Every finding on record at Sherwood Manor Nursing Home

Based on observation, record review, interview, facility document and policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure: 1. Staff donned the appropriate personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions (EBP) for 1 (Resident #63) of 3 residents reviewed for tube feedings, 2. Staff sanitized the multiuse glucometer between residents for 2 (Resident #2 and Resident #11) of 4 residents observed during medication administration, and 3. To conduct fit testing for N-95 masks which had the potential to affect all residents who resided at the facility. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions, copyrighted 2001, revealed, 2. Enhanced barrier precautions apply when: b. A resident is NOT known to be infected or colonized with any MDRO [multi-drug resistant organism)], has a wound, or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained. The policy revealed, 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. The policy revealed, 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: c providing hygiene or grooming. An admission Record revealed the facility readmitted Resident #63 on 02/06/2026. According to the admission Record, the resident had a medical history that included diagnoses of Rett's syndrome and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2026, revealed Resident #63 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS also revealed the resident received 51% or more of their nutritional intake via a feeding tube. Resident #63's Care Plan Report, included a focus area initiated 03/24/2026, that indicated the resident required total assistance for activities of daily living (ADLs), and the resident needed staff to anticipate their needs due to lack of speech. Resident #63's Order Summary Report revealed no orders for enhanced barrier precautions; however, the report included orders for the resident to receive Isosource 1.5 calories at 40 milliliters per hour via a feeding tube. An observation on 07/06/2026 at 10:29 AM revealed Licensed Practical Nurse (LPN) #1 entered Resident #63's room to provide nail care without donning a gown. LPN #1 donned gloves. During the observation, Resident #63 was observed to have feces covering their left hand and attempt to place their hand in their hair. During an interview on 07/07/2026 at 11:25 AM, LPN #1 stated she had entered Resident #63's room to complete nail care for the resident on 07/06/2026. LPN #1 verified Resident #63 was on EBP, and she should have donned a gown and gloves to provide nail care. During an interview on 07/09/2026 at 8:38 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist (IP), stated LPN #1 should have donned a gown and gloves to provide nail care to Resident #63 because the resident was on EBP and nail care was a part of personal hygiene. During an interview on 07/09/2026 at 10:02 AM, the Director of Nursing (DON) stated she expected LPN #1 to wear a gown while providing nail care to Resident #63, who was on EBP. During an interview on 07/09/2026 at 10:30 AM, the Administrator (ADM) stated she expected staff to wear a gown and gloves when providing care to residents on EBP. 2. A facility policy titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, revised 09/2022, revealed, 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. [exempli gratia, for example], stethoscopes, durable medical equipment). An undated facility document titled, Blood Sampling-Capillary (Finger Stick), revealed a section titled, Steps in the Procedure, which specified, 3. Clean glucometer with [Environmental Protection Agency] EPA approved wipe (refer to container dry time) Place glucometer on clean field. Further review revealed, 9. Clean glucometer with approved EPA wipe replace in cart. An admission Record revealed the facility admitted Resident #2 on 06/05/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with diabetic neuropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident was diabetic and received seven days of insulin during the assessment's lookback period. An admission Record revealed the facility admitted Resident #11 on 01/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. A quarterly MDS, with an ARD of 04/21/2026, revealed Resident #11 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS also indicated the resident was diabetic and received seven days of insulin during the assessment's lookback period. An observation on 07/08/2026 at 6:49 AM revealed Licensed Practical Nurse (LPN) #1 obtained a blood glucose reading from Resident #2 using a multi-use glucometer. LPN #1 was not observed to disinfect the glucometer before or after use. LPN #1 was observed placing an alcohol wipe on the glucometer but did not wipe the glucometer with it. She donned clean gloves and used an alcohol wipe from the top of the glucometer to clean the resident's finger. An observation on 07/08/2026 at 7:04 AM revealed LPN #1 obtained a blood glucose reading from Resident #11 using a multi-use glucometer. LPN #1 was not observed to disinfect the glucometer before or after use. LPN #1 was observed placing an alcohol wipe on the glucometer but did not wipe the glucometer with it and used that alcohol wipe to cleanse the resident's finger. During an interview on 07/08/2026 at 8:02 AM, LPN #1 stated she performed glucose checks for Resident #2 and Resident #11. She stated she had been educated to disinfect the multi-use glucometer between each resident using sanitizing wipes; however, she did not disinfect the glucometer between residents on the morning of 07/08/2026 because she thought that laying an alcohol wipe on the glucometer, that she would use to clean the resident's finger, would be sufficient to disinfect the machine. LPN #1 stated she had ample supply of sanitizing wipes available in the bottom drawer of her medication cart. During an interview on 07/08/2026 at 9:45 AM, the Director of Nursing (DON) stated she was made aware that LPN #1 had not disinfected the glucometer between resident use, and LPN #1 had received education to disinfect the glucometer between resident use with sanitizing wipes. She stated that the use of an alcohol wipe was not acceptable to use to disinfect the glucometer between resident use. The DON verified that the glucometer was used on twelve residents in the facility. During an interview on 07/09/2026 at 8:38 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist (IP), stated glucometers should be disinfected between each resident use with a sanitizing wipe. During a follow-up interview on 07/09/2026 at 10:02 AM, the DON stated she expected the glucometers to be disinfected with a sanitizing wipe and allowed to dry before and after each resident use. 3. A CDC document titled, National Institute for Occupational Safety and Health (NIOSH) Personal Protective Equipment, dated 02/03/2025, indicated, Before using a tight-fitting respirator in the workplace, The Occupational Safety and Health Administration (OSHA) requires users to pass a fit test to confirm proper fit and a tight seal against the user's face. Further review revealed, OSHA requires an annual fit test to confirm the fit of any respirator that forms a tight seal to your face before you use it in the workplace. During an interview on 07/08/2026 at 3:30 PM, the Director of Nursing (DON) stated she was trained to complete employee fit testing in 2023; however, she was unaware the CDC Guidelines recommended annual fit testing employees post the initial COVID-19 (coronavirus disease 2019) outbreak and had not completed any N-95 fit testing since she completed her training. During an interview on 07/09/2026 at 8:38 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist (IP), stated she had been trained to complete employee N-95 fit testing years ago but had not completed any employee fit testing since 2022 or 2023. During an interview on 07/09/2026 at 10:02 AM, the Director of Nursing (DON) stated the facility had not had a policy in place for N-95 fit testing. During an interview on 07/09/2026 at 10:30 AM, the Administrator stated she expected N-95 fit testing to be completed on hire and annually.

Based on interview, record review, and CMS (Centers for Medicare and Medicaid) guidelines, the facility failed to ensure current Minimum Data Set (MDS) assessments were accurately coded for 3 (Residents #1, #9, and #29) of 16 sampled residents reviewed for accurate assessments. Specifically, Resident #1 and Resident #29 were incorrectly coded for insulin instead of injections, and Resident #9 was incorrectly coded for antipsychotics and anticonvulsants in the Medications sections of the MDSs. Findings included: The CMS Long-Term Care Facility [LTC] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2025, revealed Section N: Medications - Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. The LTC RAI 3.0 User's Manual also indicated, N0350: Insulin, Coding Instructions for N0350A, and Enter in item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. The LTC RAI 3.0 User's Manual also indicated, N0415: High-Risk Drug Classes and Coding Instructions - Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. - Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). - Column 2: If Column 1 is checked, check if there is an indication noted for all medications in the drug class. N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days), and N0415K1. Anticonvulsant: Check if an anticonvulsant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 1. An admission Record revealed the facility admitted Resident #1 on 01/06/2026. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2026, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. In section N0350 the MDS indicated Resident #1 received one day of insulin during the last seven days. Resident #1's Care Plan included a focus area, initiated 01/07/2026, that indicated the resident was on a regular mechanical soft diet and on medication for weight control. Interventions directed staff to administer Mounjaro (a dual GIP, glucose-dependent insulinotropic polypeptide, and glucagon-like peptide-1, GLP-1, receptor agonist, medication to promote weight loss) as ordered by the physician. Resident #1's Order Summary Report, with active orders as of 07/08/2026, contained an order, dated 04/16/2026, for Mounjaro Subcutaneous Solution Auto-Injector 10 milligrams (mg)/0.5 milliliters (ml), 10 mg injected subcutaneously one time a day, every Thursday, for weight control. Resident #1's Order Summary Report did not contain an order for insulin. During an interview on 07/09/2026 at 8:37 AM, the Minimum Data Set Coordinator (MDS Coordinator) stated it was their process to complete the MDS and review it for accuracy. The MDS coordinator stated they referred to the resident's order summary to know what injections the resident was on. The MDS coordinator stated they had reviewed Resident #1's medications, and Mounjaro was not an insulin. The MDS Coordinator stated it was their expectation for Mounjaro to be coded as an injection and not as an insulin. During an interview on 07/09/2026 at 10:02 AM, The Director of Nursing (DON) stated it was their expectation for the MDS coordinator to go to each department and gather information on each resident for the MDS sections to be coded correctly. The DON stated it was their expectation for staff to verify the medications Resident #1 was on to code correctly in section N of the MDS. During an interview on 07/09/2026 at 10:02 AM, the Administrator (ADM) stated it was their expectation for the MDS coordinator to go to each department and gather information on each resident for the MDS sections to be coded correctly. The ADM stated it was their expectation for staff to verify the medications Resident #1 was on and to code section N correctly. 2. An admission Record revealed the facility admitted Resident #9 on 01/17/2025. According to the admission Record, the resident had a medical history that included a diagnosis of Parkinson's disease with dyskinesia with fluctuations. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Section N0415 of Resident #9's MDS indicated the resident was taking an antipsychotic and the resident was not taking an anticonvulsant. Resident #9's Care Plan included a focus area, initiated 10/28/2025, that indicated the resident was on anti-convulsant/seizure medication for depression management. Interventions directed staff to administer medication as ordered and to refer to physician orders for current details (initiated 10/28/2025). Resident #9's Order Summary Report, with active orders as of 07/07/2026, included an order, for divalproex sodium (an anticonvulsant) extended release (ER) 500 mg (milligrams), one tablet by mouth at bedtime for depression, dated 03/05/2026. Resident #9's Order Summary Report did not contain an order for an antipsychotic. During an interview on 07/09/2026 at 8:37 AM, the Minimum Data Set Coordinator (MDS Coordinator) stated Resident #9 was not taking an antipsychotic and that section of the MDS was not coded correctly. The MDS coordinator stated it was their expectation for the medications to be coded correctly and reflect what the resident was taking. During an interview on 07/09/2026 at 10:02 AM, the Director of Nursing (DON) stated it was their expectation for the MDS coordinator to go to each department and gather information on each resident for the MDS sections to be coded correctly. The DON stated they were not sure if Resident #9 was on an antipsychotic or an anticonvulsant, but they would expect staff to review the resident's medications and code them by the correct class. The DON stated MDS accuracy was important not only for care, but it was how the facility would be paid. During an interview on 07/09/2026 at 10:02 AM, the Administrator (ADM) stated it was their expectation for the MDS coordinator to review the resident's medications and code them by their correct drug class. 3. An admission Record revealed the facility admitted Resident #29 on 05/29/2020. According to the admission Record, the resident had a medical history that included type 2 diabetes mellitus without complications. An annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/2026, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. In section N0350 the MDS indicated Resident #29 received one day of insulin during the last seven days. Resident #29's Order Summary Report, dated 07/07/2026, did not include an active order for insulin. Resident #29's Order Summary Report included an order for Ozempic (a GLP-1, glucagon-like peptide-1, medication to help lower blood sugar levels). Resident #29's order indicated Ozempic subcutaneous solution pen-injector 2 mg/mL (milligram/milliliter), 1 mg injected subcutaneously one time a day, every Friday, related to type 2 diabetes mellitus without complications, started 03/06/2026. During an interview on 07/07/2026 at 2:48 PM, the Minimum Data Set Coordinator (MDS Coordinator) stated she had been coding Ozempic as insulin if the resident's order indicated the use was for diabetes. The MDS Coordinator stated she knew Ozempic was a GLP-1 medication but thought it was used to treat diabetes and could be counted on the MDS assessment as insulin. The MDS Coordinator stated she should not have coded Resident #29's Ozempic as insulin on the MDS. During an interview on 07/09/2026 at 10:02 AM, the Director of Nursing (DON) stated she expected MDS assessments to be complete and accurate. During an interview on 07/09/2026 at 10:30 AM, the Administrator (ADM) stated she expected the MDS assessments to be completed accurately.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a wheelchair was maintained in safe operating condition for 1 (Resident #33) of 2 residents reviewed for environment. Findings included: A facility policy titled, Homelike Environment, revised 2021, indicated, Residents are provided with a safe, clean, and Home like environment. An admission Record indicated the facility admitted Resident #33 on 04/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominate side and muscle weakness. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident used a wheelchair for mobility daily during the assessment's seven-day lookback period. Resident #33's Care Plan Report, included a focus area initiated 04/09/2024, that indicated the resident was a fall risk related to a neuro-cognitive disorder, gait/balance instability, impulsiveness, and poor safety awareness. During an observation on 07/06/2026 at 11:33 AM, Resident #33 was observed in their wheelchair. The wheelchair did not have an armrest on the right side of the wheelchair; it was bare metal. The armrest on the left side of the wheelchair had the plastic part peeling off. A facility document titled, Maintenance Work Log, for the timeframe from 04/26/2026 through 07/07/2026 revealed there was no report of Resident #33's wheelchair needing repairs, missing parts, or needing maintenance. On 07/07/2026 at 1:50 PM, Certified Nursing Assistant (CNA) #11 stated that staff put maintenance concerns in the maintenance book. She stated she would notify a nurse and the Director of Nursing (DON) if there was a maintenance concern with a resident's wheelchair. During a concurrent observation, CNA #11 observed the resident's wheelchair while the resident was sitting in therapy. She stated the wheelchair had a missing arm piece on the right side of the wheelchair. She stated the left side was also peeling. She stated the wheelchair condition was something that should be reported to maintenance. She reviewed the maintenance log and stated there had not been a report made about Resident #33's wheelchair. On 07/07/2026 at 1:55 PM, the Maintenance Supervisor stated staff told him about issues as he was going down the hall, or the staff reported it in the maintenance book. He stated if a resident did not have an arm rest or it was torn, it should be replaced. He stated he had not had anything reported to him about Resident #33's wheelchair. He reviewed the maintenance log and stated there was nothing reported related to Resident #33's wheelchair in May or June (2026). He stated he did not know the arm rests were broken and peeling. He stated he would have expected staff to inform him of the broken chair, and he would have fixed it. On 07/07/2026 at 2:06 PM, Licensed Practical Nurse (LPN) #6 stated that when resident equipment was broken, there was a maintenance logbook in which staff wrote down the issue to notify maintenance to fix. She stated she had never seen Resident #33 in their wheelchair. She stated she had not noticed the resident's wheelchair was missing an arm rest. She stated that if the resident's wheelchair were missing an arm rest, the staff should notify her so she could report the issue to maintenance. On 07/08/2026 at 8:19 AM, the DON stated the staff should report broken equipment in the maintenance log. She stated the staff had a stand-up meeting daily, and they all discussed what was in the book for the maintenance staff to repair. She stated she would expect staff to identify the broken wheelchair and report the broken wheelchair to maintenance staff for repair. On 07/08/2026 at 12:54 PM, the Administrator stated she expected staff to report immediately if there was broken resident equipment. She stated it should be put in the maintenance log so maintenance could fix it. She stated that during their morning meetings the staff talked about chairs and if they were torn or damaged.

Based on interview, record review, facility document review, and facility policy review, the facility failed to provide an accurate Advance Beneficiary Notice of Non-Coverage (ABN), which included the services that may not be covered and the estimated cost of those services for 2 (Resident #18 and Resident #34) of 3 residents reviewed for beneficiary notification. Findings included: A facility policy titled, Medicare Advance Beneficiary Notice, dated 04/2021, indicated, 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 1. An admission Record indicated the facility admitted Resident #18 on 06/18/2018. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, acute and chronic respiratory failure, and adult failure to thrive. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2026, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. A facility document titled, [Name of facility] Census List, dated 07/07/2026, indicated the facility readmitted Resident #18 from the hospital on [DATE]. The census list further indicated that Resident #18 had a payer source change on 05/09/2026. A Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) indicated, The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. The notice was signed by Resident #18 on 03/24/2026. The notice revealed the reason Medicare may not pay was due to the resident Refusing to Participate, not making progress. The notice did not indicate what care was to be provided or the estimated cost of the care. A Notice of Medicare Non-Coverage indicated Resident #18's Medicare Part A services ended on 05/09/2026. 2. An admission Record indicated the facility admitted Resident #34 on 09/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic atrial fibrillation, congestive heart failure, and chronic obstructive pulmonary disease. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2026, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A facility document titled, [Name of facility] Census List, dated 07/07/2026, indicated the facility readmitted Resident #34 from the hospital on [DATE]. The census list indicated Resident #34 had a payer source change on 01/19/2026. A Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) indicated, The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. The notice was signed by Resident #34 on 01/05/2026. The notice revealed the reason Medicare may not pay was due to the resident Refusing to Participate, not making progress. The notice indicated the care that may not be paid for was Medicare. The notice did not indicate the estimated cost of the care. The notice revealed Resident #34 had checked option one, indicating they wanted the care listed above. A Notice of Medicare Non-Coverage indicated Resident #34's Medicare Part A services ended on 01/19/2026. During an interview on 07/07/2026 at 10:54 AM, the Social Services (SS) Coordinator stated that when a new resident was admitted to the facility on Medicare Part A services, the ABN form was included in the admission paperwork for them to sign. The SS Coordinator further stated that if a current facility resident was readmitted from the hospital with Medicare Part A, she would have the resident sign an ABN form when the resident returned from the hospital. During an interview on 07/08/2026 at 12:44 PM, the SS Coordinator stated that the ABN form had to be signed anytime a resident was on skilled Medicare services. The SS Coordinator stated the purpose of the ABN form was to give the facility permission to bill Medicare. The SS Coordinator stated the service being provided was skilled services and the estimated cost was left blank because she had no way of knowing what the estimated cost for the services would be. The SS Coordinator confirmed that Resident #18 had checked the option that they wanted to receive the services, but that it was just difficult to see it on the copy. The SS Coordinator stated she always had residents sign option one because that gave the facility permission to bill Medicare; otherwise, the resident would be indicating they did not want the facility to bill Medicare. She stated there was a meeting with the therapy department every Tuesday to discuss what residents were getting ready to be discharged from therapy, and that was when they would provide the resident with the Notice of Medicare Non-Coverage form. During an interview on 07/09/2026 at 9:50 AM with the Director of Nursing (DON) and the Administrator (ADM), the DON stated she was not involved with the ABNs. The ADM stated that the facility always started discharge planning upon admission and worked with their residents to ensure they received the length of therapy that was needed. The ADM stated they would be reviewing the process for providing ABNs to residents.

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was provided with privacy while receiving incontinence care for 1 (Resident #63) of 3 residents sampled for feeding tubes. Findings included: An admission Record revealed the facility readmitted Resident #63 on 02/06/2026. According to the admission Record, the resident had a medical history that included diagnoses of Rett's syndrome and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2026, revealed Resident #63 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS also revealed the resident was non-verbal and was rarely/never understood and rarely/never understood others. Resident #63's Care Plan Report, included a focus area initiated 03/24/2026, that indicated the resident required total assistance for activities of daily living (ADLs), and the resident needed staff to anticipate their needs due to lack of speech. During an observation and concurrent interview on 07/06/2026 at 10:32 AM, Certified Nursing Assistant (CNA) #2 responded to a request for assistance by Licensed Practical Nurse (LPN) #1, who exited Resident #63's room when CNA #2 entered. During the observation, Resident #63 had a bowel movement. CNA #2 assembled supplies and donned a gown and gloves to clean the resident. CNA #2 provided incontinence care and placed a clean brief on the resident. During the observation, CNA #2 was not observed to pull the privacy curtain or shut the room door to provide privacy during the care, which was visible to staff, residents, or visitors who may pass the doorway. During an interview on 07/09/2026 at 8:38 AM, the Assistant Director of Nursing (ADON) stated that LPN #1 should have stayed in the room to assist CNA #2 with Resident #63's incontinence care on 07/06/2026. The ADON stated Resident #63's door should have been shut, the curtain pulled, and the blinds shut by LPN #1 or CNA #2 while the care was provided. The ADON stated that Resident #63 did not receive a dignified experience when incontinence care was provided without privacy. During an interview on 07/09/2026 at 10:02 AM, the Director of Nursing (DON) stated she expected Resident #63's blinds to be closed, the curtain pulled, and the door shut while providing incontinence care in order for the resident to receive care in a dignified manner. During an interview on 07/09/2026 at 10:30 AM, the Administrator (ADM) stated she expected staff to provide incontinence care to Resident #63 in a dignified manner by ensuring the resident's privacy was maintained by pulling the curtain and closing the resident's door.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident received nutritional feeding via a percutaneous endoscopic gastrostomy (PEG) tube according to physician's orders for 1 (Resident #63) of 3 residents reviewed for tube feedings. Findings included: A facility policy titled, Enteral Nutrition, revised 11/2018, revealed, 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietician. An admission Record revealed the facility readmitted Resident #63 on 02/06/2026. According to the admission Record, the resident had a medical history that included diagnoses of Rett's syndrome and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2026, revealed Resident #63 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS also revealed the resident received 51% or more of their nutritional intake via a PEG tube. Resident #63's Care Plan Report, included a focus area initiated 11/02/2023, that indicated the resident had a PEG tube in place for hydration and nutrition needs related to Rett's syndrome and was at risk for complications related to having a PEG tube in place. Interventions directed staff to administer tube feedings as ordered by the physician and refer to physician orders for details (initiated 02/02/2023). Resident #63's Order Summary Report, dated 07/07/2026, revealed an order dated 10/28/2025 for Isosource 1.5 cal (calories) at 40 milliliters (mL) per hour via PEG tube. Further review revealed the order indicated that the resident's feeding may be off for up to four hours daily. Resident #63's Treatment Administration Record [TAR] for 07/2026 revealed staff documented that the resident's Isosource 1.5 was infusing at a rate of 40 mL per hour via PEG tube on 07/05/2026 and 07/06/2026. An observation on 07/06/2026 at 10:24 AM revealed Resident #63 was lying in bed with their tube feeding attached and running via a kangaroo infusion pump, which was located beside the resident's bed with a pillowcase draped over the intravenous (IV) pole. The nutritional supplement infusing was prelabeled as Nutren 1.5 and contained a handwritten date of 07/06/2026 at 12:12 AM and the initials of Licensed Practical Nurse (LPN) #4. During an observation and concurrent interview on 07/06/2026 at 10:32 AM, CNA #2 observed Resident #63's tube feeding and confirmed that the tube feeding was labeled Nutren 1.5. During an interview on 07/07/2026 at 11:25 AM, LPN #1 stated she worked with Resident #63, and although she provided PEG tube care and administered medication to the resident via the PEG tube, she did not verify the type of nutritional supplement that was infusing. LPN #1 stated she should have verified that the resident was receiving the ordered nutritional supplement via PEG tube. During an interview on 07/07/2026 at 11:42 AM, LPN #3 stated he worked on the night of 07/06/2026 and noticed Resident #63 had the incorrect nutritional supplemental feeding running between 10:00 PM and 11:00 PM. He stated that at the time he sent a text message to the Assistant Director of Nursing (ADON) to notify her and obtain directions. LPN #3 stated that when he did not receive a return call after midnight, he changed the resident's tube feeding formula to Isosource 1.5 as ordered. He stated he had been taught to check the tube feeding formula to the resident's physician's orders, but he did not notify the provider or the dietician for further directions at the time. He stated he also could not verify how much of the incorrect nutritional supplement had been infused via PEG tube but stated it was most of the bag because it was time for the tube feeding to be changed when he realized it. An attempt was made to contact LPN #4 on 07/07/2026 at 11:33 AM, 07/08/2026 at 9:18 AM, and 07/08/2026 at 6:45 PM and were unsuccessful. During an interview on 07/08/2026 at 10:28 AM, the Registered Dietician (RD) stated that she had minor concerns with Resident #63 receiving Nutren 1.5 instead of Isosource 1.5 due to the fiber content. She stated that although it was not a significant amount, the resident did not receive the same amount of fiber content that would have been provided with the ordered Isosource 1.5 feedings. During an interview on 07/09/2026 at 8:38 AM, the ADON stated each nurse on duty should have checked Resident #63's nutritional formula to verify the correct formula and rate were infusing and should have notified the Director of Nursing (DON) and the Medical Director (MD) immediately if it was incorrect. The ADON stated that the incorrect nutritional formula should have been stopped, and the correct nutritional formula should have been initiated. During an interview on 07/09/2026 at 10:02 AM, the DON stated that she expected nurses to compare the physician's order to the formula prior to initiation, and each nurse following the initiation of the nutritional formula should verify the correct formula was being infused. During an interview on 07/09/2026 at 10:30 AM, the Administrator stated she expected nurses to verify the correct nutritional formula that was infusing each shift. During an interview on 07/09/2026 at 10:45 AM, the MD stated he was made aware that Resident #63 received the incorrect nutritional formula via PEG tube. He stated although he expected nurses to verify residents were receiving the correct nutritional formula, he did not have any significant concern that Resident #63 received the incorrect nutritional formula as the only difference between the ordered formula and the infused formula was the fiber content.

Based on observation, interview, record review, facility policy review, and review of manufacturers' instructions, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 3 medication errors out of 31 opportunities affecting 2 (Resident #2 and Resident #11) of 4 residents reviewed during the medication administration task, resulting in a medication error rate of 9.68%. Findings included: A facility policy titled, Administering Medication, revised April 2019, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. Manufacturer's instructions titled, How to use your Lantus [device brand name of a prefilled disposable long-acting insulin injection pen] pen, dated 2022, indicated: Step 3: Perform A Safety Test - Dial a test dose of 2 Units.- Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle.- Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.- If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. An admission Record revealed the facility admitted Resident #2 on 06/05/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/17/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. The MDS indicated the resident was diabetic and received seven days of insulin during the last seven days. Resident #2's Order Summary Report, with active orders as of 07/07/2026, revealed an order for Lantus (device brand name) Subcutaneous Solution Pen-Injector 100 units/milliliter (mL) 10 units injected subcutaneously one time a day related to type 2 diabetes mellitus with diabetic neuropathy, started 01/14/2026.An observation on 07/08/2026 at 6:49 AM revealed Licensed Practical Nurse (LPN) #1 administered 10 units of Lantus insulin to Resident #2. During the observation, LPN #1 was not observed to perform the safety test of priming the insulin pen. During an interview on 07/08/2026 at 8:55 AM, the Pharmacist stated insulin pens should be primed with 2 units of insulin before each administration to remove the air and ensure the resident did not miss 1 to 2 units of insulin. During an interview on 07/08/2026 at 9:28 AM, LPN #1 stated she had no knowledge of how to prime an insulin pen and did not understand the importance of completing that step. During an interview on 07/08/2026 at 9:45 AM, the Director of Nursing (DON) stated she expected LPN #1 to prime the insulin pen prior to administering each dose of insulin. 2. Manufacturer's instructions titled, How to use your Lantus [device brand name of a prefilled disposable long-acting insulin injection pen] pen, dated 2022, indicated: Step 3: Perform A Safety Test - Dial a test dose of 2 Units.- Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle.- Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.- If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Manufacturer's instructions titled, How to use your NovoLog [device name of a prefilled disposable fast-acting insulin injection pen], revised 02/2023, indicated: Step 2: Do an air shot (Prime the needle)1. Dial 2 units.2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle.3. Press the push button on your syringe as far as it will go until a drop of insulin appears. An admission Record revealed the facility admitted Resident #11 on 01/25/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus without complications. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was diabetic and received seven days of insulin during the last seven days. Resident #11's Order Summary Report, with active orders as of 07/07/2026, revealed an order for Lantus (device name) Subcutaneous Solution Pen-Injector 100 units/milliliter (mL), 120 units injected subcutaneously in the morning for diabetes, hold if finger stick blood sugar is less than 150 mg/dL (milligrams per deciliter), started 04/10/2026 and Novolog Injection Solution 10 units injected subcutaneously three times a day related to type 2 diabetes mellitus without complications, with meals, give with sliding scale, and hold for glucose 110 mg/dL and below, started 03/23/2026. An observation on 07/08/2026 at 7:04 AM revealed Licensed Practical Nurse (LPN) #1 administered 120 units of Lantus insulin and 10 units of Novolog insulin to Resident #11. During the observation, LPN #1 was not observed to perform the safety test of priming the insulin pens before administration. During an interview on 07/08/2026 at 8:55 AM, the Pharmacist stated insulin pens should be primed with 2 units of insulin before each administration to remove the air and ensure the resident did not miss 1 to 2 units of insulin. During an interview on 07/08/2026 at 9:28 AM, LPN #1 stated she had no knowledge of how to prime an insulin pen and did not understand the importance of completing that step. During an interview on 07/08/2026 at 9:45 AM, the Director of Nursing (DON) stated she expected LPN #1 to prime the insulin pen prior to administering each dose of insulin.

On 04/01/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #1 from verbal and physical abuse. During breakfast pass on 03/22/25, CNA #1 was involved in a verbal and physical altercation with Resident #1. CNA #1 was in the hallway passing drinks and Resident #1 was also in the hallway. CNA #1 was witnessed to yell, threaten and throw a glass of milk and a 2/3 full gallon of milk at Resident #1. The altercation was witnessed by CMA #1 and LPN #1 who unsuccessfully attempted to intervene and de-escalate the situation. On 04/01/25 at 5:29 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 04/01/25 at 5:49 p.m., the administrator and DON were notified of the immediate jeopardy situation and provided the IJ template. On 04/03/25 at 9:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal, read in part, IJ Plan of Removal [NAME] Manor Nursing Home Submitted by: [name withheld], Administrator Re-submitted 4/2/2025 with corrections 4/1/25 - 5:49pm - IJ received from OSDH LTC Enforcement 4/1/25 - 10:15pm DON, ADON & Administrator contacted all staff via text to in-service & educate regarding procedure when a resident is involved in a verbal and/or physical altercation (to include staff, residents & visitors) Procedure when a resident is involved in a verbal/physical abuse situation 'If there is a situation where there is a potential for verbal or physical abuse with a resident, please remove the resident to a safe place away from the altercation. Our residents must remain free from abuse and neglect, and it is our responsibility and obligation to follow that policy and procedure. If you ever witness or hear of abuse or neglect you are to report to your supervisor immediately. It is the supervisor's responsibility to report to administration immediately'. 4/2/25 - 3:37pm Resident safe surveys completed Total = 64 complete / 4 unable to communicate Current Census = 68 4/2/25 4 Residents unable to communicate: full skin assessments done -[Resident #9]-time completed 5:11pm -[Resident #8]-time completed 5:01pm -[Resident #11]-time completed 4:58pm -[Resident #12]-time completed 5:01pm 4/2/25 - 5:13pm Plan of Removal completed -Employee CNA #1 was separated from resident #1 immediately, wrote [their] statement. [They] was interviewed by police and then escorted out of the building by ADON and was terminated by DON. -All staff have abuse training on hire. -All staff will be educated regarding abuse and dealing with behaviors at minimum semi-annually and as needed. -Nursing Administration and/or Administrator will continue abuse training at every scheduled in-service for 90 days, and more often as needed. QAPI will review monthly x 90 days to ensure compliance. The IJ was lifted, effective 04/03/25 at 11:51 a.m., when all components of the plan of removal had been verified as completed. Thirteen staff members in all departments from all shifts were interviewed regarding abuse as indicated in the plan of removal. Documentation for safe surveys and skin assessments of residents were reviewed. The deficient practice remained at an isolated level with potential for more than minimal harm. Based on record review and interview, the facility failed to ensure residents were free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 76 residents resided in the facility. Findings: 1. Resident #1 was admitted with diagnoses which included unspecified dementia and schizoaffective disorder, bipolar type. An abuse and neglect policy, revised April 2021, read in part, Abuse of any kind against residents is strictly prohibited. A final incident report to the Oklahoma State Department of Health, dated 03/26/25, showed CNA #1 and Resident #1 had a verbal and physical disagreement. The report showed CNA #1 threw a glass of milk and a gallon jug of milk at Resident #1. The report showed Resident #1 was noted to have a scratch on their forehead. The report showed CNA #1 was immediately escorted out of the building and Resident #1 was sent to a hospital for evaluation. On 03/31/25 at 4:28 p.m., the administrator showed this surveyor a facility closed circuit video, dated 03/22/25, of the West/South hall of the facility. The video of the incident occurred from 8:52 a.m. to 8:55 a.m. The video showed CNA #1 pouring drinks and taking them into rooms and Resident #1 was walking in the hall. The video showed CNA #1 and Resident #1 talking next to a drink cart at the end of the hall. The video showed CNA #1 waved their hands and arms around wildly, pointing at Resident #1, stepping towards the resident, and shaking a finger in Resident #1's face. The video showed LPN #1 and CMA #1 were observed to enter the frame of the video and LPN #1 stood next to Resident #1 and CMA #1 stood next to CNA #1. The video showed CMA #1 and LPN #1 appeared to talk to both Resident #1 and CNA #1 and CNA #1 continued to make wild arm and hand gestures and did not back away from Resident #1. The video showed CNA #1 continued to point and shake a finger at Resident #1's face and gesture wildly. The video showed CNA #1 was observed to pick up a glass of milk and throw it at Resident #1. The video showed CMA #1 reached across CNA #1's chest and CNA #1 pushed CMA #1 away. The video showed CNA #1 then picked up a jug of milk from the cart and threw it at the resident. The video showed CNA #1 was observed to slip, fall to their knees, and when CNA #1 stood they were observed to swing at the resident. On 03/31/25 at 3:55 p.m., LPN #1 stated they witnessed CNA #1 and Resident #1 in a heated argument. LPN #1 stated they saw CNA #1 throw a cup of milk and a 90% full gallon jug of milk at Resident #1. LPN #1 stated they and CMA #1 tried to get CNA #1 to walk away, but instead were shoved away by CNA #1. LPN #1 stated they called the DON and another staff member called the police. LPN #1 stated they observed Resident #1 with an abrasion on their forehead after the incident. On 04/01/25 at 1:29 p.m., the DON stated in response to the incident, CNA #1 was escorted out of the facility and Resident #1 was sent to the hospital for evaluation. The DON stated they did not provide education on abuse afterwards. On 04/01/25 at 2:07 p.m., the administrator stated they did not come to the facility the day of the incident, but did watch the video surveillance of the incident when they returned to the facility. The administrator stated they did discuss providing abuse education to the staff. The administrator stated they discussed the incident at their morning staff meeting and with the facility's physician. On 04/01/25 at 3:29 p.m., CMA #1 stated they witnessed CNA #1 and Resident #1 in an argument. CMA #1 stated they and LPN #1 tried to de-escalate the situation, but CNA #1 was yelling at Resident #1 and was not backing out of the argument. CMA #1 stated they and LPN #1 were trying to stop the argument. CMA #1 stated LPN #1 was trying to keep Resident #1 safe and they were trying to get CNA #1 to walk away. CMA #1 stated CNA #1 was yelling, threw a glass of milk at Resident #1, then picked up a gallon jug of milk, and threw it at Resident #1. CMA #1 stated after CNA #1 walked away they observed Resident #1 with an abrasion on their forehead. CMA #1 stated the nose piece to Resident #1's glasses was stuck in the hair on their forehead and their glasses were on the floor across the room. CMA #1 stated CNA #1 was still very angry and they assisted Resident #1 to a safe area and stayed with the resident.

On 04/01/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure antipsychotic medications were available and residents were provided ordered medications for a serious mental illness. Resident #1 was admitted on [DATE] and had diagnoses which included schizoaffective disorder, bipolar type. The resident was ordered risperidone (an antipsychotic medication) 3mg twice daily and Seroquel (an antipsychotic medication) 25mg every evening. The resident did not receive 12 consecutive doses of risperidone, from the p.m. dose on 03/13/25 through the a.m. dose on 03/19/25. The first dose of risperidone was not administered until 03/19/25 for the p.m. dose. The resident did not receive five consecutive doses of Seroquel from 03/13/25 through 03/17/25. The first dose of Seroquel was not administered until 03/18/25. The physician was not made aware the medications were unavailable and not administered. Per interview with the DON the facility did not have a protocol in place to ensure medications were received and available for administration. Resident #1 was sent to the emergency roiagnom on [DATE] when they had threatened the nurse, had received olanzapine (an antipsychotic medication) 5mg intramuscularly (IM) while in the emergency room , and was readmitted to the facility. On 03/22/25, the resident was involved in a verbal and physical altercation with CNA #1. The resident was sent to the emergency room , was admitted for in-patient psychiatric treatment, and the resident would not return to the facility. On 04/01/25 at 5:47 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/01/25 at 5:49 p.m., the administrator and the DON were notified of the IJ situation and provided the IJ template. On 04/03/25 at 12:04 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, .4/1/25 - 5:49pm- IJ received from OSDH LTC Enforcement 4/1/25 - 6:30 pm List of residents on psychiatric medications was created and audit completed to ensure that all residents on psychiatric medications are receiving as ordered and meds [medications] are in the building 4/1/25 - 7:38pm -DON, ADON & Administrator contacted all nurses and CMA's (in person, via text and email) to in-service & educate regarding procedure when a resident medication is not available. - (See In-service procedure below) PROCEDURE WHEN PATIENT ORDERED MEDICATION IS NOT AVAILABLE/OUT 1. Certified Medication Aide must notify the nurse if a medication is not in building 2. Med Aide must document in EMAR [electronic medication administration record] progress note that they notified the nurse and document the name of the nurse. 3. The nurse needs to contact the pharmacy as to why medication is not available. 4. The nurse must then notify the Physician/Medical Director of the reason the medication is not available (ex [example]: to see if he wants to hold med or change med) 5. The nurse must write order per Doctor directive 6. The DON and/or designee must be notified if medication is not in the building. 7. The DON and/or designee will monitor daily that residents with psychiatric medication orders have their medications as ordered. **If it is a pre-auth [authorization] situation, the nurse will tell pharmacy to send 3-5-day supply at cost to the facility. Pharmacy will contact DON or Administrator for financial approval. **Any medication that is put on hold or waiting on pharmacy, the Nurse must notify the Physician/Medical Director, and an order must be written. DON must be notified by nurse as well. 4/1/25 - 10:08pm - Plan of Removal Completed Received last email to confirm all Nurse and CMA education done. Other staff working or came in to sign personally. (Total of 20) 4/3/25 - 10:15am Started inservice to speak to all nurses and cma's in person & over the phone to ensure proper understanding of the policy stated above. 4/3/25 12:00pm Plan of Removal completed Education and In-services will be on going per DON & Administrator The DON, and/or designee will check on [electronic health record name withheld] within 24 hours of a new admission to ensure that all medication to include psychiatric medications have been received. DON and/or designee will audit psychiatric medications daily to ensure that medications are in the building and if not, follow the above procedure. QAPI Committee will review monthly x 3 months to ensure compliance. The IJ was lifted, effective 04/03/25 at 11:51 a.m., when all components of the plan of removal had been verified as completed. Four CMAs, four charge nurses who work all shifts, and the DON were interviewed regarding the medication protocol to ensure availability and administration as indicated in the plan of removal. Documentation of medication audits and inservices were reviewed. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure antipsychotic medications were available and a resident was provided ordered medications for a serious mental illness to maintain their highest practicable level of mental well-being for 1 (#1) of 3 sampled residents whose medications were reviewed. The DON identified 11 residents who were ordered antipsychotic medications and 11 residents who were diagnosed with a serious mental illness. Findings: Resident #1 was admitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar type. A policy titled, Preparation and General Guidelines, dated April 2018, read in part, If 3 consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. A policy titled, Behavioral Assessment, Intervention, and Monitoring, dated March 2019, read in part, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. A physician's order, dated 03/13/25, showed the resident was ordered risperdone 3mg po twice daily for schizoaffective disorder, bipolar type. A physician's order, dated 03/13/25, showed the resident was ordered Seroquel 25mg po after the evening meal for schizoaffective disorder, bipolar type. A Medication Administration Note, dated 03/13/25 at 10:20 p.m., read in part, waiting on pharmacy. The note was documented twice for the same date and time with no specific medication documented. A history and physical, dated 03/14/25, read in parts, With schizoaffective disorder.Quetiapine [Seroquel].Risperidone. A Medication Administration Note, dated 03/14/25 at 8:09 p.m., read in part, waiting on pharmacy. A Medication Administration Note, dated 03/14/25 at 8:10 p.m., read in part, waiting on pharmacy. A Medication Administration Note, dated 03/15/25 at 10:52 a.m., read in part, risperiDONE Oral Tablet 3 MG Give 1 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .On Order A Medication Administration Note, dated 03/15/25 at 9:20 p.m., read in part, risperiDONE Oral Tablet 3 MG Give 1 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .On Order A Medication Administration Note, dated 03/15/25 at 9:20 p.m., read in part, QUEtiapine Fumarate [Seroquel] Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to UNSPECIFIED DEMENTIA, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY .On Order A Medication Administration Note, dated 03/16/25 at 10:50 a.m., read in part, risperiDONE Oral Tablet 3 MG Give 1 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .On Order A Medication Administration Note, dated 03/16/25 at 8:51 p.m., read in part, QUEtiapine Fumarate [Seroquel] Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to UNSPECIFIED DEMENTIA, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY .On Order A Medication Administration Note, dated 03/16/25 at 8:52 p.m., read in part, risperiDONE Oral Tablet 3 MG Give 1 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .On Order A Medication Administration Note, dated 03/18/25 at 11:48 a.m., showed the risperidone was on hold until 03/19/25. The reason for the hold, read in part, awaiting medication from pharmacy. A Medication Administration Note, dated 03/18/25 at 7:22 p.m., read in part, waiting on pharmacy. The specific medication was not indicated in the note. A care plan, dated 03/18/25, read in part, .ANTI-PSYCHOTIC MEDICATION: I am at risk for adverse reactions, labile moods, and falls related to anti-psychotic medication I receive R/T [related to] Schizophrenia .Administer anti-psychotic medication per current orders. Refer to physician orders for details .I am exhibiting behaviors of using a razor to my nose .Administer behavior medications per current orders .Alert my charge nurse of unusual or ongoing behavioral or mood issues .Redirect as needed. A packing slip from the pharmacy, dated 03/18/25 at 11:00 p.m., showed the pharmacy had delivered seven tablets of Seroquel 25mg and 60 tablets of risperidone 3mg for Resident #1. A physician progress note, dated 03/20/25, read in part, Acute problem addressed: Patient is delusional and hallucinatory. [Resident #1] says this is better than usual. [Resident #1] has been to inpatient psychiatry multiple times. [Resident #1] has no hallucinations that tell [them] to hurt people or hurt others .Plan: I will get psychiatry to see the patient sooner rather than later. [Resident #1] is somewhat delusional and having hallucinations but this is [their] baseline. [Resident #1] actually may be better than usual. [Resident #1] does not seem to be agitated or to the point where [they are] having hallucinations that are telling [them] to harm people or harm [themselves]. A nurse note, dated 03/20/25 at 2:48 p.m., showed the nurse had noted the resident had a scratch to their nose. The note showed the resident had stated they were a doctor and had used a disposable razor to shave something off of their nose. The note showed a message was sent to the resident's guardian for approval for psychiatric services. A behavior note, dated 03/20/25 at 8:08 p.m., showed Resident #1 was sitting in the middle of the hallway rolling tobacco in paper. The note showed when the nurse asked the resident to not sit in the middle of the hallway the resident stated they were a fourth degree black belt and threatened the nurse. The note showed the resident's guardian, DON, and physician had been notified. An emergency department provider note, dated 03/20/25, showed Resident #1 presented with agitation and had made threats toward staff. The emergency department provider note showed the resident was administered olanzapine 5mg intramuscularly due to agitation on 03/20/25 at 8:57 p.m. and would be discharged back to the facility. A behavior note, dated 03/21/25 at 5:49 p.m., read in part, Resident pacing up and down the halls requesting the 'warden' and to also have [their] blood drawn. Educated resident about needing an order from the doctor before getting labs. Resident is asking for [their] wheel chair stating 'I walk over 20 miles a day I need my wheel chair' also went on to say things to me 'I need to speak to the charge nurse' When informed that I am the charge nurse, resident would respond 'Youre [sic] hard to look at'. Resident has found a wheel chair and now rolling around the facility. Will continue to monitor and redirect resident. A behavior note, dated 03/21/25 at 5:55 p.m., showed the resident was observed by the nurse to eat in the dining room and then as they walked to their room they notified the aides they had not received a tray for dinner. A behavior note, dated 03/21/25 at 9:10 p.m., read in part, Resident has been pacing up and down the halls all shift, brushing [their] beard with [their] tooth brush, saying 'Im [sic] God, Im [sic] a Doctor, thank you Jesus, praying and speaking in a forgein [sic] language' Resident has come to the nurses desk asking for seroquel stating 'I cannot sleep without it and I will be up all night if the doctor wont give me seroquel' Doctor notified. A behavior note, dated 03/21/25 at 9:32 p.m., read in part, Resident going in and out room [ROOM NUMBER] turning the tv off and on. A behavior note, dated 03/22/25 at 8:40 a.m., read in part, Resident told [CNA #1] 'Dont [sic] touch my food you probably have aides [sic]'. An incident noted, dated 03/22/25 at 9:02 a.m., showed Resident #1 had been involved in a verbal and physical altercation with CNA #1. The note showed following the altercation the resident was taken to the emergency room for evaluation. A social services note, dated 03/28/25, showed the resident was receiving in-patient psychiatric treatment and would not return to the facility upon discharge. Review of the March 2025 medication administration record showed Resident #1 had not received Seroquel 25mg, ordered every evening, from 03/13/25 through 03/17/25. The medication administration record showed Resident #1 had received their first dose of Seroquel 25mg on 03/18/25 for the p.m. dose. The medication administration record showed Resident #1 had not received risperidone 3mg twice daily from the p.m. dose on 03/13/25 through the a.m. dose on 03/19/25. The medication administration records showed the p.m. dose on 03/18/25 and the a.m. dose on 03/19/25 of risperidone 3mg was held. The medication administration record showed Resident #1 had received their first dose of risperidone 3mg on 03/19/25 for the p.m. dose. On 04/01/25 at 10:46 a.m., CMA #2 stated if medications were not available for administration they notified the charge nurse and the pharmacy. They stated Resident #1 had requested their Seroquel several times but they did not think they had an order for Seroquel. CMA #1 stated they remembered having issues getting the risperidone from the pharmacy and not having it available to administer. They stated they thought they had notified the charge nurse but had not documented the notification. CMA #2 stated Resident #1 exhibited behaviors almost every day during their admission. On 04/01/25 at 11:02 a.m., LPN #2 stated they called the pharmacy if the CMA notified them a medication was not available for administration. They stated they did not remember orders for risperidone or Seroquel for Resident #1. They stated Resident #1 had requested 200mg of Seroquel, the physician was notified and stated they would review the resident's medications. LPN #2 stated on 03/20/25, Resident #1 was aggressive, threatened them, paced in the hallways, talked to themselves, verbalized delusions, and had been sent to the emergency room for a psychiatric evaluation. LPN #2 stated they were not aware Resident #1's Seroquel and risperidone had not been available for administration. On 04/01/25 at 11:47 a.m., the DON stated they were not sure what information they had regarding medication deliveries from the pharmacy for Resident #1. They stated once medications were delivered, everything was completed in the electronic clinical record, but they would look for delivery information. On 04/01/25 at 1:30 p.m., the DON stated they had not been made aware the risperidone and Seroquel had not been available for Resident #1. They stated they thought it was probably because the medications required a prior authorization, but they had a call in to the pharmacy for further information. On 04/01/25 at 1:42 p.m., the DON stated the only behavior they had observed for Resident #1 was pacing in the hallways. The DON stated on admission, on 03/13/25, the resident was observed to be calm, polite, and paced the hallways at times. They stated by 03/20/25 Resident #1 had threatened the nurse, was verbalizing delusions, and was sent to the emergency room for a psychiatric evaluation. The DON stated they did not know why the risperidone had been documented as on hold on 03/18/25 and 03/19/25. They stated when residents were admitted to the facility they relied on the CMAs and charge nurses to notify them if medications were not available but they had not been notified the risperidone and Seroquel were not available for Resident #1. The DON stated they reviewed the medication administration records once a month, reviewed the electronic health record to ensure newly admitted resident had physician orders, but did not review to ensure the ordered medications were available for administration. On 04/01/25 at 2:23 p.m., the administrator stated they had just noticed the risperidone and Seroquel were not available for administration for Resident #1. They stated the DON and physician should have been made aware the medications were not available for administration. The administrator stated Resident #1 had not initially exhibited behaviors, but a few days after admission they had noticed Resident #1 had began talking a little erratically. They stated at that time they had reviewed the physician orders and noted the resident was ordered antipsychotic medications but was unaware the medications were not being administered because they were unavailable. The administrator stated as days had passed they grew more concerned about Resident #1's mental health status and their vulnerable resident population. The administrator stated Resident #1 should have received their medications as ordered. The administrator stated This was avoidable. I wish myself or the team would have noticed the meds were not available. On 04/01/25 at 2:45 p.m., the consultant pharmacist stated the potential effects of Resident #1 not receiving 12 consecutive doses of risperidone would be worsening symptoms of the condition the medication was ordered to treat. They stated not receiving the dose of risperidone Resident #1 had been ordered increased the risk of symptoms returning. The consultant pharmacist stated they had informed the facility in the past to call the pharmacy if medications were not available for administration. On 04/01/25 at 2:53 p.m., physician #1 stated they had not provided the order to place risperidone on hold on 03/18/25 and 03/19/25. They stated they had not been notified the ordered risperidone and Seroquel had not been available or administered for Resident #1. They stated the potential effects of Resident #1 not receiving 12 consecutive doses of risperidone and five consecutive doses of Seroquel would be an increase in psychosis. On 04/01/25 at 3:57 p.m., the DON stated they had verified with the pharmacy that a prior authorization was needed for the risperidone and Seroquel for Resident #1.

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for 1 (#1) of 3 sampled residents who were reviewed for labs. The DON identified 71 residents who had orders for labs. Findings: Resident #1 had diagnoses which included schizoaffective disorder, bipolar type. A physician order, dated 03/13/25 showed the resident was ordered lithium (mood stabilizer medication) 300mg twice daily. A physician progress note, dated 03/14/25, showed an order for admission labs which included a lithium level. Review of the labs for Resident #1 and the order summary report for the resident's stay, dated 03/13/25 through 03/22/25, did not show obtaining a lithium level had been requested from the lab company or completed. On 04/03/25 at 4:24 p.m., LPN #3 stated they had not seen an option to obtain a lithium level in the lab portal. On 04/03/25 at 4:52 p.m., the DON stated they did not know why the lithium level had not been entered into the lab portal. They stated they had asked LPN #1 why they had not ordered the lithium level and they stated they thought it would be included in the CBC (complete blood count). The DON stated they conducted random audits to ensure labs were obtained as ordered by the physician. They stated the last audit they had conducted was on 01/30/25. The DON stated, We have a problem with labs.

On 09/26/24, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility failing to assess, monitor, and intervene for a resident at risk for pressure ulcer. Resident #1 was admitted on [DATE]. The admission skin assessment documented no skin concerns to the coccyx area. Resident #1 was totally dependent on staff, placing them at increased risk of PU/PI development. The residents record documented a physician's order for weekly skin assessments. No concerns to the coccyx was documented in these assessments. On 09/19/24 the resident's family member noted a foul odor in the room. The resident's brief was removed revealing a wound over the coccyx measuring 11cm x 13cm. The necrotic bed measured 3.5cm x 5cm and 2cm at the deepest point. The physician was notified on 09/24/24 at which time the physician ordered calcium alginate and Medihoney to the wound bed daily. On 09/24/24 the resident was transferred to the hospital per family request. On 09/26/24 at 6:00 p.m., the OSDH was notified and verified the existence of the IJ situation. On 09/26/24 at 6:33 p.m., the administrator and DON were notified of the IJ situation. On 09/26/24 at 10:07 p.m., an acceptable plan of removal was provided. The plan of removal documented: At 7:29 p.m., the DON and ADON contacted all nurses via telephone to inform them of the IJ and told them the proper procedure for identifying, assessing, monitoring, and preventing skin breakdown. 1. The nurse identifies or gets report of a skin integrity concern will immediately assess the resident, report the findings to the Medical Director and the Director of Nursing. 2. Once orders are received from the physician, the nurse will immediately call the family or responsible party to inform them of the situation and if there is a new order/treatment. No treatments or medications are to be done without a physician's order. 3. The nurse will then implement a treatment order(s) on the residents' medical record (PCC) as directed. to include cleansing, dressings, interventions such as low air loss mattress if applicable, for the identified resident. The nurse will also document and describe the following: full assessment of pressure sore to include location, stage, length, width and depth, presence of exudates or necrotic tissue. 4. Any other interventions will be initiated per facility policy and resident need. 8:05 p.m. - DON and ADON initiated facility skin sweep 8:49 p.m. - all nurses were emailed the above information and protocol 9:20 p.m. - facility skin sweep complete. On 09/27/24 at 9:00 a.m., interviews were conducted with facility staff. Staff had knowledge of the plan or removal. After the facility conducted skin assessments on all residents, the DON stated no further skin issues were found. On 09/27/24 at 3:30 p.m., the administrator was informed the immediacy had been lifted. The IJ was lifted, effective 09/27/24 at 2:47 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of potential for more than minimal harm. Based on observation, record review and interview, the facility failed to assess, monitor, and intervene for a resident at risk for pressure ulcers. The DON identified two residents with pressure wounds. Findings: An undated document titled Pressure ulcers/Skin Breakdown - Clinical Protocol., read in part ., The nursing staff and attending physician will assess and document an individuals significant risk factors for developing pressure sores . Resident #1 was admitted to the facility on [DATE] with diagnoses which includes Parkinson's disease. A care plan, dated 08/26/24, documented to monitor for skin integrity issues during all activities of daily living . A nurse's note, dated 09/21/24, documented the wound measurements as 11cm x 13cm. The necrotic bed measured 3.5cm x 5cm and 2cm at the deepest point. A nurse's note, dated 09/24/24, documented the wound measurement as 10.1cm x 10cm x2cm with the necrotic area measuring 3.4cm x 6.0cm. On 09/26/24 at 4:14 p.m., the DON stated they received a call on 09/21/24 from LPN #1 regarding a wound on the coccyx area of Resident #1. They stated they thought the LPN had notified the physician, but they had not. The DON notified the physician on 09/24/24 and received orders to apply calcium alginate and Medihoney to the wound daily. The resident was transferred to the hospital per family request. On 09/27/24 at 12:38 p.m., LPN #1 stated a CNA notified them of the wound on 09/19/24. They thought they had notified the physician, but did not. They stated they did not notified the family.

Based on observation, record review, and interview, the facility failed to: a. ensure chemicals were secured for one (West hall) of three halls observed for storage of chemicals. LPN #1 identified three shower rooms and one nursing supply closet in the facility; b. failed to ensure residents were assessed for the use of bed rails for one (#33) of one sampled residents reviewed for bed rails. The DON identified 32 residents who utilized bed rails and; c. failed to ensure residents were safely smoking for one (#8) of one sampled residents who were reviewed for smoking. The DON identified 28 residents who smoked. Findings: The Safety Data Sheet, dated 11/20/14, read in parts, .Gel Hand Sanitizer .Keep out of reach of children . The Safety Data Sheet, dated 01/20/15, read in parts, .Aloe Vera Skin Cream .Keep out of reach of children . The Safety Data Sheet, dated 03/05/20, read in parts, .Xpress Detergent Disinfectant .Harmful if swallowed . The undated, Smoking policy, read in part, .A resident who has had a decline in status must be reassessed to ensure safety is maintained . The undated, Bed Safety and Bed Rails policy, read in part, .Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks . 1. On 09/03/24 at 9:28 a.m., the door to the [NAME] hall shower room was observed to be open. A sign on the door was observed to read Keep door closed. The open shower room was observed to contain the following: a. one-one quart bottle of Xpress detergent disinfectant approximately half full sitting on the edge of the whirlpool tub. The label documented to keep out of reach of children; b. one-7.5 ounce bottle of Derma daily moisturizing lotion with aloe vera in an unlocked cabinet. The label documented to keep out of reach of children; and c. one-two ounce bottle of Senegence hand sanitizer in an unlocked cabinet. The label documented to keep out of reach of children. On 09/03/24 at 9:48 a.m., CNA #1 walked by the open shower room door and closed it. On 09/03/24 at 11:31 a.m., the door to the [NAME] hall nursing supply closet was observed to not be secured/latched. The closet contained the following items: a. two bottles of wound cleanser. The label documented to keep out of reach of children; and b. two bottles of shaving cream. The label documented to keep out of reach of children. On 09/03/24 at 11:42 a.m., LPN #1 stated the nursing supply closet stored wound care supplies. They stated the door was supposed to be kept closed and it automatically locked. On 09/04/24 at 9:30 a.m., the [NAME] hall nursing supply closet was observed to not be secured/latched. The DON stated the door was supposed to be closed fully and locked. On 09/05/24 at 11:16 a.m., the DON stated the shower room door was to be kept closed and locked. 41809 2. Resident #8 had diagnoses which included diabetes type two and end stage renal disease. A smoking assessment, dated 08/02/24, documented Resident #8 was a safe smoker. A smoking assessment, dated 08/14/24, documented Resident #8 was safe to smoke on their own. A care plan focus, dated 08/15/24, documented Resident #8 was able to smoke in designated smoking areas unsupervised. On 09/05/24 at 12:06 p.m., LPN#1 was observed to approach Resident #8 on the front porch. Resident #8 was observed with their eyes closed and a cigarette hanging out of their mouth sitting on the front porch. LPN #1 was observed to touch the resident on their back and stated don't fall asleep with that cigarette in your mouth. The nurse then stated to the surveyor, that was scary as they walked back into the facility leaving the resident on the porch. On 09/05/24 at 12:10 p.m., Resident #8 was observed on the front porch smoking and awake with maintenance staff present. On 09/06/24 at 2:09 p.m., LPN #1 stated they did not believe there was an assessment for smoking, but if there were, social services would complete it. LPN #1 stated unsafe smoking would include the resident needing assistance with exiting the door, holding the smoking material, and the ability to stay awake while smoking. LPN #1 stated, Like [Resident #8] the other day. LPN #1 stated they did not inform anyone of the incident on 09/05/24 and did not document the incident. They stated the cigarette was not lit, but had been as ash had formed on the tip. LPN #1 stated they probably should have told someone. On 09/06/24 at 2:18 p.m., the social services director stated a smoking assessment was completed on admission, with a significant change, quarterly, and followed the care plan. They stated Resident #8 was safe to smoke unsupervised. The social services director stated staff should report if a resident drops their cigarette on their clothes, if they need assistance to light or put out the cigarette. They stated nothing had been reported about Resident #8 not smoking safely. After the social services director was informed of the incident on 09/05/24, they stated an intervention and re-assessment would need to be completed. On 09/06/24 at 2:26 p.m., the DON stated social services completed the smoking assessments and all staff were to monitor. They stated staff should report if a resident falls asleep while smoking and if they dropped ashes on their clothes. The DON stated no reports of Resident #8 smoking unsafely were brought to their attention. The DON was informed of the incident that occurred on 09/05/24. 46703 3. Resident #33 had diagnoses which included type two diabetes. On 09/03/24 at 8:57 a.m., Resident #33 was observed in bed with the bed rails in the up position. On 09/03/24 at 10:00 a.m., review of the clinical record did not [NAME] an order, consent or assessment for bed rails. On 09/06/24 at 9:15 a.m., LPN #2 stated the resident used the bed rails to reposition themselves. On 09/06/24 at 9:46 a.m., the administrator stated the resident did not have an informed consent for bedrails. On 09/06/24 at 3:18 p.m., the DON stated they usually did not use bedrails unless the resident requested them, they only performed an admission assessment, did not perform a bedrail assessment, obtain orders for bedrails, or obtain a consent form. The DON stated they need to start doing assessments and obtaining orders and consents for the use of bed rails.

Based on observation, record review, and interview, the facility failed to: a. ensure infection control was maintained during blood glucose monitoring/insulin administration for two (#123 and #8) of two sampled residents observed during blood glucose monitoring. The Roster Matrix identified 16 residents who received insulin; b. ensure infection control was maintained during medication administration for two (#126 and #15) of nine sampled residents observed during medication administration. The DON identified 73 residents who received medications in the facility; c. ensure enhanced barrier precautions were utilized during medication administration via enteral tube for one (#62) of one sampled residents observed during medication administration via enteral tube. The DON identified seven residents who had enteral tubes; d. ensure infection control was maintained during wound care for two (#4 and #15) of two sampled residents observed during wound care. The DON identified ten residents who had wounds in the facility; and e. ensure infection control was maintained for indwelling urinary catheters and during catheter care for one (#123) of one sampled residents who were reviewed for indwelling urinary catheters. The Roster Matrix identified seven residents who had indwelling urinary catheters. Findings: The Administering Medications policy, dated 2001, read in part, .Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable . The Catheter Care, Urinary policy, dated 2001, read in part, .Be sure the catheter tubing and drainage bag are kept off the floor . The Enhanced Barrier Precautions policy, dated August 2022, read in part, .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high contact resident care activities requiring the use of gown and gloves .include .device care . The undated glucometer manufacturer's booklet, read in parts, .should be cleaned and disinfected between each patient .the meter must be disinfected between patient uses by wiping it with a .EPA-registered disinfecting wipe in between tests . 1. Resident #123 had diagnoses which included diabetes mellitus. Resident #8 had diagnoses which included diabetes mellitus. On 09/05/24 at 11:35 a.m., LPN #1 was observed during blood glucose monitoring for Resident #123. LPN #1 was not observed to wear gloves while obtaining the blood glucose. The LPN placed the glucometer on top of the treatment cart, drew up insulin, walked down the hall to the resident's room, and was observed to administer the insulin without donning gloves. On 09/05/24 at 11:44 a.m., LPN #1 was observed to place the glucometer into the top drawer of the treatment cart. On 09/05/24 at 12:45 p.m., LPN #1 was observed to obtain the same glucometer from the top drawer of the treatment cart and without disinfecting the glucometer, obtain a blood glucose sample from Resident #8. On 09/05/24 at 12:48 p.m., LPN #1 stated they had not donned gloves during blood glucose monitoring and insulin administration for Resident #123 because they forgot. They stated they were supposed to disinfect the glucometer with an alcohol pad after each use. On 09/05/24 at 1:40 p.m., the DON stated they had sanitizing wipes they were to use to disinfect the glucometer. They stated the wipes had a two minute contact time and alcohol was not to be utilized to disinfect the glucometer. The DON stated gloves were to be utilized for blood glucose monitoring and insulin administration. 2. On 09/03/24 at 9:22 a.m., CMA #1 was observed to place their finger into the house stock bottle of Senna 8.6 mg, obtain a pill, and place it into the medication cup for Resident #15. CMA #1 was not observed to don gloves or sanitize their hands. On 09/05/24 at 3:11 p.m., CMA #2 was observed during medication administration. CMA #2 removed Carvedilol 12.5 mg from one medication cup and placed it into another medication cup with their bare hands for Resident #126. On 09/05/24 at 3:23 p.m., CMA #2 stated they should have donned gloves rather than handling the Carvedilol with their bare hands to maintain infection control. On 09/06/24 at 11:51 a.m., the DON stated staff were to utilize gloves when handling pills. They stated the staff should not touch the pills with their bare hands. 3. On 09/04/24 at 1:23 p.m., LPN #2 was observed during medication administration via enteral tube for Resident #62. LPN #2 was not observed to don a gown when administering the medications. Resident #62 requested assistance with toileting. LPN #2 donned a gown and gloves and assisted Resident #62. LPN #2 stated Resident #62 was on enhanced barrier precautions because they had an enteral tube. They stated they should have utilized a gown when administering medications via enteral tube but had forgotten. On 09/06/24 at 2:11 p.m., the infection preventionist stated nursing staff were to utilize PPE anytime they provided direct care to residents with indwelling urinary catheters, wounds, enteral tubes, or any time they may come into contact with bodily fluids. 4. Resident #4 had diagnoses which included non-pressure wound of the right third toe and non-pressure wound of the left second toe. On 09/05/24 at 11:46 a.m., LPN #1 was observed to don a gown and gloves and provide wound care to Resident #4. LPN #1 was observed to doff their gown and gloves, walk to the treatment cart, and gathered wound care supplies for Resident #15. LPN #1 was observed to don a gown and gloves, without sanitizing or washing their hands, and provided wound care to Resident #15. LPN #1 then doffed their gown and gloves and returned to the treatment cart, without sanitizing or washing their hands. On 09/06/24 at 9:37 a.m., LPN #1 stated they were to wash their hands before and after wound care. They stated they did not know why they had not sanitized or washed their hands when they provided wound care to Resident #4 and Resident #15. On 09/06/24 at 11:51 a.m., the DON stated nurses were to wash their hands before and after wound care treatments. 41809 5. Resident #123 had diagnoses which included urinary retention and acute kidney failure. On 09/04/24 at 1:41 p.m., Resident #123 was observed wheeling into their room, with the catheter bag hanging down under their chair, touching the floor. On 09/05/24 at 12:07 p.m., Resident #123 was observed to be pushed by CNA #1 down the hall with the tubing of the catheter dragging on the floor. On 09/06/24 at 12:12 p.m., LPN #1 was observed to perform catheter care for the suprapubic catheter of Resident #123. LPN #1 was observed to place a wax sheet of paper on their cart. The cart was not observed to be sanitized prior to placing the wax paper. LPN #1 was observed to place the PPE gown on the wheelchair of Resident #123 and then wash their hands in the restroom of Resident #123. During the catheter care, LPN #1 was not observed to wash or sanitize their hands between glove changes. On 09/06/24 at 2:35 p.m., LPN #1 stated hands should be washed before and after catheter care. They stated it made sense to wash their hands between glove changes but was not sure what the protocol was for washing their hands. LPN #1 stated the wax paper placed on surfaces was aseptic or sterile technique and if the surface used to place the wax paper was dirty, they would not place the wax paper on it. LPN #1 stated they did not clean to top of their cart every time they placed wax paper down for supplies. They stated the wax paper came from a package. On 09/06/24 at 2:47 p.m., the DON stated the protocol for changing gloves at anytime was to wash/sanitize their hands between glove changes when going from dirty to clean. The DON stated the protocol for surfaces used during treatments was to sanitize with disinfectant wipes then wait two minutes, even if using wax paper to place supplies on. On 09/06/24 at 4:00 p.m., the DON stated catheter tubing and bags should not touch the floor.

Based on observation, record review, and interview, the facility failed to ensure enteral formula was administered as ordered by the physician for one (#53) of one sampled residents who were reviewed for tube feeding. The DON identified seven residents who required enteral feeding. Findings: Resident #53 had diagnoses which included encounter for attention to gastrostomy. The Care Plan, dated 02/12/24, documented to administer enteral feeding as ordered and to refer the the current physician's orders for details. The Physician's Order, dated 07/02/24, documented Resident #53 was ordered Nutren 1.5 continuous at 60ml/hr. On 09/03/24 at 8:35 a.m., Nutren 1.5 at 50 ml/hr was observed infusing for Resident #53. On 09/04/24 at 10:01 a.m., Nutren 1.5 at 50 ml/hr was observed infusing for Resident #53. On 09/05/24 at 9:15 a.m., Nutren 1.5 at 50 ml/hr was observed infusing for Resident #53. On 09/05/24 at 11:01 a.m., LPN #1 observed the enteral feeding pump for Resident #53 and stated they were to receive Nutren 1.5 at 50 ml/hr. They reviewed the label on the bag of formula and stated they would need to review the orders because the label documented Nutren 1.5 at 60 ml/hr. LPN #1 reviewed the electronic clinical record and stated the resident was ordered Nutren 1.5 at 60 ml/hr. They stated they did not know why Resident #53 was receiving 50 ml/hr. On 09/05/24 at 11:09 a.m., the DON reviewed the electronic clinical record and stated Resident #53 was ordered Nutren 1.5 at 60 ml/hr. The DON stated the nurses on each shift were to verify the correct formula and rate were being administered. They stated they did not know why Resident #53 had been receiving 50 ml/hr rather than the ordered 60 ml/hr.

Based on record review and interview, the facility failed to ensure a care plan was reviewed for one (#21) of one sampled resident reviewed for care plans. The administrator identified 73 residents resided in the facility. Findings: Resident #21 was admitted on [DATE] with diagnoses which included pressure ulcer of the sacral region, stage four. On 09/05/24 at 1:00 p.m., Resident #21's clinical record was reviewed. There was no documentation of a wound or wound care. On 09/05/24 at 2:38 p.m., MDS coordinator #1 stated there was no documentation of wound care on Resident #21's care plan, dated 07/17/24. They thought they had added it but had not.

Based on observation, record review, and interview, the facility failed to assess and inspect bed rails to identify any risks of entrapment for one (#33) of one sampled resident reviewed for bedrails. The DON identified 32 residents who utilized bed rails. Findings: On 09/03/24 at 8:57 a.m., Resident #33 was observed lying in bed with the bed rails in the up position. On 09/06/24 at 9:15 a.m., LPN #2 stated the resident used the bed rails to reposition themselves in bed. They stated the bed rails were re-assessed every month and it was documented under the assessments tab in the electronic clinical record. LPN #2 reviewed Resident #33's electronic clinical record and stated the last assessment was completed on 01/29/24. On 09/06/24 at 2:03 p.m., maintenance worker #1 stated they installed the bedrails or removed them, depending on the order. They stated the CNA's or the nurses notified them if one was loose and they addressed it but they did not routinely check them. On 09/06/24 at 3:18 p.m., the DON stated they did not usually utilize bed rails unless a resident requested them.

Based on record review and interview, the facility failed to ensure pre and post dialysis assessments were conducted for one (#8) of one sampled residents who were reviewed for dialysis. The DON identified one resident who required dialysis. Findings: The End-Stage Renal Disease, Care of a Resident with policy, dated September 2010, read in part, .Resident with end-stage renal disease [ESRD] will be cared for according to currently recognized standards of care . Resident #8 had diagnoses which included end stage renal disease. A Physician's Order, dated 08/01/24, documented the resident was to receive dialysis weekly on Tuesday, Thursday, and Saturday. The Care Plan, dated 08/01/24, documented the resident required dialysis three times a week, staff were to monitor and report signs of infection, renal insufficiency, and monitor the shunt access site. The admission assessment, dated 08/14/24, documented the resident received dialysis. Review of the electronic clinical record did not reveal pre or post dialysis assessments had been completed for Resident #8. On 09/06/24 at 9:23 a.m., LPN #1 stated they did not perform pre and post dialysis assessments. They stated they monitored for bleeding, nausea, and asked how the resident was feeling but did not document. On 09/06/24 at 9:27 a.m., the DON stated they were to check on the resident after dialysis, obtain vital signs, and implement any new orders from the dialysis center. The DON stated the CMAs obtained vital signs if medications the resident was ordered required a blood pressure or a heart rate. They stated having residents who required dialysis was new to the facility and they were not aware pre and post dialysis assessments were required. On 09/06/24 at 9:32 a.m., the administrator stated they recently began admitting residents who required dialysis. They stated they would need to review the policy.

Based on record review and interview, the facility failed to ensure weights were obtained per the physician's order for one (#8) of three sampled residents who were reviewed for nutrition. The DON identified one resident who was ordered daily weights. Findings: The Weight Assessment and Intervention policy, dated March 2022, read in parts, .Residents are weighed upon admission and at intervals established by the interdisciplinary team .Weights are recorded in each unit's weight record chart and in the individual's medical record . Resident #8 had diagnoses which included end stage renal disease. A Physician's Order, dated 08/01/24, documented, starting 08/02/24 the staff were to obtain daily weights every day shift. Review of the electronic clinical record and the weight logs documented on paper, dated 08/02/24 through 09/05/24, revealed daily weights had been obtained 19 times out of 35 opportunities for Resident #8. The Care Plan, dated 08/15/24, documented the resident had cardiac issues and staff were to refer to the physician's order and obtain weights as ordered. On 09/06/24 at 12:23 p.m., LPN #1 stated the restorative aide was responsible to obtain daily weights. On 09/06/24 at 12:32 p.m., the DON stated the restorative aide obtained weights, documented on paper logs, and provided the information to the MDS coordinator to be entered into the electronic clinical record. The DON stated if the restorative aide was off work, the charge nurse was to obtain or assign a CNA to obtain the daily weights. On 09/06/24 at 12:53 p.m., the DON stated the MDS coordinator monitored to ensure weights were obtained as ordered by the physician. The DON stated they did not know why daily weights had not been obtained for Resident #8. On 09/06/24 at 12:55 p.m., the MDS coordinator stated they entered and monitored the weekly and monthly weights. They stated they did not enter or monitor the daily weights. They stated they felt there was confusion on if the charge nurse or the restorative aide was to obtain the daily weights.

Based on observation, record review, and interview, the facility failed to ensure treatments provided for non-pressure wounds had been ordered by the physician for one (#4) of two sampled residents who were reviewed for wound care. The DON identified five residents who had non-pressure wounds in the facility. Findings: The Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, dated 2021, read in part, .The physician will authorize pertinent orders related to wound treatments . Resident #4 had diagnoses which included non-pressure wound of the right third toe and non-pressure wound of the left second toe. The Care Plan, dated 08/07/24, documented the resident had wounds to their toes on their bilateral feet and to provide treatments per the current physician orders. The Wound Evaluation and Management Summary by the wound physician, dated 08/15/24, documented the resident had a non-pressure wound of the left third toe. The Wound Evaluation and Management Summary by the wound physician, dated 08/22/24, documented the resident had a non-pressure wound of the left third toe which had resolved. The Weekly Skin Condition Report, dated 08/23/24, read in part, .Has several places on toes on bilateral feet that are scabbed over. Applying Betadine daily . The report was completed by LPN #1. The Weekly Pressure Ulcer QI Logs, for August 2024, documented the resident had an unstageable area to the right great toe. The Weekly Skin Condition Report, dated 09/02/24, documented the resident did not have any skin breakdown. The report was completed by LPN #1. On 09/03/24 at 10:06 a.m., the resident was observed in the living room. The resident's white sock on the right foot was observed to have a pink-tinged area above the second and third toes. On 09/03/24 at 10:23 a.m., LPN #1 stated the discolored area on the sock was from the Betadine applied to the resident's toe. Review of the physician's orders dated 09/01/24 through 09/03/24 did not reveal any wound care orders. The Wound Evaluation and Management Summary by the wound physician, dated 09/05/24, documented the resident had a non-pressure wound of the left second toe and a non-pressure wound of the right third toe. On 09/05/24 at 11:46 a.m., LPN #1 stated the resident had a couple of new wounds on their toes and Betadine was being applied. LPN #1 stated they had been putting Betadine on the newly identified areas since they had discovered them around 08/26/24 through 08/28/24. LPN #1 stated they had not obtained orders or notified the wound physician they had been treating the new wounds with Betadine because they knew that is what the wound physician would order. On 09/05/24 at 1:52 p.m., LPN #1 stated when the staff identified a new wound they were to complete an initial assessment, document in the progress notes and on the wound log, notify the DON, and obtain orders from the physician. They stated they had not notified the wound physician about the new wound they had identified for Resident #4 because they were going to consult with them on 08/29/24 when they did weekly rounds. LPN #1 stated they were off work the day the wound physician made rounds so they had not obtained treatment orders for the areas. They stated they should have documented in the progress notes and wound log but they had not completed any documentation. They stated they had not notified the DON since they were going to consult with the wound physician. On 09/05/24 at 2:02 p.m., the DON stated the nurses were to notify the physician and obtain treatment orders for any wound identified. On 09/05/24 at 2:05 p.m., LPN #1 reviewed the Weekly Skin Condition Reports dated 08/23/24 and 09/02/24 and stated they may have identified the new wound on 08/30/24 but was not sure. They stated the 09/02/24 report was not accurate. On 09/06/24 at 8:54 a.m., the DON stated LPN #1 had revised the Weekly Skin Condition Reports dated 08/23/24 and 09/02/24. They stated LPN #1 documented they had obtained treatment orders for Resident #4 from the facility's physician on 09/02/24. On 09/06/24 at 9:20 a.m., Physician #1 stated the wound physician provided treatment orders for Resident #4 and they did not remember giving an order for Betadine for wounds on Resident #4's toes. On 09/06/24 at 9:52 a.m., LPN #1 stated they thought they had called Physician #1 for treatment orders on 09/02/24 but forgot to put the orders into the electronic health record. LPN #1 stated I don't know, I think I am confused. I don't remember if I called [Physician #1].

Based on record review and interview, the facility failed to ensure allegations of abuse were reported to all required state agencies within the required time for two, (#1, and #2) of three sampled residents reviewed for abuse allegations. The Administrator identified the facility census to be 67. Findings: An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised April 2021, read in part, .All reports of resident abuse .are reported to local, state and federal agencies .must be reported immediately to the administrator and to other officials according to state law .'Immediately' is defined as .within two hours of an allegation involving abuse . 1. Resident #1 had diagnosis to include Parkinson's disease and physical debility. An Interim Payment Assessment, dated 06/03/24, documented Resident #1 had moderately impaired cognitive skills for daily decision making, and was dependent on staff for hygiene and toileting. An Initial Incident Report Form, dated 06/15/24, documented Resident #1 to have allegations of sexual abuse against CNA #2. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form, dated 06/18/24, documented CNA #2 had allegations of abuse, and was suspended on 06/16/24. The investigative notes did not document CNA #2 had been reported prior to 06/18/24, three days after the allegation of abuse. 2. Resident #2 had diagnosis to include major depressive disorder, dysphagia, intellectual disability, and cognitive impairment. A Quarterly Assessment, dated 05/08/24, documented Resident #2 had unclear speech. A Combined Initial and Final incident report form, dated 06/02/24, documented the facility was notified on 06/13/24 at 3:00 p.m., of an allegation of possible exploitation of Resident #2 by CMA #1 and Laundry staff #1. The investigative notes, dated 06/13/24, documented on 06/12/24, during the afternoon hours, the administrator received a call from the sheriff's office regarding concerns of having video with FaceTime that included Resident #2, CMA #1, and Laundry Staff #1. The report documented CMA #1 and Laundry Staff #1 will be reported to the Nurse Aide/Nontechnical Worker registry. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form, dated 06/14/24, documented CMA #1 was not suspended but was terminated on 06/12/24. A second form, dated 06/14/24, documented Laundry Staff #1 was suspended on 06/13/24. The Investigative notes did not document CMA #1 or Laundry Staff #1 had been reported from 06/12/24 until 06/14/24, two days after a call was received from the sheriff's office to report concerns of possible abuse, exploitation, or privacy. On 06/21/24 at 10:50 a.m., the Administrator and DON were asked what the facility abuse policy for the time frames to report an allegation of abuse has been reported and an investigation was initiated. The Administrator stated the facility reports all abuse to OSDH within 4 hours. They were shown the facility policy that documented reporting to all state agencies of an allegation of abuse within two hours. The Administrator stated, they did not realize the two hour limit was required.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident that required the assistance of two staff members to transfer was transferred in a safe manner. The director of nursing identified five residents that required the assistance of two staff members to transfer that resided in the facility. Findings: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An incident report, dated 12/03/16, documented the resident was being transferred by a CNA to the geri-chair and began sliding. The CNA then eased the resident to the floor. The incident report documented the CNA heard a pop and the resident complained of pain to her leg. The resident was subsequently transferred to the hospital for evaluation and treatment. A quarterly assessment, dated 12/06/16, documented the resident was moderately impaired cognitively, required extensive assistance with most ADLs, and required assistance of two with bed mobility and transfers. On 03/02/17 at 1:30 p.m., CNA #1 was asked if she had cared for resident #5. She stated yes. The CNA was asked how many staff members had been required to assist with transferring the resident. She stated two. On 03/02/17 at 1:40 p.m., CNA #2 was asked if she had ever provided care to resident #1. She stated she had. The CNA was asked how many staff members had been required to assist with transferring the resident. She stated two. On 03/02/17 at 1:45 p.m., CNA #3 was asked if she had ever provided care to resident #5. She stated she had. The CNA was asked how many staff members were required to assist with transferring the resident. She stated two. On 03/02/17 at 1:50 p.m., CNA #4 was asked if she had ever provided care to resident #5. She stated yes. The CNA was asked how many staff members had been required to assist with transferring the resident. She stated two. On 03/02/17 at 2:00 p.m., the DON was asked if she had knowledge of what had occurred with resident #5. She stated on Saturday 12/03/16, the resident was assigned a newly hired, but experienced CNA that was working with a preceptor. She stated the preceptor stepped out of the resident's room for a brief period and when she returned, the resident had been lowered to the floor. The DON was asked what the facility policy was regarding a newly hired CNA and the preceptor. She stated the new hire was to work with the preceptor at all times. She stated the CNA had asked resident #5 if she could stand to pivot transfer and the resident had stated yes. The CNA reportedly stood the resident up, heard a pop, and immediately lowered the resident to the floor. The resident was subsequently transferred to the hospital for evaluation and treatment. The DON stated the CNA had been counseled regarding the facility policy of providing care with the preceptor only. In addition, a star program had been developed and initiated. The star program identified the method of transfer for each resident. A star had been placed next to the name plate of each resident's room, denoting the method of transfer with 1 for assistance of 1, 2 for assistance of 2, 1 for independent with transfers, H for Hoyer lift transfers, and SS for sit to stand lift transfers. In addition, the information had been documented in each resident's kardex in the computer charting program. The DON stated a facility wide in-service regarding the proper methods of transferring, facility policy on transfers, and the newly instituted star program had been held. The DON stated the in-servicing and star programs had been completed by 01/23/17.