signatures were found missing from the controlled medication reconciliation log used during cart exchange. Signatures were missing from the following dates: two on 8/06/2026, one on 8/07/2026, two on 8/09/2026, one on 8/11/2026, one on 8/12/2026, and one on 8/13/2026. During an interview on 8/13/2026 at 3:00 PM, LVN C stated the reconciliation logs should be signed at each shift change to be sure of the medication inventory. LVN C stated if the logs were not signed at the time of shift change, there could be missing medication and residents might not receive the benefit of their medications if they were unavailable. During an interview on 8/13/26 at 3:58 PM, the DON stated the controlled reconciliation logs needed to be checked and verified daily. The DON stated the counts happened every shift, but they needed to verify those counts to make sure they were getting done. Record review of the facility policy titled Documentation of Controlled Substances, with a revision date of 10/01/19, noted Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Controlled Substances Record documentation will be maintained accurately ., 7. Two Licensed Nurses or Medical Aides or combination thereof, are responsible to complete a count of all controlled substances at the change of shift or any time that the narcotic keys are surrendered from one nurse to another.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 2 carts (the one-east cart and the two-west cart) reviewed for medication storage and labeling. The facility failed to ensure all insulins located inside the one-east cart were properly labeled with opened dates. The facility failed to ensure all medications located inside the two-west cart were stored in labeled containers. These failures could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribedThe findings included: During an observation of the one-east cart on [DATE] at 2:47 PM, 1 of 4 insulin pens in the cart did not contain an opened date indicating when they were removed from refrigeration. During an interview with LVN B on [DATE] at 2:49 PM, LVN B stated if there was no use by date on the insulin pen, it would be unknown when the pen came out of the refrigerator and when it would expire. LVN B stated if a pen was expired, the potency could be reduced and if used, the resident might not get the full benefit of their medication. During an observation of the two-west cart on [DATE] at 2:58 PM, three loose pills were discovered in the bottom of the second drawer of the cart. During an interview on [DATE] at 2:59 PM, LVN C stated if pills were loose in the cart unlabeled, it would not be known what the pills were. LVN C stated if someone thought they had put a pill in a dosing cup and did not see it fall in the cart, a resident might not receive the pill and would not get the benefit of the medication. During an interview on [DATE] at 3:58 PM, the DON stated insulins should have the date they came out of the refrigerator, because insulins could lose their effectiveness if stored past the expiration date. Regarding unlabeled pills in the medication carts, the DON stated his expectation for staff was that they ensure their carts are clean upon receipt of the cart from the outgoing staff. Record review of the facility policy titled Labeling of Medications, with a revision date of [DATE] noted Prescription drugs will be kept in container labeled by a pharmacist or in the original manufacturer's container ., Prescription medications will be labeled with the following information H. Expiration date . Record review of the facility policy titled Medication Administration, dated [DATE], noted 1. Keep medication cart clean, organized, and stocked with adequate supplies ., 12. Identify expiration date.

Based on observation, interviews, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 hallways (hallway 100) observed for meal distribution.The facility failed to ensure residents were safe from potentially contaminated food when DA H did not sanitize their hands between giving residents food trays in their rooms.The deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses.The findings included:Observation on 08/11/2026 at 12:13 p.m., revealed DA H, in the 100 hall, grabbed a meal tray from the meal cart and delivered it to room [ROOM NUMBER], then without sanitizing their hands grabbed the next meal tray from the meal cart and delivered it to room [ROOM NUMBER]. The DA H then grabbed the next meal tray from the meal cart without sanitizing their hands and delivered it to room [ROOM NUMBER]. Additionally, DA H grabbed another meal tray from the meal cart and delivered it to room [ROOM NUMBER] and without sanitizing their hands grabbed another meal tray from the meal cart and delivered it to room [ROOM NUMBER]. During an interview on 08/11/2026 at 12:19 p.m., DA H stated when they passed out meal trays to residents' rooms there were supposed to sanitize upon entering and exiting each resident's room. DA H stated the purpose of sanitizing their hands was to prevent infections. During an interview on 08/13/2026 at 11:44 a.m., the DM stated their expectation of staff when passing out meal trays would be to sanitize their hands before and after going into residents' rooms. The DM stated the purpose of sanitizing their hands was for infection control. During an interview on 08/13/2026 at 3:59 p.m., the DON stated their expectation of staff when delivering meal trays to residents' rooms would be sanitizing their hands upon exit of resident's rooms especially if they have EBP in place. The DON stated the purpose of sanitizing their hands was for infection control. Record review of the facility's policy titled, Handwashing, located in the nutrition and foodservices policies and procedures manual, dated 10/01/2018, revealed:2. Hands should be washed after the following occurrences: l. assisting residents Record review of the facility's policy titled, Employee Sanitation, located in the nutrition and foodservices policies and procedures manual, dated 10/01/2018, revealed:5. Handwashing a. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times:vii. after engaging in other activities that contaminate the hands.

Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (1) of five (5) residents (Resident #1) reviewed for clinical records. The facility failed to ensure RN A documented a repeat blood pressure level when the initial level was below the approved range to administer Metoprolol Succinate (a blood pressure medication). This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #1's admission Record, dated 12/13/2025, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was listed as his own responsible party with his [family member] listed a secondary contact. Resident #1 discharged on 12/09/2025. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 12/13/2025 at 10:58 a.m., revealed diagnoses including encounter for orthopedic (the branch of medicine dealing with conditions affecting the bones or muscles) aftercare following surgical amputation (the action of cutting off a limb, such as a leg below the knee), heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs), and hypertension ( a chronic condition where the pressure in the body's blood vessels is consistently too high). Record review of Resident #1's discharge with return anticipated MDS, dated [DATE] and signed 12/11/2025 as completed, did not reflect Resident #1's mental status score. Resident #1's functional abilities were documented as requiring partial/moderate assistance for transfers. Record review of Resident #1's Brief Interview for Mental Status, dated effective 11/27/2025, reflected Resident #1 had a memory problem and was moderately impaired regarding making decisions for daily life. Record review of Resident #1's Order Recap Report, dated 12/13/2025 for orders dated 11/26/2025- 12/09/2025, reflected the physician order Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN HOLD IF SBP < 100, DBP < 60, or HR < 60. The order was noted as dated 11/26/2025 with start date 12/27/2025 and end date 12/12/2025. Record review of Resident #1's Skilled Administration Record, dated 12/01/2025- 12/31/2025, reflected the order Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN HOLD IF SBP < 100, DBP < 60, or HR < 60. The administration record indicated the medication was administered on 12/02/2025 by RN A. The hours of administration were documented as *6a 1. The blood pressure and pulse values for 12/02/2025 were documented as NA. NA was not defined on the record. Record review of Resident #1's EMR Blood Presssure tab, undated and accessed 12/13/2025 at 11:33 a.m., revealed two (2) blood pressure values for 12/02/2025, 127/57 mmHg by RN A at 07:04 a.m. and 150/69 mmHg by 09:26 p.m. by LPN B. Record review of Resident #1's progress notes dated 11/13/2025- 12/14/2025 did not reveal a progress note regarding the provision of Metoprolol Succinate on 12/02/2025 or a reassessment of Resident #1's blood pressure. Resident #1 was unavailable on 12/14/2025 and 12/15/2025 for observation or interview due to his status as an in-patient at a local military hospital that does not allow visitation. During an interview on 12/14/2025 at 10:42 a.m., Resident #1's family member and listed contact stated she had concerns regarding Resident #1's blood pressure treatment at a prior facility, but she did not reveal concerns regarding his blood pressure treatment at the facility he discharged from on 12/09/2025. During an interview on 12/15/2025 at 03:13 p.m., MD C stated he was providing care to Resident #1 while the resident was admitted to the facility. MD C denied having had received notification of Resident #1's blood pressure having been below administration range for the Metoprolol Succinate order. MD C stated he did not have concerns if RN A had administered Resident #1 the Metoprolol Succinate on 12/02/2025 if the DBP was at 57 mmHg and below the hold order. MD C stated the only impact would have been that Resident #1 could have experienced some dizziness. During an interview on 12/15/2025 at 03:35 p.m., RN A stated she couldn't recall administering Resident #1 his Metoprolol Succinate on 12/02/2025 but stated she probably re-checked Resident #1's blood pressure prior to administering since the initial DBP was outside the administration range. She stated she would re-check a resident's blood pressure if the values seemed outside the resident's normal range or were outside the administration range. She stated, if she had re-checked Resident #1's blood pressure, she probably didn't document the new values. She stated the impact of not documenting the new values was that the administration would show as a medication error. She stated she was aware the hold values for the medication administration were written into the order and if she administered the medication when the resident's blood pressure was already low, the medication could cause the resident's blood pressure to drop even lower. She stated she would have continued to monitor Resident #1 throughout her shift on 12/02/2025. During an interview on 12/15/2025 at 04:47 p.m., the DON stated *6a 1 for administration time referred to medications scheduled to be administered between 06:00 a.m. to 01:00 p.m. The DON stated if the medication order stated to hold if the DBP was below 60 mmHg and the measured DBP was 57 mmHg, he would have expected the staff member to have contacted the physician. He stated, while reviewing Resident #1's EMR, that he believed the administration documentation was in error because the EMR would have triggered a warning to the administering nurse if the blood pressure was outside the administration range. The DON stated the administering nurse could have prevented the error if she had entered the repeat blood pressure she had obtained into the administration record. The DON revealed the lack of documentation for the repeat blood pressure value would not have impacted Resident #1's care but might result in the resident's physician questioning why Resident #1's DBP was low. The DON stated he would have expected the administering nurse to have documented the new vitals by entering the repeat vitals into the administration record or the vitals tab. Record review of facility policy, Documentation in Medical Record, date implemented 10/24/2022, reflected Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.3. Principles of documentation include, but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observations, interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident # 1) of 5 residents reviewed for MDS accuracy. Resident #1's re-entry MDS assessment from the hospital did not reflect the fall which resulted in a fracture and was the reason she went to the hospital. This failure affects residents who reside at the facility and could result in missed care.The findings included: Record review of Resident #1's electronic face sheet dated 11/18/2025 reflected she was an [AGE] year-old female who was originally admitted to the facility on [DATE], fell at the facility which resulted in a fracture, and she was sent to the hospital on [DATE]. She was then readmitted to the facility from the hospital on [DATE]. Her diagnoses included: fracture of the upper end of right humerus (upper arm bone), metabolic encephalopathy (diffuse brain dysfunction that can lead to confusion, memory loss and loss of consciousness) and chronic kidney disease (kidneys have become damaged over time and can lead to increased risks of other health issues such as heart disease and stroke). Record review of Resident #1's MDS admission re-entry assessment dated [DATE] reflected she could understand and be understood. She required maximum assistance with her care. She scored 12 of 15 on her BIMS which indicated her cognitive status was moderately impaired. Review of section J1700. Fall History on Admission/Entry or Reentry inaccurately reflected Resident #1 did not have any fall in the last month prior to admission/entry or reentry. Record review of Resident #1's comprehensive care plan dated 10/29/2025 reflected under Focus, the resident has had an actual fall due to poor balance and an unsteady gait. Record review of Resident #1's incident report titled unwitnessed fall dated 10/29/2025 at 11:53 pm reflected was found on the floor by door. Patient was lying on her right side. Record review of the hospital record dated 10/30/2025 reflected patient fell when she was tying to get out of bed. She landed on her right hip. Observation on 11/18/2025 at 12:13 pm, Resident #1 was dressed in a hospital gown, and she wore a brief and was lying in bed in her room. The bed was in a low position; the call light was next to her on the bed. During an interview on 11/18/2025 at 12:15 pm, Resident #1 stated that she had a fall trying to get out of bed and did not remember to use her call light to call for assistance. During an interview on 11/18/2025 at 12:40 pm, the DON stated Resident #1 had a fall in the facility on 10/29/2025 and was sent to the hospital where she was found to have a fractured femur. He stated the fall should have been reflected on her re-entry MDS to reflect her actual condition which led to her care and the development or updating of her care plan. He stated the care she required could be missed with an inaccurate MDS. During an interview on 11/18/2025 at 2:18 pm, LVN A stated she completed Resident #1's re-entry MDS and she did not know why she missed coding her fall. She stated she updated the resident's care plan and still missed checking off on her MDS that she had a fall. She stated that an inaccurate care plan could result in missed care for a resident. During an interview on 11/18/2025 at 2:56 pm, the ADM stated she was accountable for the MDS assessments, and she stated she did not know how LVN A missed the fall, and she stated that the MDS assessment was directly related to a resident's care plan and a resident could miss care if the MDS was not correct. Review of the CMS Long Term Care RAI 3.0 User's Manual Version 1.20.1, October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status. Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600).

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #2) of 5 residents reviewed for implementation of care plans. Resident #2 did not have a floor mat on each side of his bed as was specified in his comprehensive plan of care for fall prevention. This failure affects residents at high risk for falls and could result in injury or disability. The findings included: Record review of Resident #2's electronic face sheet dated 11/18/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: displaced fracture of the left femur (type of fracture where the bone has broken and is out of alignment from its original position), atherosclerotic heart disease (characterized by plaque buildup in the artery walls which can restrict blood flow and lead to heart attacks or strokes), bipolar disorder (characterized by extreme mood swings that include emotional highs and lows), dementia (loss of cognitive functioning), and anxiety (feeling of worry, nervousness, or unease). Record review of Resident #2's 5-day scheduled assessment MDS dated [DATE] reflected he could understand and be understood. He scored 12 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required extensive assistance with ADLs. He had a fall in the previous month prior to admission or reentry. Record review of Resident #2's comprehensive care plan dated 09/08/2025 reflected Problem, is at risk for falls, Interventions, keep the bed in the low position as tolerated place fall mats at the sides of the bed. Record review of Resident #2's Kardex (communication form used by CNAs to tell them what care needed to be provided) as of 11/18/2025 reflected Safety, place fall mats at the sides of the bed. Record review of facility tracking and trending log from September to November 2025 reflected Resident #2 had one witnessed fall and 6 unwitnessed falls without injury. Observation on 11/18/2025 at 10:32 am of Resident #2 revealed he was in his room lying in bed, family member at his side. He had a fall mat on the floor on the right side of his bed; no other floor mat was observed to be in his room. During an interview on 11/18/2025 at 10:33 am with Resident #2's family member, she stated Resident #2 had a fall at home and broke his leg and that was why he was at the facility for rehabilitation. She stated he would be discharged from the facility to an ALF because he has had numerous falls, and his safety concerned her. Observation on 11/18/2025 at 12:30 pm of Resident #2 accompanied by the DON revealed Resident #1 was lying in bed eating lunch and there was one mat on the floor on the right side of the bed. The DON confirmed there was not a floor mat on the left side of the bed. During an interview on 11/18/2025 at 12:35 pm, Resident #2 stated he had falls and when questioned by the DON if he had falls on one side of the bed, he responded no, I fall off both sides of the bed. During an interview on 11/18/2025 at 12:40 pm, the DON stated it was important to implement interventions in the care plan because that was what was assessed to be the care a resident needed. He stated Resident #2 could fall on the floor without the mat and even with a low bed could sustain injury from landing on the floor. During an interview on 11/18/2025 at 1:32 pm, RN B stated she was the charge nurse on Resident #2's hall and she did rounds but did not notice he did not have floor mat on each side of the bed. She stated she did not know why she did not notice. She stated she would get a mat right away because it was important in case he fell from the bed to prevent or minimize injury. She stated she had access to Resident #2's care plan and nurses passed notes about residents needed care at shift change. During an interview on 11/18/2025 at 2:18 pm, CNA C stated she was the CNA for Resident #2 and did not notice he did not have a floor mat on each side of the bed. She stated she used the Kardex to see what a resident needed for care and safety. She stated she reviewed Resident #2's Kardex. She stated it was important to have a mat on each side of the bed for Resident #2 to prevent injury from falling. During an interview on 11/18/2025 at 2:56 pm, the ADM stated she did round on residents and expected staff to implement care plan interventions because it was what was assessed for a resident to meet their needs. Record review of the facility policy and procedure titled Comprehensive Care Plans dated 10/224/2022 reflected, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. Record review of the facility policy and procedure titled Fall Prevention Program dated 08/15/2022 reflected Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care, interventions will be monitored for effectiveness, and the plan of care will be revised as needed.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #28) out of 8 residents reviewed for environmental concerns. The facility failed on 06/03/2025 when Resident #28's window (1 of 2) would not close all the way in his room remaining open approximately 1-inch, which could have resulted in damage to the interior windowsill according to the Maintenance Director. The facility failed on 06/03/2025 when Resident #28's room refrigerator had not been functioning for an unknown amount of time resulting in Resident #28's RP not being able to bring in outside food for Resident #28. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. The findings included: Record review of Resident #28's admission record, dated 06/03/25, reflected Resident #28 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include repeated falls, weakness, and dementia (decline in cognitive functioning, including memory, thinking, and reasoning, to the extent that it interferes with daily life and activities). Record review of Resident #28's admission MDS assessment, dated 05/05/25, reflected Resident #28 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Observation and combined interview with Resident #28 and Resident #28's RP on 06/03/25 at 11:07 AM reflected, one of his windows (1 of 2) was slightly open. They stated they could not close it before today and demonstrated they could not close it by trying to close it again unsuccessfully. They stated they had put a towel to cover the crack so bugs and rain could not get in. They revealed this window had been cracked for at least last week. They stated when it rained last week water got in and this was when they told a staff member, who they were unable to identify. Observation of the interior windowsill revealed the top of the windowsill near the window was slightly warped. Observation and interview on 06/03/25 at 11:12 AM, reflected Resident #28's refrigerator was empty and was 58 degrees Fahrenheit. Resident #28's RP stated she had not used the refrigerator since Resident #28 was admitted to the facility and because the refrigerator had been broken so she could not store cold food properly in it. Resident #28's RP stated she had not told anyone about the broken refrigerator. Observation on 06/04/25 at 8:27 AM revealed that 1 of Resident #28's window (1 of 2) was slightly open approximately 1-inch. Interview and observation on 06/04/2025 at 2:58 PM revealed one of Resident #28's windows was cracked open approximately 1-inch. Observation revealed the vinyl material constructed on the windowsill to be warped along the window side of the windowsill. The Maintenance Director closed the window. The Maintenance Director confirmed damage to the windowsill. He stated he was not aware of the window being cracked open or the water damage to the windowsill. He stated he was not notified of Resident #28's room window was having issues closing, and he was not aware of how long the window had been cracked open. The Maintenance Director stated he was aware of the requirement to ensure walls are maintained, cleanable and in good repair. He further stated as the Maintenance Director it was his responsibility to maintain the building wall conditions. Maintenance Director understood and agreed not maintaining the walls could cause deterioration of the walls, leaving the walls uncleanable which could cause water penetration promoting mold growth, causing air-borne illnesses with the potential to expose the residents to unsanitary conditions, affecting the health and safety of the residents. Observation on 06/05/25 at 8:27 AM, reflected Resident #28's refrigerator was empty and was 60 degrees Fahrenheit. Interview on 06/05/25 at 4:21 PM, SW I, who was the ambassador for Resident #28's room, meaning he did morning rounds to make sure there weren't any concerns for Resident #28, to include anything that may need repair in his room. SW I stated the refrigerator this morning was 45 degrees Fahrenheit, so he let the Maintenance Director know and expected this to be fixed. He revealed he was not aware that Resident #28's window was unable to be closed. SW I stated anyone who went in Resident #28's room and noticed anything out of the ordinary, should report it to someone so they could find out who could fix any issue that came up. Interview on 06/05/25 at 4:44 PM, the ADM revealed the thermometer was broken in Resident #28's refrigerator which was why it was showing a wrong number. She was aware Resident #28's refrigerator was replaced earlier this week, but was not aware of why it was replaced. She stated the refrigerator felt cool when she assessed today and the thermometer had to be broken. The ADM revealed the facility placed 3 thermometers in the refrigerator to see if it was working. Interview and observation on 06/06/25 at 9:41 AM, Resident #28's RP stated Resident #28's refrigerator was replaced last night (06/05/2025) because it had not been working. It was observed that the refrigerator was functioning and maintaining proper temperature (less than 40 degrees Fahrenheit). Resident #28's RP stated Resident #28 had been progressing at this facility to include increased appetite, increased food consumption, and strength due to therapy. Resident #28's RP revealed they were satisfied with the nutritional interventions the facility implemented because it had helped Resident #28. Interview on 06/06/25 at 9:53 AM, the SW H stated she knew people wanted the windows open to get fresh air, but it was hard to close the windows sometimes. She stated it was important for windows to close so things like insects would not come in. She stated it was important for Residents' refrigerator to work so food would not get spoiled. She stated it was important to provide a homelike environment because it made the facility feel like home and helped with residents' dignity. SW H further stated the facility did not want the facility to be institutionalized looking, so the residents were not scared of staying in this facility and not being at home. Interview on 06/06/25 at 1:00 PM, the Maintenance Director revealed Monday 06/02/25 there was a work order for Resident #28's refrigerator. The Maintenance Director said the refrigerator was not at temperature because the temperature control was turned really low, but they decided to replace the refrigerator anyway. He revealed on Tuesday, 06/03/25, they found the refrigerator door was not closing all the way. They revealed they did not know how long Resident #28's refrigerator was broken before Monday. Maintenance Director stated ambassadors did morning rounds where they checked the refrigerator temperatures and this was one opportunity to catch if the refrigerator was broken, but anyone who visited resident rooms could have caught this. The Maintenance Director further stated Resident #28's window was slightly open, but he just had to push it down to close it. He revealed there was water damage on the windowsill, inside Resident #28's room and this could have happened last week. Interview on 06/06/25 at 1:30 PM, the Maintenance Director revealed the facility could not calibrate the thermometers, but they would compare it to a digital thermometer before they put it in the refrigerator. He stated the thermometers they used were not reliable and would break. He expected the facility staff to know if a thermometer was broken if the temperature read too high. He said if the thermometer read too high, this meant the thermometer was broken. He stated when they put a new refrigerator into a resident's room, they had to monitor it to ensure it was functioning correctly. Record review of work order created 06/02/25, reflected the refrigerator was not working even though it was plugged in, and they replaced the refrigerator on 06/02/25. Record review of work order created 06/05/25 at 8:04 AM by SW I for Resident #28's refrigerator reflected there was a refrigerator temperature issue, and he was continuing to monitor refrigerator temperature. Record review of Statement of Resident Rights, provided by the facility and undated, reflected You have a right to: . safe, decent and clean conditions. Facility did not have a policy for homelike environment or functioning equipment. Record review of facility's policy, Potluck Meals and Foods from Home, dated 10/01/18, reflected 2. The facility must ensure safe food handling techniques once the food is brought into the facility including . holding cold items <41 degrees . Record review of facility's policy, Food Safety for Residents, dated 2018, reflected Keep Food out of the Danger Zone . 2. Cold perishable food . should be kept at 40 degrees Fahrenheit or below. Discard any cold leftovers that have been left out for more than 2 hours at room temperature. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 17.24% based on 5 out of 29 opportunities, which involved 2 of 6 Residents (Resident #161 and Resident #171) reviewed for medication administration, in that: 1. The facility failed on 6/5/25 to ensure RN F observed if Resident #171 took her metoclopramide (used to treat various gastrointestinal conditions), pantoprazole (decreases the amount of acid produced in the stomach), and sucralfate (to treat an active duodenal ulcer. Sucralfate works mainly in the lining of the stomach and is not highly absorbed into the body.) medications. 2. The facility failed on 6/5/25 to ensure LVN G observed if Resident #161 took her docusate (stool softener used to treat constipation) and liquid protein (concentrated liquid protein supplement) medications. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #171's admission Record, dated 6/6/25, revealed an [AGE] year-old female admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, wheezing, cough, end stage renal disease, malignant neoplasm of pancreas (Pancreatic cancer), and diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine). Record review of Resident #171's admission MDS assessment, dated 5/31/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #171's care plan, revised on 6/5/25, revealed the resident had an ADL self-care performance deficit and required limited assistance x1 by staff with personal hygiene and oral care. Record review of Resident #171's physician order summary, dated 6/6/25, revealed orders for: - Metoclopramide HCl Oral Tablet 10 MG give 1 tablet by mouth before meals and at bedtime for GERD, with a start date of 5/28/25 and no end date. - Sucralfate Suspension 1 GM/10ML give 1 gram by mouth before meals for gastric protection, with a start date of 6/5/25, and no end date. - Pantoprazole Sodium Oral Tablet Delayed Release 40 MG give 1 tablet by mouth two times a day for acid reflux, with a start date of 5/28/25, and no end date. During an observation on 6/5/25 at 8:03 a.m. RN F planned to administer medications to Resident #171. Resident #171 was sitting up in a chair and stated she was not able to sleep all night due to her stomach bothering her. RN F handed Resident #171 a medicine cup with the metoclopramide and pantoprazole in it. The resident held the medication cup in her hands and continued speaking to the nurse. RN F placed a medication cup with the liquid sucralfate in it on the resident's bedside table. RN F then stated he was running behind. RN F then left the resident's room without observing if she took the medications or not. 2. Record review of Resident #161's admission Record, dated 6/6/25, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of gram negative sepsis (bacteria entering the blood stream), cellulitis of left limb (bacterial infection of the skin), and gout (a form of arthritis that causes sudden, sever pain and inflammation in one or more joints). Record review of Resident #161's BIMS assessment, dated 5/28/25, revealed her cognition was fully intact. Record review of Resident #161's care plan, initiated 5/28/25, revealed the resident had an ADL self-care performance deficit and required x2 staff for personal hygiene and oral care. Record review of Resident #161's Physician orders, dated 6/6/25, revealed orders for: - Protein Oral Liquid give 30 ml by mouth two times a day for supplement to promote wound healing, with a start date of 5/28/25, and no end date. - Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, hold for loose stools, with a start date of 5/28/25, and no end date. During an observation on 6/5/25 at 9:07 a.m. LVN G planned to administer medications to Resident #161. LVN G handed Resident #161 a cup of pills. Resident #161 took the docusate pill out of the medicine cup and placed it on her bedside table. She stated she did not know if she wanted to take that one. Resident #161 then asked LVN G to split the other pills in half for her. LVN G split them in half and Resident #161 took them. LVN G mixed the protein liquid with water and left it on the resident's bedside table. It was unknown if the resident ever took the docusate or drank the liquid protein. During an interview on 6/5/25 at 3:25 p.m. the DON stated staff had to observe residents taking their medications for patient safety and to make sure they are getting the treatments as ordered. The DON stated they did not have any residents who could administer their own medications. Record review of the facility's document titled Medication Pass Competency Assessment revealed RN F completed assessments on 7/2/24 and LVN G completed assessments on 5/27/25. The competency stated .17. The resident is observed to ensure the medication is swallowed and not left at the bedside . Record review of the facility's policy titled Medication Administration, dated 10/01/19, stated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 3 medication cart (200 hall east and west carts) reviewed for labeling and storage of drugs. 1. The facility failed to ensure Resident #31's furosemide package directions matched the physician orders blood pressure parameters on the 200-hall east cart. 2. The facility failed to ensure 200-hall west medication cart was not left unlocked and out of sight from the nurse. 3. The facility failed to provide change direction labels for Resident #161's medication package of allopurinol which had medication order change from 100 mg (1 tablet) to 150 mg (1.5 tablets) on the 200-hall west cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: 1. During an observation on 6/5/25 at 8:18 a.m. the 200-hall east medication cart contained Resident #31's furosemide. The pharmacy label stated furosemide 20 tablet give 1 by mouth. Call for SBP less than 10 or DBP less than 60 before administration. Record review of Resident #31's physician orders, dated 6/5/25, revealed an order Furosemide Tablet 20 MG Give 1 tablet by mouth one time a day for CHF Contact MD for SBP<100 or DBP<60 before administering diuretic, with a start date of 5/23/25, and no end date. During an interview on 6/5/25 at 8:46 a.m. RN F stated the label should say less than 110 or 100. He stated he would call the pharmacy if he was unsure, but he thought it should say less than 100. RN F stated he would always call the provider if it was less than 100. 2. During an observation on 6/5/25 at 8:59 a.m. the 200-hall-west cart was unlocked and unattended. LVN G was in a resident room with his back turned away from the cart in the hallway. 3. During an observation on 6/5/25 at 9:07 a.m. revealed the 200-hall west medication cart contained Resident #161's allopurinol. The pharmacy label stated 100 mg of allopurinol give 1 tablet by mouth daily. Record review of Resident #161's physician orders, dated 6/6/25, revealed an order for Allopurinol Tablet 100 mg Give 1.5 tablet by mouth one time a day for Gout Give 1.5 tablet to equal 150mg, with a start date of 5/29/25, and no end date. During an interview on 6/5/25 at 9:41 a.m. LVN G stated they could add a change direction label on the resident's medication, but he was unsure if they had any. LVN G stated he should keep his cart lock for patient safety. During an interview on 6/5/25 at 3:27 p.m. the DON stated staff should lock carts when they walk away to prevent anyone from taking something from it or moving things around. The DON stated the facility had stickers to put on the medication packages if there was a correction for the label or a change in direction sticker. The DON stated they also could obtain a new label from the pharmacy or verify the parameters for the medication in the EMR. The DON stated the medication package label should match the current orders to ensure patient safety and to ensure the nurse is triggered to check parameters for safe medication administration. Record review of the facility's document titled Medication Pass Competency Assessment LVN G completed assessments on 5/27/25. The competency stated .10. The medication cart and medication room are free from any pre-poured medications . Record review of the facility's policy titled Medication Administration-Medication Cart and Supplies for Administering Meds, dated 10/01/2019, stated .Med CARTS: 3. Do not leave the medication cart unlocked or unattended in the resident care areas .

Based on interviews and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet resident choices for 2 of 8 residents (Resident #24 and #172) and 1 of 1 kitchen reviewed for dietary needs. The facility failed to ensure there was not a repetitive menu for the residents resulting in complaints about the lack of variety in food options. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their religious nutritional preferences met. Record review of Resident #24's admission record, dated 06/03/25, reflected Resident #24 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include constipation. Record review of Resident #24's admission MDS assessment, dated 04/20/25, reflected Resident #24 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Record review of Resident #24's comprehensive care plan reflected problem The resident has nutritional problem or potential nutritional problem r/t refusal of meals . with goal The resident will maintain adequate nutritional status . Record review of Resident #172's admission record, dated 06/06/25, reflected Resident #172 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include major depressive disorder and dementia (decline in cognitive functioning, including memory, thinking, and reasoning, to the extent that it interferes with daily life and activities). Record review of Resident #172's admission MDS assessment, dated 05/19/25, reflected Resident #172 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Record review of Resident #172's comprehensive care plan did not reflect anything related to food intake or diet. Record review of facility's Week 1 through Week 5 Spring/Summer 2025 menu reflected every morning refried beans was on the menu. It further revealed the following meals also included beans, which would have the residents eating beans 2 times a day on these days: In Week 1, pinto beans were served in Thursday's lunch, red bean soup was served in Saturday's dinner, and refried beans were served in Sunday's dinner. This equated to 10 out of 21 meals in Week 1 including beans. In Week 2, pinto beans were served in Tuesday's dinner. This equated to 8 out of 21 meals in Week 2 including beans. In Week 3, refried beans were served in Wednesday's dinner, pinto beans were served in Saturday's lunch, and lentil soup was served in Sunday's dinner. This equated to 10 out of 21 meals in Week 3 including beans. In Week 4, black beans were served in Wednesday's dinner, and 3 bean salad was served in Saturday's dinner. This equated to 9 out of 21 meals in Week 4 including beans. In Week 5, pinto beans were served in Tuesday's lunch, pinto beans were served in Friday's dinner, and seasoned beans were served in Saturday's lunch. This equated to 10 out of 21 meals in Week 5 including beans. Record review of grievance for Resident #24, dated 05/30/25, reflected he complained about too many beans being served on menu with a final resolution of updating tray care to reflect no beans. Interview on 06/03/25 at 11:33 AM, Resident #24 revealed the facility served beans a lot and he had trouble with constipation and diarrhea, so he did not want to eat beans. Interview on 06/04/25 at 10:04 AM, Resident #172 revealed the facility served beans too much. Interview on 06/06/25 at 10:07 AM, the RD and CDM revealed there were some days where beans were served two times in a one day, because refried beans were served every morning. They revealed this was a new menu so they mentioned they would adjust the menu according to the feedback they had from the residents. They revealed if there were complaints, they would adjust the menu to not include certain items. The RD revealed she understood why someone would not want beans 2 times a day. Interview on 06/06/25 at 12:37 PM, the ADM revealed they reviewed the menu before they used it in the facility. She revealed she was not aware there were beans in the menu 2 times in one day. She revealed she would get with the RD to find better alternatives because it would help to have a variety of foods in the menu. Record review of facility's policy, Menu Planning, dated 06/01/19, reflected, The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious, and meets the preferences of the resident population. No other policy was provided in regard to menus.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to label their food products with their respective discard dates. These failures could place residents at risk for food borne illness. The findings included: Interview and observation on 06/03/25 at 09:55 AM, all packaged foods in the fridge, located off the tray line, had dates: 06/02/25 and 06/03/25 with no discard dates. The CDM and RD revealed they did not have to put the discard dates on the labels, but the kitchen staff knew to discard food products after 3 days. Interview and observation on 06/04/25 at 11:10 AM, all packaged food in the fridge, located off the tray line, reflected prepared date and discard dates. The CDM and RD revealed they put discard dates on the labels just to be safe, but their policy did not tell them to put discard dates. They revealed they do follow the FDA Food Code. The RD revealed it could be helpful to put discard dates, so staff knew when to discard food products with a quick glance. The RD further revealed they did not have updated policies after the food code was updated in 2022. Interview on 06/06/25 at 02:25 PM, [NAME] A revealed he did not write discard dates on food products for food storage in the refrigerators because they knew to throw the food out after 72 hours. He revealed he was in-serviced this week and he knew to write discard dates on food products that were stored in the refrigerator. Record review of facility's policy Food Storage, revised June 1, 2019, reflected, 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 4 staff (RN F and LVN G) and 5 of 8 Residents (Resident #40, Resident #161, Resident #165, Resident #166, and Resident #217) reviewed for infection control: 1. The facility failed to ensure RN F sanitized the blood glucose monitor between use for Resident #166 and Resident #165. 2. The facility failed to ensure RN F did not touch pills with his bare hands and then administer the medication to Resident #40. 3. The facility failed to ensure RN F cleaned an insulin pen's rubber stopper with an alcohol swab prior to insulin administration for Resident #165. 4. The facility failed to ensure LVN G used a clean paper towel to turn of the sink after washing his hands during medication pass for Resident #161. 5. The facility failed to ensure Resident #217 was on EBP due to her surgical wound. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. During an observation on 6/5/25 at 8:25 a.m. RN F checked Resident #166's blood glucose. RN F then returned to his medication cart and placed the monitor on top of the cart. RN F did not sanitize the monitor and continued passing medications to other residents. During an observation on 6/5/25 at 8:33 a.m. RN F used the same blood glucose monitor to check Resident #165's blood glucose. RN F did not sanitize the monitor before or after use. During an interview on 6/5/25 at 8:48 a.m. RN F stated he should sanitize the blood glucose monitor between residents to prevent the spread of potential pathogens from staff to residents or from residents to residents. 2. During an observation on 6/5/25 at 8:30 a.m. RN F used his keys to open the medication cart, opened his medication cart, looked for a medication, touched his keyboard to look for an order on the computer, and then RN F dispensed a medication from a blister package for Resident #40. RN F grabbed the pill from the back of the package with is bare hand and put in it in medication cup. Resident #40 then took the pill. During an interview on 6/5/25 at 8:50 RN F stated he was told he could touch pills with his fingers, and he did not need to wear gloves when handling medications. RN F stated on further thought he could have contaminated his hands prior and then touched the pill. 3. During an observation on 6/5/25 at 8:33 a.m. RN prepared an insulin glargine (a long action insulin) pen injection for Resident #165. RN F stated he needed to prime the pen with 5 units of insulin prior. RN F then placed the needle on the pen and did not clean the rubber stopper area with an alcohol pad prior. During an interview on 6/5/25 at 3:32 p.m. the DON stated staff should clean the glucose monitors with a wipe after each resident. The DON stated each cart had two monitors so they could clean one monitor, allow it to sit, meet the contact time with the cleaner, and use the other clean monitor in the meantime. The DON stated he thought the insulin pen should be cleaned prior to placing the needle on the end just like you would an insulin vial. The DON stated he did not think it specified in the insulin administration competency to clean the pen prior, but it would be important to ensure there is no cross contamination. The DON stated cleaning with an alcohol swab prior to placing the needle on the pen would ensure you remove any potential pathogens from the pen. 4. During an observation on 6/5/25 at 9:25 a.m. LVN G went into Resident #161's bathroom to wash his hands during medication administration. LVN G washed his hands at the sink and turned off the faucet with his barehand. LVN G then dried his hands with a paper towel. LVN G returned to his medication cart and split pills for Resident #161. LVN G then administered the medications to Resident #161. LVN G then returned to wash his hands at the sink and again turned off the faucet with his barehand. During an interview on 6/5/25 at 9:41 a.m. LVN G stated the paper towels were across the room and not easily accessible when washing his hands. LVN G stated he should use a clean paper towel to turn off the faucet because there could be bacteria on the handle when he turned it to begin with. During an interview on 6/5/25 at 3:36 p.m. the DON stated staff should use a clean paper towel to turn off the water to prevent infection. 5. Record review of Resident #217's Face Sheet, dated 6/6/25, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with diagnoses of aftercare following a joint replacement surgery, presence of right artificial hip joint, and type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood). Record review of Resident #217's BIMS Assessment, dated 6/2/25, reflected her cognition was fully intact for daily decision making. Record review of Resident #217's Comprehensive Person-Centered Care Plan, revised on 6/5/25, reflected the resident was at risk for impaired skin integrity related to impaired mobility and recent surgical procedure/hospitalization. The interventions included conduct skin inspections / examinations weekly and as needed and document findings. Record review of Resident #217's physician orders, dated 6/4/25, revealed orders for: - Wound care order: Right hip surgical site dressing with PICO drain (a device that provides negative pressure wound therapy to draw out excess fluid from a wound and protect the incision or wound.) is not to be removed until follow up is complete and or NPWT (negative pressure wound therapy) is complete. May change dressing if soiled and or dislodged. For treatment, refer to PRN order. If dressing change is provided, assess pain level pre and post treatment and every day shift, with an order date of 6/2/25, and no end date. - Wound care order: Right hip surgical site dressing with PICO drain is not to be removed until follow up is complete and or NPWT is complete. May change dressing if soiled and or dislodged. For treatment, refer to PRN order. If dressing change is provided, assess pain level pre and post treatment and as needed, with an order date of 6/2/25, and no end date. During an observation and interview on 6/3/25 at 9:52 a.m. Resident #217 stated she just had hip replacement surgery. She stated she had been assessed by therapy and had taken one shower since being admitted a few days prior. She stated a staff member helped her cover her surgical wound dressing with a waterproof dressing so she could shower. She stated no one had provided wound care since her admission because she had a wound vacuum device covering the surgical incision that was not supposed to get wet. She stated they would only do the wound care if it became dislodged. Resident #217's room did not have any signage for EBP. During an interview on 6/5/25 at 3:18 p.m. the DON stated EBP was used for any wounds and no wounds were excluded unless they were minor skin tears or stage 1 pressure wounds with no skin breaks. The DON stated Resident #217 should be on EBP due to the potential of infection to her wound. During a follow up interview on 6/6/25 at 9:51 a.m. the DON stated their policy for insulin administration stated the did not need to disinfect the insulin pen prior to placing the needle on the pen. The DON stated he thought the policy was acceptable. Record review of insulin glargine infection 100 units/mL manufacturer guidelines, dated 08/22, stated .Step 2 . Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle straight with the pen, and screw the needle on . Record review of the facility's policy titled Medication Administration Injectable Administration, dated 10/01/19, stated Procedure . Clean stopper with alcohol pad and allow to air dry (except on pen devices and pre-filled syringes) . Record review of the facility's policy titled Enhanced Barrier Precautions, dated 4/5/24, stated Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following:1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub . 4. High-contact resident care activities include: a. Dressing b. Bathing . h. Wound care: any skin opening requiring a dressing 5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . Record review of the facility's policy titled Hand Hygiene, dated 10/24/22, stated Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . 5.Hand hygiene technique when using soap and water . d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f.Use clean towel to turn off the faucet .

Based on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 2 of 2 residents (Resident #22 and #272) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #22 who discharged on 03/01/25 and #272 who discharged on 05/14/25 within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: 1. A record review of Resident #22's admission record dated 06/06/24, revealed a [AGE] year-old male with an admission date of 12/16/24 and a discharge date of 03/01/25 with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs), acute respiratory failure with hypoxia (a condition where lungs are unable to adequately transfer oxygen into the bloodstream, leading to a dangerously low blood oxygen level), sepsis unspecified organism (a life-threatening complication of an infection), dysphagia (difficulty swallowing) and gastrostomy status (the presence of a gastrostomy tube going into the stomach to provide nutritional support). A record review of Resident #22's medical record revealed an entry MDS dated [DATE] and an admission MDS assessment dated [DATE] which revealed a BIMS score of 13 which indicated no impairment to his cognition. Further review of Resident #22's medical record revealed a 5-Day PPS MDS assessment dated [DATE]. A note on the MDS list in the medical record indicated Discharge - ARD 03/01/25 - 83 days overdue. 2. Record review of Resident #272's admission record, dated 06/03/25, reflected Resident #272 was an [AGE] year-old female admitted to the facility on [DATE] and discharged with home health services on 05/14/25, with diagnoses to include skin transplant. Record review of Resident #272's MDS assessment, dated 05/06/25 and no type selected, reflected Resident #272 had a BIMS score of 15 out of 15, indicating intact cognition. A note on the MDS list in the medical record indicated Discharge - ARD 05/14/25 - 9 days overdue and Discharge Return Not Anticipated MDS assessment, dated 05/14/25, was In Progress. An interview with the DON on 06/06/25 at 10:00 am, the DON was asked about 2 residents (Resident #22 and Resident #272) who did not have discharge MDS assessments. The DON stated he does not review the MDS assessments and that was done by someone at their corporate office. An interview with the two MDS Coordinators, LVN B and LVN C, on 06/06/25 at 10:22 am, revealed the 2 residents who did not have a discharge MDS were just missed and they will do a Discharge Return Anticipated for Resident #22 and Discharge Return Not Anticipated for Resident #272. The MDS Coordinators stated it was important to do Discharge MDS assessments so that CMS and insurance would be notified of changes. A facility policy titled Assessment Frequency/Timeliness dated 10/24/24 stated: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner according to the current RAI Manual. 6. An OBRA discharge assessment will be completed within 14 days of the discharge date . Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.19.1, dated October 2024, revealed 10. Discharge Assessment Return Anticipated [ .] Must be submitted within 14 days after the MDS completion date.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #23 and 52) of 8 residents reviewed for care plans. The facility failed to update Resident #23's care plan, undated, included his need for set up and clean-up assistance with eating and Resident #52's care plan, undated, failed to include his ADL self-performance deficit for eating when Resident #52 needed extensive help and needed to be fed. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Record review of Resident #23's admission record, dated 06/03/25, reflected Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include type 2 diabetes. Record review of Resident #23's admission MDS assessment, dated 03/25/25, reflected Resident #23 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. It reflected Resident #23 needed set up or clean-up assistance with eating, where the helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Record review of Resident #23's comprehensive care plan did not reflect interventions for EATING (set up or clean-up assistance with eating), under the problem The resident has an ADL self-care performance deficit., which was initiated 03/24/25. Record review of Resident #52's admission record, dated 06/03/25, reflected Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (weakness on half of body) follow cerebral infarction (ischemic stroke) affecting right dominant side. Record review of Resident #52's admission MDS assessment, dated 03/25/25, reflected Resident #52 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. It reflected Resident #52 needed substantial/maximal assistance with eating, where the Helper does MORE THAN HALF the effort Record review of Resident #52's comprehensive care plan did not reflect interventions for EATING (set up or clean-up assistance with eating or needing to be fed, under the problem The resident has an ADL self-care performance deficit., initiated 05/01/25. Interview and observation on 06/05/25 at 12:28 PM, Resident #23 was struggling to peel off the plastic covering over his soup. He stated he did not like when he had to take off the plastic covering over food products because it was too hard for him. Observation revealed his dessert also had plastic wrapping over it. Interview on 06/05/25 at 12:33 PM, CNA D and CNA E stated Resident #23 needed set up for eating, which would include taking the wrap off his food products. They stated Resident #52 needed extensive help with eating and needed to be fed. They revealed they knew this because it was spread by word of mouth. They relied on therapy to keep in contact with them. They stated their nurses and other CNAs would also let them know about this. Interview on 06/05/25 at 10:30 AM, MDS Coordinator B and MDS Coordinator C revealed to code MDS assessment for ADLs they speak with the therapy department and nursing staff. They revealed they would educate staff if there were any updates. They revealed the IDT oversaw the care plans to make sure the care plans were updated. They revealed it was important update the care plans as this updated the Kardex, which listed tasks for the CNAs to complete, that the CNAs access. They revealed this was important for resident care and resident safety. Record review of facility's policy Care Plan Revisions Upon Status Change, dated 10/24/22, reflected 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.

Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 3 (Residents #25, #104 and #253) of 24 residents reviewed for baseline care plans. 1. Resident #25's baseline care plan dated 04/04/2024 did not reflect he received antibiotic therapy at dialysis. 2. Resident #104's baseline care plan dated 04/18/2024 did not reflect she received an antipsychotic medication. 3. Resident #253's baseline care plan dated 04/22/2024 did not reflect she was on oxygen therapy. This deficient practice could affect residents admitted to the facility and result in missed or inadequate care. The findings included: 1. Record review of Resident #25's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: septicemia (the body's extreme reaction to an untreated infection that causes the body to attack body organs that could lead to organ failure and then death); metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood); and ESRD (End Stage Renal Disease). Record review of Resident #25's MDS dated [DATE] revealed the resident had a BIMS score of 15. Under section O for Special Treatments, Procedures, and Programs, Group Other subgroup H1, revealed IV medications not checked, and subgroup H4, antibiotics was not checked. Record review of Resident #25's baseline care plan dated 4/5/2024 revealed dialysis with days was not care planned under medical conditions it was checked no and IV antibiotic Ceftazidime was not care planned which was to be administered at dialysis on scheduled dialysis days. Additional orders for dialysis days were to remove pressure dressing from shunt site 4 hours after dialysis was not care planned. During an interview on 2/26/2024 at 3:14 PM the DON stated it is important to assess a resident for accuracy of the care plan to establish point of care, and to ensure it is followed by staff. 2. Record review of Resident #104's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: pneumonia (an infection in your lungs caused by bacteria, viruses or fungi), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities. Record review of Resident #104's MDS dated [DATE] revealed it was incomplete due to the resident's recent admission and did not contain BIMS or medication information. In Section I - Active Diagnoses, Psychiatric/Mood Disorder, the diagnoses Anxiety Disorder and Depression (other than bipolar) were checked. Record review of Resident #104's Order Summary Report Active Orders as of 04/18/2024 revealed the resident had an order for: Sertraline HCL Oral Capsule 200 mg (Sertraline HCL), give one tablet by mouth one time a day for depression. The order date was 04/18/2024 with a start date of 04/19/2024. Record review of Resident #104's baseline care plan dated 04/18/2024 revealed under C. Orders, 2. Medications Ordered there was no check mark in the box next to 2b. Psychotropic Medications. During an interview on 04/24/2024 at 1:29 PM with the DON he stated the psychotropic medication Sertraline was not checked off on the resident's baseline care plan and should have been. The DON further stated they try to scrub the care plans as best as possible but sometimes things get missed, and it was important the baseline care plan indicated the medications the resident was receiving so all staff members will know to monitor for side effects. During an interview on 04/26/2024 at 2:55 PM with ADON A she stated one of the supervisors initiated Resident #104's Baseline care plan but she signed off on it, and they both missed indicating the resident was taking a psychotropic medication. 3. Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's hospital discharge summary dated 04/21/2024 reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She said it was important to have the initial baseline care plan because it communicated the residents needs and without her oxygen she could be in respiratory distress. Interview on 04/26/2024 at 2:40 PM with ADON A revealed she reviewed the residents' baseline care plans and did not realize the oxygen therapy was missed. She stated it was important to have the resident's oxygen in her base line care plan to communicate her care needs. She stated Resident #253 could have respiratory issues without her oxygen. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed, and her baseline care plan needed to have her oxygen addressed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. Record review of the facility policy and procedure revised date 10/5/23 titled Baseline Care Plan reflected The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 36232 47622

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for one of one facility, in that: The Food Service Supervisor (FSS) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the staff roster provided by the facility, undated, revealed the hire date for the FSS was 09/01/2019. Record review of the FSS' certification documentation revealed a certificate stating the FSS successfully completed the Texas Food Safety Manager Certification Examination, effective 10/11/2023, expiration date 5 years from the effective date. Record review of facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility. During an interview on 04/23/2024 at 10:50 AM, the FSS stated he was hired by the facility as a cook in 2019 and assumed the position of FSS in 09/2023. The FSS further stated upon assuming the FSS position, he completed a Texas Food Manager's Certification program, received a certificate, and believed this certification met the requirements for the position. During an interview on 04/23/2024 at 1:33 PM with the Administrator she stated she knew the Texas Food Manager's Certification was not a national certification and was not the appropriate certification for the position of FSS. The Administrator further stated she paid for the FSS to take the National Food Manager Certification exam; however, the FSS completed the Texas Food Manager Certification Exam in error. During an interview on 04/26/2024 at 11:45 AM the administrator stated the FSS demonstrated knowledge deficits and would benefit from additional training and possible mentoring from an existing FSS. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 2 of 7 Residents (#1 and #2) reviewed for accidents in that: 1. Resident #1, who had a severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect daily life), drank from a bottle of Dakin's Solution (bleach mix) left at her bedside by ADON B after he finished Resident #1's wound care treatment, and as a result Resident #1 vomited and had loose stool, poison control had to be notified and an intravenous catheter had to be inserted to give Resident #1 fluids. 2. Resident #2, who had a severe cognitive impairment had prescription medications, [MEDICATION(S)] spray (Flonase) 50 micrograms per spray (3/4 full) and [MEDICATION(S)] 2 percent ointment (in an almost full 22-gram tube), left in his room unsecured, unattended, and unlocked. This failure placed Residents who lived in the facility at risk for ingestion of a hazardous substance, very serious side effects, permanent disability, or even death. This failure resulted the an identification of an IJ on 5/3/21. While the IJ was removed on 5/5/21, the facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. The findings were: Record review of Resident #1's face sheet dated 5/3/21 revealed an admitted [DATE] and diagnoses which included [CONDITION(S)] (the body's extreme response to an infection), urinary tract infection, stroke, high blood pressure, and memory loss following a stroke. Record review of Resident #1's care plan dated 4/12/21 revealed she had an unstageable pressure injury (a wound caused by pressure with dead tissue covering its base) to the bottom of her spine. Record review of Resident #1's BIMS assessment dated [DATE] revealed she scored a 3, which meant she had severely impaired cognition (trouble remembering, learning new things, concentrating, or making decisions that affect daily life). Record review of Resident #1's MDS dated [DATE] revealed Resident #1 required supervision with one-person assistance for eating and drinking and was admitted with an unstageable pressure injury to her sacrum (the bottom of the spine) which required treatment. Record review of Resident #1's speech therapy notes dated 4/27/21 revealed she needed work on recognizing objects and had moderate accuracy with object naming abilities. Record review of Resident #1's doctor's orders current as of 4/28/21 revealed an order dated 4/20/21 Sacrum: cleanse with normal saline, pat dry with 4 x 4's (4 inches by 4 inches gauze), apply nickel size of Santyl (ointment used to remove dead tissue) to wound bed, place Dakin's moistened (wet gauze with Dakin's solution) 4 x 4 gauze over. Fold Kerlix (rolled gauze) over and secure with an abdominal pad and tape one time a day for wound care. Record Review of Resident #1's incident report dated 4/28/21 completed by the DON revealed a charge nurse had completed wound care using Dakin's Solution (bleach mix) on Resident #1 around 3:30 p.m., at 4:00 p.m. the ST went into Resident #1's room and found the resident vomiting, the ST noticed the bottle of Dakin's Solution at Resident #1's bedside with a straw in it. It was documented Resident #1 was able to say she had taken 3 sips of the Dakin's Solution. Record review of Resident #1's treatment administration record dated April 2021 revealed ADON B signed out Resident #1's wound care treatment to her sacrum which required Dakin's Solution as completed on 4/28/21. Record review of Resident #1's care plan dated 4/29/21 revealed she ingested (swallowed) Dakin's Solution (bleach mix) with interventions which included monitor temperature and pulse, monitor for periods of lethargy, or changes in sleep, and report any changes to the doctor. Record review of Resident #1's care plan dated 4/29/21 revealed she had an unstageable pressure injury to her sacrum with interventions which included administer treatments as ordered. Record review of Resident #1's doctor's order dated 4/29/21 revealed an order for normal saline solution 0.9 percent via intravenous route (directly into the vein) at 50 milliliters an hour for dehydration. Record review of Resident #1's skilled administration record (medication record) revealed Resident #1 received normal saline fluids in a vein in her left arm on 4/29/21. Record review of the facility's provider investigation report dated 5/5/21 revealed on 4/28/21 the ST entered Resident #1's room and saw a bottle of Dakin's Solution with a straw in it on Resident #1's bedside table. Resident #1 apparently stated she opened the bottle and had taken 3 sips. The investigation report revealed Resident #1 vomited and had an episode of loose stool upon initial ingestion of the solution. Further review revealed the facility's response was to assess Resident #1, notified the doctor who ordered laboratory values and fluids through her vein, notified poison control, Resident #1 was monitored for 12 hours after the incident for any negative outcomes, and there was a facility room search conducted on all patients to ensure there were no medications at bedside in patient rooms. The facility's investigation confirmed the incident from 4/28/21 happened. Record review of Resident #1's observation log for signs of metabolic distress (nausea, vomiting, changed mental status) after swallowing Dakin's Solution dated 4/28/21 revealed the facility had to monitor Resident #1 immediately after the incident and for 12 hours later and report any changes to her doctor. Record review of Resident #1's doctor's orders dated 4/28/21 revealed an order for intravenous line placement (catheter into a vein) and laboratory values of a complete blood count and a basic metabolic panel. Record review of Resident #1's progress note dated 4/28/21 revealed poison control was notified at 4:00 p.m. after Resident #1 drank the Dakin's Solution. In an interview on 4/29/21 at 3:15 p.m. the Administrator confirmed on 4/28/21 at 4:00 p.m. Resident #1 was seen by the ST in her room with an opened bottle of the Dakin's solution on her bedside table, opened with a straw in it. The Administrator stated the ST reported Resident #1 had vomit in her bed when she walked in. In an interview on 4/29/21 at 3:30 p.m. the DON revealed Resident #1 was alert to herself only and had [CONDITION(S)] (difficulty speaking). The DON stated Resident #1 was able to tell the ST she had drank 3 sips of the Dakin's solution from her bedside table and she threw up shortly after drinking the solution. The DON revealed the expectation was staff never left treatment supplies or medications in resident rooms. In an interview on 4/29/21 at 3:45 p.m. Resident #1 revealed she remembered there was a big bottle of something with the letters k-i-n on her bedside table on 4/28/21, and it said solution on the bottle, and she could not recall how the bottle got there. Resident #1 stated the bottle was for cleaning something, so she had 4 straws full and boy was it terrible! An observation on 4/29/21 at 3:46 p.m. revealed Resident #1 moved her hands over her mouth (throw up motion). In an interview on 4/29/21 at 3:48 p.m. Resident #1 stated it kept coming and coming and then it stopped (while moving her hand over her mouth). An observation on 4/29/21 at 4:00 p.m. revealed the Administrator handed the investigator a bottle of Dakin's solution which was found at Resident #1's bedside on 4/28/21 opened with a straw in it. Observation of the bottle revealed it was a 16-fluid ounce bottle about half full of clear liquid with a chemical odor present. Record review of the facility's Dakin's Solution label revealed the bottle was 16 fluid ounces with an expiration date of 11/2022 and a lot number of 6556. The label showed the active ingredient in the solution was sodium hypochlorite (bleach), the solution was meant for external use only, and to keep out of reach of children. If swallowed the container instructed to get medical help or call the poison control center right away. Record review on 5/10/21 of Dakin's Solution substitute safety data sheet dated 3/7/18 on the [NAME] website at https://imgcdn.[NAME].com/CumulusWeb/Click_and_learn/SDS_CENTRX_DAKINS_SOL_EXEMPTION.pdf revealed the solution should not be taken internally and it was for external use only. Record review of the Centers for Disease Control and Prevention's Chemical Disinfectants dated 9/18/16 revealed sodium hypochlorite was the same as household bleach. Record review of the Safety Data Sheet for bleach dated 6/12/15 revealed the chemical name was sodium hypochlorite, it was corrosive, harmful if swallowed, it should be stored locked up, and could cause acute health hazards. In an interview on 4/29/21 at 4:01 p.m. the Administrator revealed the bottle of Dakin's Solution she provided was the bottle found on Resident #1's bedside table on 4/28/21. In an interview on 4/29/21 at 4:30 p.m. CNA A revealed he cared for Resident #1 on 4/28/21 from 6:00 a.m. to 6:00 p.m. and he was called into Resident #1's room by the ST around 4:00 p.m. so she could go and get the nurse and when he entered Resident #1's room he saw a brown bottle on her bedside table labeled Dakin's Solution and it had a straw in it. CNA A revealed the Resident #1 told him she drank some of the solution. CNA A revealed Resident #1 had vomited and had a loose stool. In an interview on 4/29/21 at 4:45 p.m. ADON B revealed he worked with Resident #1 on 4/28/21 and noticed she had wound care treatment ordered in the electronic record. ADON B revealed he saw a closed bottle of Dakin's Solution already in Resident #1's room at her bedside, and he used it for her wound care around 3:30 p.m. on 4/28/21. ADON B revealed he thought he had taken to bottle of Dakin's Solution out of Resident #1's room. ADON B revealed he was told at 4:00 p.m. by the Speech Therapist, Resident #1 had apparently drank some Dakin's Solution and had threw up in the bed. ADON B stated he did not remember leaving the solution at Resident #1's bedside, but he had used it for her wound care. ADON B stated he had not any training on leaving chemicals or medications at the bedside before he was removed from the schedule for a facility investigation or as of 4/29/21, but he knew the expectation was staff never left hazardous items in resident rooms and said the Dakin's Solution should have been locked away after use. In an interview on 4/29/21 at 3:15 p.m. the Administrator confirmed on 4/28/21 at 4:00 p.m. Resident #1 was seen by the ST in her room with an opened bottle of the Dakin's solution (diluted bleach mix), opened with a straw in it on her bedside table. The Administrator stated the ST reported Resident #1 had vomit in her bed when she walked in. Revealed the facility actions included training staff on not leaving hazardous items medications in resident rooms. In an interview on 5/3/21 at 1:45 p.m. the DON revealed on 4/28/21 half of the facility's full-time nursing staff was scheduled off and did not receive training on not leaving hazardous items/ liquids or medications in residents' rooms and the facility made no effort to communicate the training to the staff who were off or to schedule a meeting because they were to be trained upon their return to work. Further interview revealed the training included nursing staff, administrative staff, therapy staff, and dietary staff. The facility had no documented evidence of the housekeeping or laundry staff being fully trained on not leaving hazardous liquids or medications in residents' rooms, even though those departments entered Resident rooms to complete assigned duties. The DON revealed he had not provided training to staff specific to checking rooms for hazardous liquids or medication and removing it if found. The DON stated the administrative staff and supervisors were to inspect all residents' rooms to ensure there were no hazardous materials daily. The DON stated if it had a label with keep out of reach of children, or the staff were unsure they were instructed to remove the item to the charge nurse. In an interview on 5/4/21 at 11:20 a.m. the Administrator revealed she was made aware on 4/28/21 that Resident #1 was found to have an opened bottle of Dakin's Solution (diluted bleach) at her bedside with a straw in it and admitted ly drank 3 sips. The Administrator stated she oversaw the actions by the facility in response to Resident #1's incident by reviewing the documentation of room inspections for any concerns for medications/ hazardous items being left out in resident rooms, and she and the DON started staff education regarding not leaving hazardous items in resident rooms on 4/28/21, the training was given to the nursing staff and the management staff who were in the facility, and planned to train all other staff once they returned to work their regular schedule. She stated she spoke to staff about the severity of hazardous chemicals and medications being left in resident rooms during meetings with staff. The Administrator said the situation was severe because not only was Resident #1 at risk for harm, but any other resident who might come across hazardous items in their room and mistakenly swallow them. The Administrator revealed it was very important the facility addressed and corrected the actions which led to the incident with Resident #1 because it could cause resident harm if it was not corrected. Further interview revealed the facility had not trained staff on the medication bedside storage or the medication administration policies. In an interview on 5/4/21 at 12:05 p.m. the DON revealed he was made aware on 4/28/21 Resident #1 was found to have an opened bottle of Dakin's solution (diluted bleach) at her bedside with a straw in it and admitted ly drank 3 sips. He revealed he assigned the daily room rounds to staff to check for any hazardous liquids in resident rooms, he revealed from 4/28/21 to 4/30/21 the rooms rounds focused on hazardous chemicals and wound care related supplies, but not medications in resident rooms, so he thought Resident #2's family could have brought in the medication and the staff were unaware, but they had been unable confirm it with Resident #2's family. The DON revealed several departments entered resident rooms through the day including housekeeping, laundry, maintenance, nursing, therapy, activities, and social services. The DON revealed he had not inserviced the staff on hazardous materials not being left in resident rooms before 4/28/21 because it was the first time the incident happened, and there was no specific facility training on securing medications and hazardous items. 2. Record review of Resident #2's face sheet dated 5/3/21 revealed an admitted [DATE] and diagnoses which included adult failure to thrive (severe weight loss, poor nutrition, physical inactivity) heart failure, kidney disease, and difficulty swallowing. Record review of Resident #2's BIMS assessment dated [DATE] revealed Resident #2 had a score of 6 (severely impaired cognition). Record review of Resident #2's MDS dated [DATE] revealed he had severely impaired cognitive status. An observation on 4/30/21 at 11:40 a.m. in Resident #2's room revealed 2 prescription medications on the countertop to the left of Resident #2's bed. Both medications had printed labels with Resident #2's first and last names on them. One medication label read [MEDICATION(S)] spray (Flonase) 50 micrograms per spray (Lot # RT7975/ Expiration 8/2023), the instructions were one spray in each nostril twice per day, the fill date was 4/4/21,the bottle was 15 milliliters, and was about 3/4 of the way full. The second medication label read [MEDICATION(S)] 2 percent ointment (in a 22-gram tube), the instructions were to apply in the nose twice daily, the fill date was 4/12/21, and the tube was opened, but almost full. An observation on 4/30/21 at 11:50 a.m. revealed Resident #2 was in his wheelchair about 2-3 feet from the countertop with prescription medications observed on it. In an interview on 4/30/21 at 11:55 p.m. PTA C revealed he was assigned to provide therapy to Resident #2. PTA C stated Resident #2 was able to wheel himself in his wheelchair about 5 feet by himself before he needed a break. In an interview on 4/30/21 at 11:57 a.m. Resident #2 was unaware of any prescription medications being in his room and stated he did not know what the medications were for. In an interview on 4/30/21 at 12:00 p.m. the Treatment Nurse confirmed 2 prescription medications of [MEDICATION(S)] spray and [MEDICATION(S)] ointment were in Resident #2's room on the countertop to the left of Resident #2's bed. The Treatment Nurse revealed the expectation was medications were not be left in a resident's room in the open because medications had to be locked in a secured place. The Treatment Nurse revealed he was not the Charge Nurse for Resident #2 and did not recall medications being in Resident #2's room for room sweeps. In an interview on 4/30/21 at 12:05 p.m. LVN D revealed she was the day shift nurse for Resident #2. LVN D revealed did not know Resident #2 had any medications in his room and did not notice them on her morning rounds, but stated the expectation was the admitting nurse checked the Resident's belongings for any medications upon admission because medications needed to be locked in a secured place. LVN D revealed she was unable to tell who admitted Resident #2 by looking in the electronic record due to staff names being coded. LVN D stated Resident #2 had no orders for the 2 prescription medications found in his room. After looking at the medications, LVN D confirmed they had Resident #2's name on them and the label was not from the facility's pharmacy, and she had not administered the medications. LVN D revealed she had not recently been trained on not leaving medications at the bedside. In an interview on 4/30/21 at 12:30 p.m. the DON revealed LVN D had not been trained on ensuring there were no hazardous items or medications in Residents' rooms yet because she was part of the new rotation of nurses and was off on 4/28/21 when the training was started. In an interview on 4/30/21 at 2:25 p.m. LVN D confirmed she was the nurse who admitted Resident #2 to the facility, but she could not remember if the medications were with his personal belongings on his admitted . LVN D stated we have so many admissions, I do not remember. In an interview on 5/3/21 at 10:20 a.m. the DON revealed Resident #2 had a communication deficit and a BIMS score of 6 and the Resident had no medication self- administration assessments because of his impaired mental cognition. In an interview on 5/3/21 at 1:45 p.m. the DON revealed on 4/28/21 half of the facility's full-time nursing staff was scheduled off and did not receive training on not leaving hazardous items/ liquids or medications in residents' rooms and the facility had not tried to communicate the training to the staff who were off or to schedule a meeting because they were to be trained upon their return to work. Further interview revealed the training included nursing staff, administrative staff, therapy staff, and dietary staff. The facility had no documented evidence of the housekeeping or laundry staff being fully trained on not leaving hazardous liquids or medications in residents' rooms, even though those departments entered Resident rooms to complete assigned duties. The DON denied having any staff training specific to checking rooms for hazardous liquids or medication and removing it if found. The DON stated the administrative staff and supervisors were to round on all residents' rooms to ensure there were no hazardous materials daily, and documented results on a resident roster sheet. In an interview on 5/4/21 at 12:05 p.m. the DON revealed he reviewed checklists of resident rooms inspected for medications for room inspections completed from 4/28/21 to 4/30/21 but could not explain why medications were found in Resident #2's room on 4/30/21. Further interview revealed it was extremely important to identify and correct the action which led to Resident #1's incident to ensure she and other residents were not at risks for exposure to potentially hazardous items at their bedside or having their safety put in danger. In an interview on 5/6/21 at 4:35 p.m. the Administrator stated Resident #1 drinking Dakin's Solution was concerning to the facility because hazardous items being left in resident rooms could cause harm leading to death. The Administrator revealed the first actions in response to Resident #1's incident included checking all resident rooms for any medications/ hazardous items and removed them, but there was no validation or follow up in place, so the management team had not confirmed the rooms were checked, they took staff member's word for checked rooms, which possibly led to Administration not knowing Resident #2 had prescription medications in his room. The administrator revealed if the room checks were properly done, she would have been aware of Resident #2's incident. Record review of the facility's resident rooms inspection checklist to ensure there were no medications or hazardous items left in resident's rooms dated 4/28/21, 4/29/21, and 4/30/21 revealed Resident's #1 and #2 had their rooms checked and no hazardous items were found in their rooms. Resident #2 had his room checked by the Treatment Nurse and the DON. Record review of Resident #2's doctor's orders current as of 4/30/21 revealed no orders for [MEDICATION(S)] spray (Flonase) 50 micrograms per spray one spray in each nostril twice per day, or [MEDICATION(S)] 2 percent ointment apply in the nose twice daily. Record review of the facility's medications brought in by resident's policy dated 10/1/19 revealed medications brought in from outside the facility could only be used if there was a written doctor's order. Record review of the facility's medication administration policy dated 10/1/19 revealed no medications should be left on the medication cart or counters and staff should keep mentally impaired residents in mind. Record review on 5/10/21 of the United States Food and Drug Administration information on [MEDICATION(S)] ointment dated March 2017 at website: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/ 1s034lbl.pdf revealed it was for use in the nose only and could cause severe allergic reactions, headache, respiratory problems, cough, and itching. Further review revealed the medicine should be kept out of reach of children. Record review 5/10/21 of the United States Food and Drug Administration information on [MEDICATION(S)] dated January 2019 at website: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/ 1s045lbl.pdf revealed adverse reactions which included headache, nose bleeds, burning inside the nose, cough, nausea and vomiting, and serious allergic reaction. Further review revealed the medicine should be kept out of reach of children. Due to the above failures the facility Administrator was notified an IJ had been identified on 5/3/21 at 5:43 p.m. The facility's POR was accepted on 5/5/21 at 2:47 p.m. and included: Plan of Removal for Immediate Jeopardy (quoted as written in Administrator's format and wording). The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the above issue: - Patient (Resident) #1 was re-interviewed and reassessed by ADON RN on 5/3/21. Patient continues to show no adverse effects of the alleged ingestion and denies any complications or concerns. - Patient #1 was re-interviewed by a Licensed Master Social Worker on 5/3/21 and is not exhibiting any signs of psychosocial distress or concern over the alleged incident. Patient will continue to be interviewed by the facility Social Worker weekly or as needed to validate patient is not exhibiting or expressing any negative psychosocial effects from the alleged incident. - Patient #2 was interviewed and assessed by ADON RN on 5/3/21. Patient denied using the medications at bedside and did not recall the medications being in the room. - An ad hoc (as needed) QAPI meeting was held on 5/3/21 with the Administrator, Director of Nurses, Assistant Director of Rehabilitation, Medical Director, Assistant Director of Nurses - All patient rooms have been inspected to ensure no medications are in rooms on 5/3/21. Rooms were inspected by Care Management Nurse, Treatment Nurse, Clinical Supervisor LVN, RN ADON, MSN DON, Administrator. Sweeps tracked on daily roster. No medications were identified in patient rooms during the room inspections. - Patient resident representatives have been contacted and educated on not bringing outside medications into patient rooms and all medications must be turned into the Charge Nurse. Admission packet section on page 29 is implemented regarding personal medications. Guardian Angels will call new admission patient representatives upon admission and provide education to patient representative. Guardian Angel will educate new patients on personal medications at bedside. - Education for employees was completed on 5/3/21 and 5/4/21 on medication and hazardous chemicals in patient rooms by the Director of Nursing and Assistant Director of Nursing and/ or designee. - Department heads will conduct daily rounds and observations in patient rooms for medications or hazardous chemicals at bedside. If medications are identified they will be removed immediately and given to the Charge Nurse. In order to validate compliance of department head rounding and inspections, the Administrator and or Director of Nursing will do random observations of 5 patient rooms daily for 4 weeks. Then weekly for 2 weeks and the findings of these rounds will be taken to QA for further review for the next 3 months. Surveyor Verification of Plan of Removal was as follows: - In an interview at 4:15 p.m. Resident #1 she remembered drinking the solution and denied any discomfort. Interviews with the Administrator and Director of Nursing (DON) on 5/4/21 at 5:00 p.m. confirmed Resident #1 had a focused assessment and interview completed in response to her swallowing a hazardous chemical. Observation of Resident #1 on 5/4/21 at 4:15 p.m. revealed no concerns for adverse outcomes or signs of discomfort. Her room was clean and in good repair with no hazardous items or medications observed. Record review of Resident #1's progress note dated 5/3/21 revealed she had a focused assessment completed by one of the facility's Assistant Directors of Nursing related to the ingestion of Dakin's Solution (diluted bleach mix) on 4/28/21. The assessment was negative for adverse effects to Resident #1s lungs, stomach, no documented nausea or vomiting, and vital signs were within normal limits for the Resident. Observations of Resident #1 on 5/4/21 revealed no concerns for adverse outcomes, and interview at the same time revealed Resident #1 remembered drinking the solution and denied any discomfort. - An interview with the SW on 5/5/21 at 10:23 a.m. confirmed he had interviewed Resident #1 regarding her swallowing the Dakin's Solution on 4/28/21. Review of Resident #1's progress note dated 5/3/21 revealed she was interviewed by one of the facility's SW and recalled drinking the solution but had no feelings of fear, anxiety, or depression related to the incident or care received from staff. - Interviews with the Administrator and Director of Nursing (DON) on 5/4/21 at 5:00 p.m. confirmed Resident #2 had a focused assessment and interview completed to about the prescription medications left in his room on 4/30/21. Observations of Resident #2 on 5/5/21 at 12:10 p.m. revealed no concerns for adverse outcomes, and interview at the same time revealed Resident #2 could not remember any prescription medications in his room and denied any pain or discomfort. His room was neat and clean with no hazardous items or medications observed. Record review of Resident #2's progress note dated 5/3/21 revealed he had a focused assessment completed by one the facility's Assistant Directors of Nursing related to the medications left in his room on 4/30/21. Resident #2's assessment was negative for any adverse outcomes. An interview during the focused assessment revealed he denied pain or nausea and was not aware any medications were left in his room. - Interviews with the Administrator and DON on 5/4/21at 5:00 p.m. confirmed the facility had a Quality Assurance and Process Improvement meeting in response to the Immediate Jeopardy on 5/3/21 which included the Medical Director, the Administrator, DON, and ADON RN and provided a copy for the investigator. This meeting was in response to Resident #1 ingesting Dakin's Solution and prescription medications being found un-secured in Resident #2's room. The Administrator revealed meeting reviewed facility actions including providing education to all employees to observe for medications or potentially hazardous items at the bedside. The DON was to delegate resident room rounds for compliance and report results to QAPI. On-going monitoring is expected to monitor compliance, and a copy of the QAPI was provided. The staff listed were able to verify the content and plan moving forward. An interview with the MD on 5/3/21 at 2:45 p.m. confirmed he was in attendance of the QAPI meetings on 5/3/21 and informed of the Immediate Jeopardy concern in the facility and agreed with the facility's plan to address resident safety as it related to potentially hazardous items at the bedside. - Interviews with the Administrator on 5/4/21 at 5:00 p.m. and random management staff (Director of Therapy, Housekeeping Supervisor, Activity Director, SW) on 5/5/21 from 10:00 a.m. to 11: 15 a.m. confirmed the facility staff had been rounding frequently to inspect rooms for any potentially hazardous items. Observations of random resident rooms and care areas from 5/4/21 to 5/5/21 revealed no concerns for medications or other potentially hazardous items in rooms or care areas. Interviews with alert Residents (#3, #4, #5, #6, and #7) on 5/5/21 from 12:50 p.m. to 1:15 p.m. confirmed staff had been into their rooms frequently and explained no medications were allowed in the room and had been checking for any potentially dangerous items in their rooms. Record review of daily resident rosters dated 5/3/21 to 5/5/21 showed all rooms were inspected for medications/ hazardous chemicals and no concerns were identified. - Interviews with the Administrator and DON on 5/4/21 at 5:00 p.m. confirmed the facility placed calls to Resident Representatives on 5/3/21 and 5/4/21 and provided education regarding medications and potentially hazardous items in resident rooms and stated the assigned Guardian Angel staff members were educated and expected to inform assigned residents and representatives of rules on medications and other potentially hazardous items being left in resident rooms. Phone calls were placed to a random sample of 7 Resident Representatives on 5/4/21 from 1:50 p.m. to 3:30 p.m. to verify phone calls were made regarding not bringing outside medications into Resident rooms and checking any medications in with the nurse. Interviews revealed Resident Representatives were contacted, educated, and understood the material which was presented by the facility on 5/3/21 and 5/4/21. Resident Representatives demonstrated knowledge of not bringing any medications into the Residents' rooms and if they had any medications they were checked in with the nurse on duty. Record review of the facility's inservice sheets dated 5/3/21 revealed the facility either spoke to or left messages for all Resident Representatives regarding not dropping medications off in resident rooms, types of medications, and checking in with the charge nurse. Record review of the facility's [TRUNCATED]