Every finding on record at Southern Specialty Rehab & Nursing

Based on observations , interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of 12 confidential residents and 1 of 4 residents (Resident #7) reviewed for dignity in that: The facility failed to ensure staff were not utilizing their personal cell phones while providing care, which included assisting residents with their showers and performing peri-care. The facility failed to ensure LVN D provided privacy and dignity during wound care for Resident #7. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.Findings include: At an undisclosed date and time twelve confidential residents stated the use of cell phones by CNAs while performing care made them feel embarrassed, concerned about the quality of the care being provided, and their privacy was violated. The twelve confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents stated staff utilize their cell phones while performing showers, when performing care in resident rooms, and while performing peri-care. The confidential residents stated the staff text and talk on their phones while walking down hallways, at the nurses' stations, and while in the dining area during meals. The twelve residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 06/11/26 at 12:35pm, the DON stated staff should not be on their cell phones in resident care areas. He stated residents should be provided care with no outside distractions; the residents should always be the staff's priority. He stated all staff were trained in privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the DON. He stated staff were monitored by sporadic rounds completed by the DON and the ADON. The DON stated Resident Rights and cell phone usage are discussed at quarterly training and more often if there is a complaint. He stated the potential negative outcome would be a violation of privacy and a lack of attention to the care being provided to the residents. During an interview on 6/11/2026 at 1:25pm, the ADM stated staff should not have cell phones or earbuds on their person while performing care. He stated cell phones should be kept in breakroom lockers. Staff should provide undivided attention to residents while performing care. The ADM stated all staff are trained in resident rights, dignity, and cell phone usage during the on boarding process, continuous online training, and in-services. Staff are monitored for cell phone use by rounding completed by the ADON and the DON. The ADM stated the potential negative outcome for residents is a violation of their privacy and a lack of attention to the resident. Record review of the admission record for Resident #7, dated 06/09/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarctions affecting the left non-dominant side (paralysis of the left side) and urinary tract infection (bladder infection). Record review of the comprehensive MDS assessment for Resident #7, dated 12/20/25 revealed Resident #7's cognitive skills for daily decision making were severely impaired. During an observation on 06/10/26 at 3:30 PM, LVN D provided wound care to Resident #7's wounds and did not close the door or pull the privacy curtain around Resident #7 during care. Two female residents were observed passing by Resident #7's room and looked into his room while care was being provided. Resident #7 was able to be viewed from the doorway. During an interview on 06/10/26 at 4:42 PM, LVN D stated she had been trained to close the door and pull the privacy curtain for privacy during resident care. LVN D stated she did not close the door because she was waiting for the CNA and thought the CNA would close the door. LVN D stated she was trained about once a month regarding dignity for a resident. LVN D stated the residents could have self-image risks. During an interview on 06/11/26 at 1:32 PM, the DON stated he expected the staff to pull the curtain all the way around the resident and close the door when providing resident care. The DON stated the staff was recently trained on dignity, but he would have to look for the date. The DON stated he did not know why the door was left open and the curtain not pulled around Resident #7 during resident care. The DON stated residents could be at risk for getting embarrassed. During an interview on 06/11/26 at 2:07 PM, the ADM stated he expected the staff to close the door and pull the privacy curtain during resident care to maintain privacy. The ADM stated maybe LVN D was nervous and that was why she did not close the door or pull the privacy curtain. The ADM stated he would have to look for the last time the staff was trained on dignity. The ADM stated the residents were at risk of being embarrassed or having a dignity issue. Record review of the undated facility policy titled Resident Rights revealed the following: Policy: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Policy Interpretation and ImplementationThe facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or representative.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 3 Residents (Resident #7, #20, and #46) reviewed for incontinent care. The facility failed to ensure Resident #7's, #20's, and #46's catheter strap was in place and holding. The facility failed to ensure CNA E cleansed Resident #7's catheter with the correct technique to prevent infections. The facility failed to ensure Resident #20 catheter drainage bag was placed below the bladder. These failures placed the residents at risk of their Foley catheters getting dislodged, unwanted pain, trauma, infections, and decreasing their quality of life. Findings include:Resident #20Record review of Resident #20's face sheet dated 06/11/2026 revealed a [AGE] year-old-female admitted on [DATE] with the following diagnoses: respiratory failure, anoxic brain damage (no oxygen to brain), overactive bladder and retention of urine. Record review of Resident #20's quarterly MDS dated [DATE] revealed Resident #20 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS further revealed Resident #20 was dependent (helper does all the effort) for ADLS. Bladder and Bowel section revealed Resident #20 had an indwelling catheter. Record review of Resident #20's care plan dated 03/24/2026 revealed a focus area of Resident #20 had a foley catheter related to neurogenic bladder (nerve damage disrupts communication between bladder and brain) with interventions to assure the drainage bag was below the level of the bladder at all times. Record review of the Order Summary Report dated 06/11/2026 for Resident #20 revealed an order dated 03/08/2021 to ensure catheter strap in place and holding every shift.During an observation on 06/10/2026 at 11:30 a.m. RN B observed catheter drainage bag for Resident #20 was lying in bed with catheter bag lying on foot of bed. Resident #20's catheter tubing was under her right leg and curled up on the bed. Observation revealed no catheter strap. He stated, the catheter drainage bag is not in the right place.Resident #46Record review of Resident #46's face sheet dated 06/11/2026 revealed a [AGE] year-old-male admitted on [DATE] with the following diagnoses: respiratory failure, quadriplegia (paralysis of all four extremities), epileptic seizure (abnormal electrical activity in the brain), and dysphagia (difficulty swallowing).Record review of Resident #46's quarterly MDS dated [DATE] revealed Resident #46 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS further revealed Resident #46 was dependent (helper does all the effort) for ADLS. Bladder and Bowel section revealed Resident #46 had an indwelling catheter. Record review of Resident #46's care plan dated 01/08/2024 revealed a focus area of Resident #46 was on enhanced barrier precautions with interventions catheter care. Record review of the Order Summary Report dated 06/11/2026 for Resident #46 revealed an order dated 03/27/2026 to ensure catheter strap in place and holding every shift.During an observation on 06/10/2026 at 11:12 a.m. Resident #46 lying in bed with catheter tubing under his right leg with no catheter strap in place. LVN A stated he had a shower today and may have come off in the shower. He stated he was not aware Resident #46 did not have a catheter strap. LVN A verified the physician order stating Resident # 46 did have an order for a catheter strap to be in place.Record review of the face sheet for Resident #7, dated 06/09/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarctions affecting the left non-dominant side (paralysis of the left side) and urinary tract infection (bladder infection).Record review of the comprehensive MDS assessment for Resident #7, dated 12/20/25 revealed Resident #7's cognitive skills for daily decision making were severely impaired.Record review of the care plan for Resident #7, last review completed on 04/02/26 revealed: Focus: [Resident #7] has an indwelling catheter r/t neurogenic bladder. Interventions/Tasks: Ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra with an initiation date of 04/24/26.During an observation on 06/10/26 at 2:50 PM, CNA E provided catheter care and incontinence care to Resident #7. Resident #7 was observed without a leg strap for the catheter tubing on either leg. CNA E cleansed the catheter with a wipe and grabbed the catheter where it meets the penis and rubbed the catheter in a back-and-forth motion, going away from the penis and towards the penis several times. CNA E then grabbed a clean wipe and wiped the catheter once going away from the penis and then wiped the catheter again going away from the penis with the same side of the wipe that was used prior.During an interview on 06/11/2026 at 10:56 a.m., CNA C stated the catheter drainage bag was to catch urine. She stated the purpose of the catheter strap was to keep the catheter from pulling. She stated she had been trained in foley catheter straps and drainage bags. She stated she checks on residents every two hours. She stated nursing staff was responsible for monitoring catheter drainage bags and straps. She stated the potential negative outcome of having a drainage bag on the bed could be urine going back into the resident and UTIs. She stated the potential negative outcome of not having a catheter strap could be pulling the foley catheter out.During an interview on 06/11/2026 at 10:20 a.m., DON stated the purpose of a catheter drainage bag was to catch urine. He stated the purpose of the catheter leg strap was to keep the catheter tubing secure. He stated he was not aware that the catheter drainage bag was on Resident #20's bed and was not aware Residents #20 and #46 did not have a catheter leg strap. He stated the nursing staff was responsible for monitoring catheter drainage bag placement and catheter leg straps every 2 hours during rounds. He stated all nursing staff had been trained in foley catheters. He stated the potential negative outcome of placing the catheter drainage bag on the bed could be lack of dignity and draining urine back into the bladder causing a UTI. He stated the potential negative outcome of not having a catheter leg strap could be pulling causing pain or pulling catheter out causing trauma.During an interview on 06/11/2026 at 10:38 a.m., ADM stated the purpose of a catheter drainage bag was to catch urine. He stated the purpose of the catheter leg strap was to keep the catheter tubing secure and prevent pulling. He stated he was not aware that the catheter drainage bag was on Resident #20's bed and was not aware Residents #20 and #46 did not have a catheter leg strap. He stated the nursing staff was responsible for monitoring catheter drainage bag placement and catheter leg straps during rounds and foley care. He stated all nursing staff had been trained in foley catheters. He stated that the potential negative outcome of placing the catheter drainage bag on the bed could be UTI and urine will not drain causing urine to sit in the bladder. He stated the potential negative outcome of not having a catheter leg strap could be pulling catheter out causing pain.During an interview on 06/11/26 at 11:28 AM, CNA E stated she was trained to clean the catheter from the point where it goes in the penis and then wipe 4 inches away from the penis. CNA E stated something was stuck on the catheter and that was why she used a back-and-forth motion. CNA E stated she did not know the last time she was trained on catheter care and stated she had several in-services since then. CNA E stated the residents had a risk for infection.During an interview on 06/11/26 at 1:32 PM, the DON stated during catheter care he expected the staff to always clean away from the penis. The DON stated he expected the staff to use one single swipe to cleanse away from the penis in one fluid motion. The DON stated the staff had been trained not to go back with the same soiled cloth or wipe. The DON stated he did not know why CNA E did not cleanse the catheter going away from the penis. The DON stated the residents had a risk for infection or skin breakdown.During an interview on 06/11/26 at 2:07 PM, the ADM stated staff were to follow the policies for catheter care. The ADM stated he expected the staff to use one wipe and then throw it away and get a new one. The ADM stated the risk to the residents was UTI or infection.During an interview on 06/11/2026 at 02:08 p.m. RN B stated the catheter drainage bags should be below the resident's bladder. RN B stated Resident #20 did not have a catheter strap. He stated the purpose of the catheter drainage bag was to catch the urine. He stated the purpose of the catheter leg strap was to keep the tubing from pulling and secure. He stated he was not aware the catheter drainage bag was placed on the bed and the resident did not have a catheter strap. He stated he had been trained on foley catheter care related to catheter drainage bags and catheter leg straps. He stated the nursing staff was responsible for monitoring catheter bag placement and leg straps. He stated the potential negative outcome could be urine flowing back up and UTIs. He stated the potential negative outcome of not having a catheter leg strap could be pulling the catheter out and causing pressure ulcers.Record review of the facility policy titled, Catheter Care, undated reflected the following: General Guidelines: .5. Check the residents frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site.Procedure: .15. Keep the drainage bag below level of bladder when cleaning the urethral area.17. Then wash the catheter from the meatus down the tube about 3 inches. On 06/11/2026 at 10:00 a.m. requested policy of following physician orders. During an interview on 06/11/2026 at 03:00 p.m. corporate nurse stated she could not find a policy on following physician orders.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: On 06/10/2026 DA failed to properly wear hair net while serving food.On 06/11/2026 DM failed to properly wear hair net while preparing food. This failure could place residents at risk for food contamination. Findings included: During an observation on 06/10/2026 at 12:00 p.m. DA was wearing a black beanie covering the top of head leaving hair braids uncovered while assisting with serving the noon meal. During an observation on 06/11/2026 at 10:45 a.m. DM was wearing a black headband with hair uncovered while preparing noon meal. During an interview on 06/11/2026 at 10:48 a.m., the DA stated the purpose of a hair net was to keep hair from getting in the food. He stated he did not need to cover his braids, only his beard and top of head. He stated he had been trained in hair restraints while in the kitchen. He stated the potential negative outcome of not wearing hair restraint could be hair falling into food. During an interview on 06/11/2026 at 10:51 a.m., the DM stated all staff in the kitchen were to wear hair restraints covering all hair including braids. She stated she was aware DA was not properly wearing his hair restraint and did an in-service with DA on proper hair restraints on 06/10/2026. She stated she wore a hair net over her head band but forgot to put it on. She stated the purpose of the hair restraint was to keep hair from falling into food. She stated all staff had been trained on proper hair restraints. She stated she was responsible for monitoring kitchen staff for proper hair restraints. She stated the potential negative outcome could be the food being contaminated with hair. During an interview on 06/11/2026 at 11:20 a.m., the ADM stated he was not aware the kitchen staff were not properly wearing hair restraints. He stated the purpose of the hair restraint was to keep hair out of the food. He stated all staff have been in-serviced on wearing proper hair restraints while in the kitchen. He stated the DM and ADM were responsible for monitoring compliance with hair restraints. He stated the potential negative outcome could be infection control and someone could get sick from hair falling into food. Record review of the facility's policy, titled Infection Control, dated revised April 9, 2025, reflected the following: We will ensure that all employees practice infection control in the Food and Nutrition Services Department and maintain sanitary food preparation.Procedure.9. Restricted access to kitchen and dining areasa. Only authorized employees necessary for the operation of the food service establishment, or as part of an organized educational event, shall be allowed in the food preparation or utensil washing areas, and all shall wear a hairnet or hair covering.

Based on observation, interview, and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration and health for 1 of 3 Residents (Resident #6) reviewed for sufficient hydration.The facility failed to follow Resident #6 physician orders for hydration. This failures could affect residents receiving enteral hydration and place them at risk of health complications and decline in health. Findings included: Resident #6 Record review of Resident #6's face sheet dated 06/11/2026 revealed a [AGE] year-old-male admitted on [DATE] with the following diagnoses: acute and chronic respiratory failure, quadriplegia (paralysis of all four extremities), and persistent vegetative state. Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS further revealed Resident #6 had a feeding tube. Record review of Resident #6's care plan dated 01/08/2024 revealed a focus area of Resident #6 had potential fluid deficit related to depends on all staff for h2o via g-tube with intervention to administer fluids per g-tube as ordered. Record review of the Order Summary Report dated 06/11/2026 for Resident #6 revealed an order dated 03/27/2026 for 45 ml/H20 for 22 hours with 2hr gut rest. Observation on 06/09/2026 at 07:00 a.m. revealed Resident #6 was in room and receiving g-tube feeding. Feeding pump rate displayed on pump screen was H2O 30ml/hr. Observation on 06/10/2026 at 10:10 a.m. revealed Resident #6 was in room and receiving g-tube feeding. Feeding pump rate displayed on pump screen was H2O 30ml/hr. During an interview and observation on 06/10/2026 at 03:43 p.m. observed LVN A confirmed Resident #6's pump rate was set at 30ml/hr for H2O. He stated Resident #6's physician order was H2O 45ml/hr for 22 hours with 2 hours of gut rest. He stated he was not sure why the rate on the pump was set at 30ml/hr unless the order had been changed. He stated he was not aware of any order changes. During an interview on 06/11/2026 at 10:03 a.m., LVN A stated the purpose of a resident receiving water with tube feeding was to keep the resident hydrated. He stated he was not aware the rate was wrong for Resident #6. He stated he monitors feeding tube pump rates at the beginning of his shift and 3 to 4 times during his shift. He stated he had been trained in feeding tube pumps and how to set the rate. He stated the LVN was responsible for setting the right rate when the H2O was started and any changes throughout the shift. He stated the potential negative outcome could be dehydration. During an interview on 06/11/2026 at 10:20 a.m., DON stated the purpose of a resident receiving water with tube feeding was to provide hydration above the formula. He stated he was not aware the water rate for Resident #6 was wrong. He stated the nurse should monitor the water rate at least once a shift during the initial assessment. He stated all staff have been trained on feeding pumps and pump rates. He stated he expects the nurses to check the orders and rates and make sure they match every shift and when they hang a new bag. He stated the primary nurses were responsible for the feeding tube pump and setting the rate. He stated the potential negative outcome could be dehydration, receiving too much or not enough liquids, and tube clogging up. During an interview on 06/11/2026 at 10:38 a.m., ADM stated the purpose of a resident receiving water was to provide hydration. He stated he was not aware Resident #6 were not receiving the proper water rate. He stated the nurse was to monitor the feeding pump rate daily and when they hang new bags. He stated all nurses have been trained in feeding pump rates. He stated the clinical staff (DON, ADON and CN) were responsible for feeding tube rates. He stated the potential negative outcome could be the residents receiving too much or not enough fluids, fluid overload and dehydration. Record review of the facility policy, titled Enteral Nutrition, undated, revealed the following: We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth.Procedure:1. The nursing services department is responsible for all feeding equipment and the administration of tube feedings.3. If the physician and family opt for a feeding tube orders are written to include the following: .2. The volume to be given in 24-hours and the number of milliliters per feeding if not continuous drip.5. Problems with the administration of the tube feeding are monitored and corrected by nursing. The dietitian is responsible for evaluating nutritional adequacy and fluid requirements. On 06/11/2026 at 10:00 a.m. requested policy of following physician orders. During an interview on 06/11/2026 at 03:00 p.m. corporate nurse stated she could not find a policy on following physician orders.

Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding for 1 of 3 residents (Resident #6) reviewed for enteral nutrition, in that: The facility failed to follow Resident #6's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition and place them at risk of health complications and decline in health. The findings include: Record review of Resident #6's face sheet dated 06/11/2026 revealed a [AGE] year-old-male admitted on [DATE] with the following diagnoses: acute and chronic respiratory failure, quadriplegia (paralysis of all four extremities), and persistent vegetative state. Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS further revealed Resident #6 had a feeding tube and received 51% or more of total calories through tube feeding. Record review of Resident #6's care plan dated 01/08/2024 revealed a focus area of Resident #6 had a potential risk for malnutrition related to BMI with interventions to administer enteral feedings as ordered. Record review of the Order Summary Report dated 06/11/2026 for Resident #6 revealed an order dated 03/27/2026 for enteral feed every shift Isosource 1.5 85ml/hr for 22 hours. Observation on 06/09/2026 at 07:00 a.m. revealed Resident #6 was in room and receiving g-tube feeding. Feeding pump rate displayed on pump screen was 55ml/hr. Observation on 06/10/2026 at 10:10 a.m. revealed Resident #6 was in room and receiving g-tube feeding. Feeding pump rate displayed on pump screen was 55ml/hr. During an interview and observation on 06/10/2026 at 03:43 p.m. observed LVN A confirmed resident pump rate was set at 55ml/hr. He stated Resident #6's physician order was Isosource 1.5 - 85ml/hr for 22 hours with 2 hours of rest. He stated he was not sure why the rate on the pump was set at 55ml/hr unless the order had been changed. He stated he was not aware of any order changes. During an interview on 06/11/2026 at 10:03 a.m., LVN A stated the purpose of a resident having a feeding tube was to receive nutrition. He stated he monitors feeding tube pump rates at the beginning of his shift and 3 to 4 times during his shift. He stated he had been trained in feeding tube pumps and how to set the rate. He stated the LVN was responsible for setting the right rate when the feeding was started and any changes throughout the shift. He stated the potential negative outcome could be malnutrition and weight loss. During an interview on 06/11/2026 at 10:20 a.m., DON stated the purpose of a feeding tube was to provide proper nutrition to the residents. He stated he was not aware the feeding rate for Resident #6 was wrong. He stated the nurse should monitor the feeding pump rate at least once a shift during the initial assessment. He stated all staff have been trained on feeding pumps and pump rates. He stated he expects the nurses to check the orders and rates and make sure they match every shift and when they hang a new bag. He stated the primary nurses were responsible for the feeding tube pump and setting the rate. He stated the potential negative outcome could be not enough nutrition, poor wound healing, weight loss, stomach distention, bowel distention, reflux and aspiration. During an interview on 06/11/2026 at 10:38 a.m., ADM stated the purpose of a feeding tube was to provide calorie intake and weight management. He stated he was not aware Resident #6 was not receiving the proper feeding rate. He stated the nurse was to monitor the feeding pump rate daily and when they hang new formula. He stated all nurses have been trained in feeding pump rates. He stated the clinical staff (DON, ADON and CN) were responsible for feeding tube rates. He stated the potential negative outcome could be the residents receiving too much or not enough calories and protein. Record review of the facility policy, titled Enteral Nutrition, undated, revealed the following: We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth.Procedure:1. The nursing services department is responsible for all feeding equipment and the administration of tube feedings.3. If the physician and family opt for a feeding tube orders are written to include the following: .2. The volume to be given in 24-hours and the number of milliliters per feeding if not continuous drip.5. Problems with the administration of the tube feeding are monitored and corrected by nursing. The dietitian is responsible for evaluating nutritional adequacy and fluid requirements. On 06/11/2026 at 10:00 a.m. requested policy of following physician orders. During an interview on 06/11/2026 at 03:00 p.m. corporate nurse stated she could not find a policy on following physician orders.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 5% based on 2 out of 40 opportunities, for 2 of 4 Residents (Residents #47 and #56) reviewed for medication administration, in that:-The facility failed to ensure MA G provided the correct dose of the medication guaifenesin 600mg to Resident #56.-The facility failed to ensure MA G provided the correct dose of the medication cranberry 500mg to Resident #47.These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.Findings included:Resident #56Record review of Resident #56's admission record, dated 06/11/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: acute respiratory failure (lungs do not function properly), protein-calorie malnutrition (bad nutrition), and quadriplegia (paralysis from the neck down).Record review of Resident #56's physician orders, dated 06/10/26, revealed an order for Mucinex Oral Tablet Extended Release 12 Hour 600 mg (Guaifenesin) Give 1 tablet by mouth one time a day for cough with a start date of 08/17/25.During a medication administration observation on 06/10/26 at 8:14 AM, MA G was observed dispensing guaifenesin 400mg 1 tablet by mouth to Resident #56. Resident #47Record review of Resident #47's admission record, dated 06/11/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: acute respiratory failure (lungs do not function properly), immunodeficiency (the body's defense system is weakened), and neuromuscular dysfunction of bladder (bladder muscles do not work properly).Record review of Resident #47's physician orders, dated 06/10/26, revealed an order for Cranberry Soft Oral Tablet Chewable 500 mg Give 1 tablet by mouth two times a day related to neuromuscular dysfunction of bladder, with a start date of 09/08/24.During a medication administration observation on 06/10/26 at 8:23 AM, MA G was observed dispensing Cranberry 450 mg 1 tablet by mouth to Resident #47. During an interview on 06/10/26 at 10:11 AM, MA G stated she had caught the error for Resident #56 and one of the other nurses went to get the correct dose of Mucinex. MA G stated she did not have the correct dose in her medication cart. MA G stated she did not see that the Cranberry tablet for Resident #47 was the wrong dose. MA G stated it was her fault.During an interview on 06/11/26 at 11:32 AM, MA G stated she had been trained on the 5 rights for medication administration, but it had been a while. MA G stated a potential negative outcome for the residents was they could not be getting the right dose that they would need and it was not good.During an interview on 06/11/26 at 1:32 PM, the DON stated he was unsure of when the last time the staff was trained on medication administration and stated he would have to ask the ADM. The DON stated he was not aware of medication administration training being provided with him working as DON at the facility. The DON stated he expected the 5 rights of medication administration to be followed, the correct medication/dose, the correct time, the correct route and the reason for the medication. The DON stated he did not know why the wrong doses of medications were given. The DON stated it was easy to get lazy, especially if it was the same people and it could have been nerves as well. The DON stated a potential negative outcome for the resident was no outcome or not enough outcome from the medication.During an interview on 06/11/26 at 2:07 PM, the ADM stated he expected the staff to look at orders and medications and ensure the correct dose before giving. The ADM stated the staff knew to let someone know if an over the counter medication was the wrong dose. The ADM stated he did not know why MA G gave the wrong doses for the medications. The ADM stated that depending on the medication, the medication could be harmful or cause adverse side effects to the residents.Record review of facility policy titled, Medication Administration and General Guidelines dated 2025 reflected the following: Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Procedure:.2. Medications are administered in accordance with written orders of the attending physician.Checklist for completing proper steps in administration of medications.Adheres to the 6 rights of Medication AdministrationRight Dose.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 RT carts (RT Cart A) reviewed for medication storage. The facility failed to ensure RT Cart A was locked when not in use or unattended. This failure could place residents at risk of medication errors or adverse effects. The findings included:During an observation on 06/11/26 at 8:44 AM, RT Medication/Treatment Cart A was observed in the 200 Hall unlocked and unattended with the keys hanging from the opened lock. No staff or residents were observed within eyesight of the cart.During an observation and interview on 06/11/26 at 8:46 AM, RT F stated she had gone in a resident's room quickly to see what he needed. RT F stated she should have locked her cart when she stepped away from it. RT F opened the top drawer, and medications and supplies were observed in the cart. RT F stated she did not know the last time she was trained to keep her cart locked when she stepped away from it. RT F stated she did not know of a potential negative outcome to the residents.During an interview on 06/11/26 at 1:32 PM, the DON stated he expected the staff to keep their carts locked when not near them and their keys to be kept in their pocket or on their person. The DON stated the staff were trained on medication storage within the last couple of months, but he did not have an exact date. The DON stated he did not know why RT F did not lock her cart when she walked away from it. The DON stated a potential negative outcome to the residents was that they could get a medication they do not need or a possible allergy to the medication. During an interview on 06/11/26 at 2:07 PM, the ADM stated he expected the staff to lock their carts when they were not with them. The ADM stated the facility had done in-services regarding medication storage but did not have an exact date. The ADM stated he did not know why RT F did not lock her cart before she walked away. The ADM stated a potential negative outcome to the residents was that the resident could get in there and grab or take the medications.Record review of the facility policy titled, Medication Storage in the facility dated 2025 reflected the following: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure:.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #7) reviewed for infection control. The facility failed to ensure CNA E changed her gloves and performed hand hygiene before going from dirty to clean during incontinence care for Resident #7. This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the admission record for Resident #7, dated 06/09/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarctions affecting the left non-dominant side (paralysis of the left side) and urinary tract infection (bladder infection). Record review of the comprehensive MDS assessment for Resident #7, dated 12/20/25 revealed Resident #7's cognitive skills for daily decision making were severely impaired. During an observation of catheter care and incontinence care on 06/10/26 at 2:50 PM, CNA E provided catheter care and incontinence care to Resident #7. CNA E wiped Resident #7's buttocks, removed the dirty brief and then placed a clean brief and a clean draw sheet under Resident #7. CNA E did not change her gloves or perform hand hygiene after removing the dirty brief and before placing the clean brief and draw sheet under Resident #7. During an interview on 06/11/26 at 11:28 AM, CNA E stated she caught her mistake during incontinence care for Resident #7 after the fact. CNA E stated she was supposed to change her gloves after cleaning the resident and before putting on a new drawsheet and brief. CNA E stated she did not remember the last time she was trained on infection control. CNA E stated the risk to the resident was infection. During an interview on 06/11/26 at 1:32 PM, the DON stated he expected the staff to have clean gloves and clean hands when putting on a clean brief on a resident. The DON stated he did not know the last time CNA E was trained on infection control and stated he would look for it. The DON stated he did not know why CNA E did not change her gloves and perform hand hygiene between dirty and clean procedures. The DON stated the residents had a risk for infection. During an interview on 06/11/26 at 2:07 PM, the ADM stated he expected the staff to take their gloves off, wash their hands and put on clean gloves between dirty and clean to prevent the spread of infection. The ADM stated CNA E was recently trained for infection control but did not know exactly when. The ADM stated a potential negative outcome to the residents was that it could cause a UTI or infection. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions undated reflected the following: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand HygieneHand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:.after contact with a resident's mucous membranes and body fluids or excretions.GlovingGloves are worn for three important reasons1. To provide a protective barrier and prevent cross contamination of the hands when touching .body fluids.2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes or non-intact skin.3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident.can transmit these microorganisms to another resident.Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) reviewed for wound care.- LVN A failed to utilize proper hand hygiene and glove practices during wound care for Resident #1. This failure could place residents at risk for cross contamination and infection.Findings included:Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute respiratory failure (when the lungs cannot properly oxygenate the blood or remove carbon dioxide), dependence on respirator ventilator status, pressure ulcer of the sacral region (triangular bone at the base of the lumbar vertebrae and between the hip bone) and quadriplegia (paralysis affecting all four limbs and the torso).Record review of Resident #1's quarterly MDS , dated 11/12/2025, Section C- Cognitive Pattern, revealed a BIMS score of seven which indicated Resident #1 had severe cognitive impairment.Record review of Resident #1's care plan, dated 04/01/2025, revealed, [Resident #1] has a pressure ulcer or potential for pressure ulcer development: . Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD . Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN,. The care plan revealed an intervention for Enhanced Barrier Precaution , dated 4/01/2025, with the following, Gloves and gown should be donned (put on) if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care (delivers liquid nutrients directly into the stomach or small intestine), catheter care, trach ( a surgically created opening (stoma) in the neck leading directly to the trachea (windpipe) to facilitate breathing care, bathing, or other high-contact activity.Record review of Resident #1's physician orders, dated 02/06/2026, revealed, TX to stage 4 Pressure wound (a severe, full-thickness wound extending deep into muscle) of the left buttock cleanse with vashe (solution designed for cleaning, irrigating, and moistening acute and chronic wounds) wound cleanser.iodosorb gel (antimicrobial wound dressing designed to treat chronic wounds).collagen (wound care dressing to accelerate healing) then calcium alginate (a natural, highly absorbent wound dressing ).cover with gauze island (a sterile, multi-layer, self-adhesive bandage used for wound care).daily and prn. Physician orders further revealed, TX of the sacrum (a triangular bone in the lower back): cleanse with vashe wound cleanser.iodosorb gel (antimicrobial wound dressing designed to treat chronic wounds).collagen then calcium alginate.cover with gauze island.daily and prn.During a wound care observation on 2/17/2026 at 3:40 p.m. for Resident #1 , LVN A put on a pair of gloves and a gown that had thumb holes. The thumb holes went over the first pair of gloves. LVN A proceeded to put a second pair of gloves over the first pair of gloves. LVN A removed Resident #1's wound dressings from the sacrum and left buttock. LVN A removed the top pair of gloves from both her hands and placed a new glove, over the first glove, to the right hand only. LVN A did not utilize hand hygiene and maintained the first pair of gloves on to both hands. LVN A used the right hand to clean the sacrum wound, removed the right top glove with the left gloved hand and donned a new glove over the first glove, to the right hand only. LVN A applied the treatment and dressing to the sacrum and removed the glove from the right hand. LVN A again utilized the left gloved hand to remove the dirty top glove from the right hand. LVN A did not put on a new glove to either hand. LVN A utilized the first pair of base gloves to clean the left buttock wound. LVN A removed gloves from both hands, used ABHS and donned new gloves. LVN A applied treatment to Resident #1's left buttock wound and removed the glove from the right hand, using her left hand. LVN A used the left gloved hand again to put on a new glove to the right hand and dressed the wound.During an interview with LVN A on 2/17/2026 at 4:00 p.m., she stated she was not trained on wound care upon hire in January of 2026. She stated she had been a nurse for approximately 30 years in Ohio. She stated she did not have any form of competency check-off and all she knew was from her previous training courses in her career. She stated she was aware Resident #1 had a history of MDRO and required contact precautions to prevent the spread of infection. She stated she double gloved (placed two pairs of gloves over each other) during the wound care because she had done so when she worked in home care. She stated she was concerned about the gloves breaking and getting something on her, as that had happened to her in her previous job and was trying to keep herself and the resident safe. She stated she was not sure why she double gloved this time as she had not been doing that in the past and it was her first time doing so with Resident #1. She stated she did not change the glove to her left hand with each glove change because she had not used it during the wound care, so it was not dirty. She stated she removed the right-hand glove carefully and felt the left-hand glove was not contaminated. She stated hand hygiene was used between glove changes because there could be a potential for contamination during the care or when removing gloves. She stated a potential negative outcome of double gloving could be potentially contaminating the second pair of gloves and spreading infection. LVN A stated, I don't know why we need to change both gloves if we are just using one hand. I guess I was thinking of sterile technique, but I guess the clean glove could technically become soiled and contaminate the new glove since it is not being changed out.During an interview on 2/17/2026 at 4:52 p.m., the Regional Compliance Nurse (RCN) stated she was responsible for training the nursing staff, and trained LVN A, upon hire. She stated she did one on one wound care observations and training with LVN A prior to LVN A assuming her duties. She stated she had conducted the training for LVN A from 1/26/2026 to 1/29/2026. She stated LVN A was not trained to double glove and had not observed LVN A do that during the wound care observations. She stated she would be providing additional training to LVN A prior to resuming as the wound care nurse. RCN stated double gloving and not changing both gloves during wound care could have the potential for spreading infection.During an interview on 2/18/2026 at 11:44 a.m., the ADM stated the RCN had been conducting the training for the new nursing staff as they did not have a DON at that time. He stated they had a new DON that was hired approximately three weeks ago and two new ADONs that would assume the training responsibilities. He stated infection control training was done yearly and as needed and they would be doing an in-service training regarding proper glove usage. He stated it was never appropriate to utilize double gloving during any resident care for any staff member. He stated the potential risk of not using proper glove technique and hand hygiene could be potentially spreading infection. He stated LVN A should have removed both gloves and utilized ABHS in between glove changes while she provided wound care.Record review of facility policy titled, Fundamentals of Infection Control Precautions undated revealed, You may use alcohol-based hand cleaner or soap/water for the following: .Before and after changing a dressing.after removing gloves or aprons.after handling soiled or used linens, dressings, bedpans, catheters and urinals. In addition, gloves or the use of baby wipes are not a substitute for hand hygiene.Gloving. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.Failure to change gloves between resident contacts is an infection control hazard.Record review of facility email dated 2/9/2026 at 8:49AM from RCN to ADM revealed; Entrance: 1/26-1/29.Specifics: Wound care nurse training. Training completed on [EMR] Weekly skin assessments to be completed by the wound care nurse. Shower schedule must be done by wound care nurse, update list and task in [EMR] Wound care must be completed by wound care nurse, do not delegate wounds to floor nurses. Step by step education provided on ulcer assessments/ non pressure ulcer assessments and care plans. All new admission and readmission skin assessments must be completed by the wound care nurse, on weekends and after hrs [hours] admissions/readmissions please do a second skin assessments. Per [facility] expectations, wound care nurses do not have an office. Wound care nurses must be in the on-call schedule. Education provided on EBP, how to put orders on special instructions, task and care plan updates.

Based on interview, observation, and record review, the facility failed to ensure that residents were free of significant medication errors for 6 of 10 residents (Resident #1, 2, 3, 5, 6, and 7) reviewed for pharmacy services. The facility failed to administer: Resident #1's order for Hydralazine and Amlodipine for blood pressure. Resident #2's order for Lamotrigine and Levetiracetam for seizures. Resident #3's order for Carvedilol for blood pressure, Entresto for heart failure, Torsemide for edema, and screen her blood pressure. Resident #5 order for Ziprasidone for Schizophrenia, Resident #6's order for Carvedilol for atrial fibrillation and congestive heart failure, Eliquis for heart failure, Levetiracetam for seizures, Lisinopril for high blood pressure, Vimpat for epilepsy, and screened for blood pressure. Resident #7's order for Midodrine for her blood pressure, Levetiracetam for convulsions, and screened for blood pressure. This failure could place residents at risk of complications, as well as jeopardizing their health and safety. Findings included:-Record review of Resident #1's admission Record dated 11/04/25 indicated her initial admission was 03/21/25 and was readmitted [DATE]. Record review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Brief Interview for Mental Status score (BIMS) was not filled out because resident rarely or never understood. Record review of Resident #1's Care Plan dated 09/05/25 included a focus area for hypertension, initiated 03/24/25 and revised 04/07/25, with interventions to educate the caregiver on the importance of medication, administer hypertensive (blood pressure consistently remains above normal levels) medications as order, monitor side effects such as orthostatic hypotension (a condition where blood pressure drops significantly upon standing up from a sitting or lying position), monitor tachycardia (increased heart rate exceeding 100 beats per minute), monitor the medications effectiveness, monitor/document/report to physician (MD) as needed any signs/symptoms (s/sx) of malignant hypertension to include headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, and difficulty breathing. Record review of Resident #1's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included essential-primary hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying medical cause). The order was to administer: *Hydralazine HCI (hydrochloride) oral tablet, 25 milligrams (mg.), start date 03/07/25, give via G-tube (gastrostomy tube) every 6 hours as needed for elevated blood pressure (BP) related to hypertension, and systolic blood pressure ((SBP) indicates a significantly elevated risk for heart disease, stroke, and other cardiovascular issues) more than 160. *Amlodipine Besylate oral tablet 10 mg., start dated 03/08/25, give 10 mg. via G-Tube one time a day related to essential (primary) hypertension hold for SBP less than 110 or HR less than 60 Record review of Resident #1's Treatment Administration Record (TAR) dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the A.M. (morning or ante meridiem before midday) 10/29/25, entries were blank, indicting her blood pressure was not taken and recorded. And further review of the TAR indicated her Amlodipine Besylate and Hydralazine HCI were not administered on 10/29/25. Observation and an attempted interview on 11/03/25 at 4:50 P.M. revealed Resident #1, who was lying in her bed, had a trachea (a cartilaginous tube that connects the larynx to the lung's bronchi, enabling air passage) and a tube feeding (delivers liquid nutrition through a flexi tube that goes in through your nose or directly into your stomach or small intestine) attachments. Resident #1 nodded her head up and down to all the questions asked of her, she was unable to respond appropriately. During an interview on 10/31/25 at 6:40 P.M with Licensed Vocation Nurse (LVN D) indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #1. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #1, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #1 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #1's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #1, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #1. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #1. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #1. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #1; however, he confirmed the medications were not administered to Resident #1 because nobody did it. The Administrator said this medication errors were not discovered until 11/03/25 during Health and Human Services investigation. During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #1. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #1, because she was only Resident #1's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #1, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #1's noon medications. During an interview on 11/03/25 at 2:04 P.M. with Medication Aide (MA F) indicated she worked Hall 100 hall that included Resident #1; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #1, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the Director of Nurses (DON), indicated on 10/31/25 he became aware that Resident #1, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said he assessed Resident #1, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:48 P.M., Nurse Practitioner (NP-A) indicated her concern would be Resident #1's Amlodipine Besylate and/or Hydralazine HCI not being administered on 10/29/25 because it could increase her blood pressure and potentially lead to a stroke. -Record review of Resident #2's admission Record dated 11/04/25 indicated her initial admission was 08/01/22 and was readmitted [DATE]. Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed her BIMS score was a 7 indicating severe cognitive status. Record review of Resident #2's Care Plan dated 09/10/25 included a focus area for seizure disorder initiated 10/15/22 with an intervention to give seizure medications as order by her physician. Record review of Resident #2's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included other seizures (different types of seizures beyond the most common ones, including various generalized seizures like absence, atonic-complete loss of muscle and myoclonic seizures-brief involuntary muscle jerks, and focal seizures which start in one part of the brain). The order was to administer: * Lamotrigine oral tablet 25 mg., start dated 03/08/25, during the A.M., give 2 tablets via G-tube two times a day for seizures.*Levetiracetam oral tablet 500 mg., start date 02/19/25, during the A.M., give 1 table via G-tube two times a day for seizures. Review of Resident #2's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed on 10/29/25 the A.M. entries were blank, indicating Resident #2 did not receive her Lamotrigine and Levetiracetam. Observation and interview on 11/04/25 at 11:33 A.M. revealed Resident #2, who was lying in her bed, had a trachea and tube feeding attachments. Resident #2 indicated she couldn't recall when she received her medications. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #2. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #2, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #2 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #2's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #2, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #2. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #2. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #2. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #2; however, he confirmed the medications were not administered to Resident #2 because nobody did it. The Administrator said this medication errors were not discovered until 11/03/25 during Health and Human Services investigation. During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #2. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #2, because she was only Resident #2's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #2, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #2's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #2; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #2, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #2, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #2, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:51 P.M., NP-A indicated her concern with Resident #2 not being administered her AM 10/29/25 medications, would be her Lamotrigine and Levetiracetam, which could have led to a seizure. -Record review of Resident #3's admission Record dated 11/04/25 indicated her initial admission was 05/18/22 and was readmitted [DATE]. Record review of Resident #3's Quarterly MDS assessment dated [DATE], revealed her Brief Interview for Mental Status score was a 7 indicating severe cognitive status. Record review of Resident #3's Care Plan dated 09/02/25 included the following focus areas: *Pacemaker that was initiated 07/13/22 and updated 02/22/23 with interventions to educate the caregiver on the importance of medication; give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increase heart rate (Tachycardia) and effectiveness.*Hypertension with hyperlipidemia initiated on 07/13/22 and updated 02/22/23 with interventions to educate the caregiver on the importance of medication; give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increase heart rate (Tachycardia) and effectiveness. -Record review of Resident #3's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included hypotension (a condition in which the force of blood against the artery wall is consistently too high), cardiac arrest (occurs when the heart suddenly stops beating, preventing bold from circulating throughout the body, Thrombocytopenia ( a condition characterized by a low platelet count in the blood), chronic combined systolic and diastolic heart failure (a condition where the heart muscle is weakened (systolic dysfunction) and/or stiffened (diastolic dysfunction) simultaneously, leading to impaired pumping ability, and essential-primary hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying medical cause). The order was to administer: *Carvedilol Tablet 6.25 mg. via G-tube, start dated 01/19/24, two times a day related to essential primary hypertension, hold for SBP less than 100, DBP less than 60, HR less than 55. *Entresto (Sacubitril-Valsartan) oral tablet 24-26 mg., start date 04/05/25, give 1 tablet via G-tube two times a day related to chronic combined systolic (congestive) and diastolic (congestive) heart failure; and *Torsemide oral tablet 10 mg., start date 01/19/25, give 20 mg via G-tube one time a day for edema, give 2 tables to equal 20 mg dosage. Review of Resident #3's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the morning entries on 10/29/25 were blank, indicting her blood pressure was not taken and recorded, and she was not administered her Carvedilol, Entresto, and Torsemide. Observation and interview on 11/03/25 at 11:37 A.M. revealed Resident #3, who was lying in her bed, had a trachea and tube feeding attachments. Resident #3, who nodded her head up and down (indicating a yes response), and side to side (indicating a no response) to questions asked of her, indicated she had could not recall when she received her medications. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #1. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #3, and had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #3 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #3's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #3, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #3. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #3. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #3. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #3; however, he confirmed the medications were not administered to Resident #3 because nobody did it. The Administrator said this medication errors were not discovered until 11/03/25 during Health and Human Services investigation. During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #3. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #3, because she was only Resident #3's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #3, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #3's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #3; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #3, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #3, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #3, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 2:55 P.M., NP-A indicated her concern with Resident #3 not being administered her AM 10/29/25 medications, would be her Torsemide, Entresto, and Carvedilol due to a potential for heart failure. -Record review of Resident #5's admission Record dated 11/04/25 indicated her initial admission was 08/23/23 and was readmitted [DATE]. Record review of Resident #5's Quarterly MDS assessment dated [DATE], revealed her BIMS score was a 6 indicating severe cognitive status. Record review of Resident #5's Care Plan dated 09/11/25 the focus area for anti-psychotic medications initiated 09/12/23 due to diagnosis of schizophrenia with interventions to administer medications as ordered, and to discuss with physician and family the ongoing need for the use of these medications. Record review of Resident #5's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included recurrent severe without psychotic features, Schizophrenia. The order was to administer: *Ziprasidone HCl oral capsule 80 mg., started 10/16/23, give 1 capsule via G-tube one time a day related to Schizophrenia, unspecified. Record review of Resident #5's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed the A.M. 10/29/25 entry was blank, indicating Ziprasidone was not administered. Observation and interview on 11/03/25 at 5:00 P.M. revealed Resident #5, who was lying in her bed, had a trachea and tube feeding attachments. Resident #5 indicated she could not recall if she had been administered her medication. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #5. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #5, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #5 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #5's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #5, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #5. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #5. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #5. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #5; however, he confirmed the medications were not administered to Resident #5 because nobody did it. The Administrator said this medication errors were not discovered until 11/03/25 during Health and Human Services investigation. During an interview on 11/04/25 at 1 P.M. with LVN C indicated on 10/29/25 at 9:00 A.M. she started her shift and was not informed that she was the charge nurse for Residents #5. LVN C said it was not until 11:30 A.M. that she checked her office emails and discovered an email from ADON, directing her to take over the residents because the Administrator and DON, who were in the building, were in training. LVN C said at approximately 11:30 am she met with the ADON and obtained the medication cart keys from her and informed her it was too late to administer the morning medications, because it was almost noon. LVN C said she did not call the physician or the family to inform them of the medication errors for resident #5, because she was only Resident #5's charge nurse for approximately 45 minutes, before she had to conduct rounds with the wound care physician. During an interview on 11/03/25 at 12:01 P.M. LVN E indicated she was working on 10/29/25 from 6 A.M. to 6 P.M. and there was not a nurse assigned to Resident #5, until 11:30 P.M. That's when LVN E said she heard LVN C informed the ADON that it was too late to give the 6:00 A.M. medications but would administer Resident #5's noon medications. During an interview on 11/03/25 at 2:04 P.M. with MA F indicated she has worked Hall 100 hall that included Resident #5; however, her medications must be administered by a nurse via G-tube. MA F said on 10/29/25 at after 6 A.M., she was passing the morning medications to her Residents, when she noticed Residents #5, had not received her medications, because there was not a nurse on duty to administer her medications. During an interview on 11/04/25 at 3:48 P.M. with the DON, indicated on 10/31/25 he became aware that Resident #5, was not administered for her medications on 10/29/25 during the 6 A.M. medication pass. The DON said the risk of not administering resident their scheduled medications could increase their risk of seizure activity, increase their blood pressure, lower their blood pressure, depending on what medication was not administered. The DON said he assessed Resident #5, who did not have a negative outcome due to missing her medications. During an interview on 11/04/25 at 3:03 P.M., NP-A indicated the concern she would have with Resident #5 not being administered her medications on 10/29/25, would be her Ziprasidone, because she has a diagnosis of Schizophrenia that could increase hallucinations. -Record review of Resident #6's admission Record dated 11/04/25 indicated her initial admission was 12/07/22 and was readmitted [DATE]. Record review of Resident #6's Quarterly MDS assessment dated [DATE], revealed her BIMS score was not filled out because resident rarely or never understood. Record review of Resident #6's Care Plan dated 09/08/25 included the focus area of congestive heart failure that was initiated 12/08/22 and revised on 03/02/23 with interventions to give cardiac medications as ordered. And the focus area for seizure disorder with interventions initiated 12/08/22 and revised 03/02/23 with interventions to give seizure medications as ordered. Record review of Resident #6's Order Summary Report dated 11/04/25 with active orders as of 10/01/25, revealed a [AGE] year-old female with diagnoses that included heart failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, and hypertension. The order was to administer: * Carvedilol Tablet 12.5 mg., start dated 06/11/25, give 12.5 mg. via G-tube two times a day for atrial fibrillation and congestive heart failure related to paroxysmal atrial fibrillation (I48.0) hold if systolic is less than 100, hold if diastolic is less than 60, hold if pulse is less than 55. * Eliquis oral tablet 5 mg., (Apixaban), start dated 06/11/25, give 5 mg. via Peg-tube two times a day for secretions related to heart failure, unspecified, paroxysmal atrial fibrillation. * Levetiracetam tablet 500 mg., start dated 06/11/25, give 500 mg via G-tube two times a day for seizure.* Lisinopril tablet 2.5 mg., start dated 06/11/25, give 2.5 mg. via G-tube one time a day for hypertension related to essential (primary), hypertension (110) hold for SBP less than 100, DBP less than 60. * Vimpat tablet 100 mg. (Lacosamide), start dated 08/24/25, give 10 ml via G-tube two times a day for seizure related to epilepsy, unspecified, not intractable, without status epilepticus (prolonged seizure). *Midodrine HCl Tablet 5 mg., give 5 mg via G-Tube every 8 hours as needed for hypotension related to orthostatic hypotension, hold for SBP greater than 130, and DBP greater than 60. Record review of Resident #6's TAR dated 11/04/25 that covered the dates 10/01/25 through 10/31/25 revealed on 10/29/25 the following entries were blank, indicting her blood pressure was not taken and recorded, and she was not administered her Eliquis, Levetiracetam, Lisinopril, Vimpat, and her Midodrine. Observation and interview on 11/03/25 at 5:08 P.M. with Resident #6, who was lying in her bed, had a trachea and tube feeding attachments. Resident #6 did not respond to questions asked of her. During an interview on 10/31/25 at 6:40 P.M with LVN D indicated she worked on 10/29/25 and left shift at approximately 7:30 A.M after the Administrator directed her to leave at 7:49 A.M. because he was taking over her residents, that included Resident #6. During an interview on 11/03/25 at 9:54 A.M. with LVN B indicated the morning medications are administered between 6 A.M. and 8 A.M. LVN B said on 10/29/25 at 7 A.M. she witnessed the Administrator and ADON at the facility. Then at approximately 10:45 A.M. she received red alerts on her electronic medication administration record, revealing resident #6, had not received her morning medications. LVN B said she was approached by the DON at 11 A.M. and she informed him Resident #6 had not received her morning medications. Afterwards, LVN B said she witnessed ADON asking LVN C to administer Residents #6's medication; however, she explained that she could not administer her morning medications because it was too close to the next medication pass. LVN B said the nurse assigned to Hall 100, which included Residents #6, failed to show up to work at 6 A.M. and a replacement was not assigned to resident #6. During an interview on 11/04/25 at 1:00 P.M. with the Administrator, indicated on 10/29/25 at 7:45 A.M. he witnessed the night nurse, LVN D, on duty because the day nurse failed to show up for her shift at 6 AM. The Administrator, who is an LVN, took over LVN D's position so she could leave her night shift, which included caring for resident #6. The Administrator said in Hall 100 he completed resident's blood sugar test and then was informed by ADON that LVN C would take over the residents on Hall 100, which included Resident #6. The Administrator said he could not recall what time he left the residents he was caring for in Hall 100, including Resident #6; however, he confirmed the medications were not administered to Resident #6 because nobody did it. The Administrator said this medication errors were not discovered until 11/03/25 during Health and Human Services investigation. During an interview on 11/04/25 a

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 of 3 residents (Resident #1) reviewed for care plans as follows: The facility failed to ensure to document Resident #1 was required to wear a fire-resistant apron and receive direct supervision from staff while smoking in the care plan, which resulted in staff not being trained or made aware of how to provide the resident with proper care. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:18 PM. While the immediate jeopardy was lifted on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs which could result in serious harm and injuries. Findings included: Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7 resident shakes/has tremors while smoking, 8 resident falls asleep while smoking, 9 had past accidents/incidents with smoking materials, 10 are there any visible burn marks on the resident's clothing or coat, 11 does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2 This resident requires direct supervision while smoking, 3 this resident requires a fire-resistant smoking apron while smoking, 6 the evaluation has been discussed with the resident. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. During an observation on 8/22/25 at 11:44 AM, revealed Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when another resident spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron as she held an unlit cigarette that she stated she would smoke later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room but they have never stayed to supervise her. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but she was not asleep. She stated she was completely blind. During an interview on 8/22/25 at 3:36 PM, CNA D said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware of Resident #1 if had to be supervised when she smoked or any other accommodations. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff with lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff go back inside; they did not watch her. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in the building. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear protective apron when smoking. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 10:57 AM, LVN B said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes in a resident's smoke assessment. During an observation and interview on 8/23/25 at 11:16AM, Resident #1 was observed smoking with no apron and sitting at table with an ashtray. No staff were present in the room. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. The SW said Resident #1 would get upset and said they were trying to make her look bad when they tried to address it with her. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments but she thought the EHR prompted staff when they were due. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next week. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. He said the care plan should have been updated with the updated smoking assessment results so everyone could know what was going on with resident because that was what staff refer to when they provide care to the residents. He stated not updating care plans could cause residents to be unsafe or a resident could get injured. He said he was not aware Resident #1's care plan was not updated. The ADM said care plans were supposed to be updated immediately with changes. He said changes in care plans were communicated to the DON and the DON should review them on a regular basis. He said currently the Compliance Nurse had been trying to manage it the best she could but she worked at several different facilities. He said smoking assessments were completed monthly if that was what was documented in the care plan. He said not following care plan could result in an injury to a resident. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates needed to the MDS and care plan were to discuss them during morning meetings to ensure care plans were being followed. During an interview on 8/23/25 at 7:12 PM, LVN C said he checked the care plan to determine how to care for residents. He said the ADON was responsible to update care plans. Record review of the facility policy titled, Comprehensive Care Planning, undated, revealed in part the following: he facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASAR and the resident's representative(s)- The resident's goals for admission and desired outcomes. The resident's preference and potential for future discharge. The facility document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. Discharge plans in the comprehensive care plan, as appropriate. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was determined to be an IJ on 8/23/25 at 4:15PM. The Administrator and Regional Compliance Nurse were notified on 8/23/2024 at 4:18 PM and IJ situation was identified due to the above failure and the IJ Template was provided. The following Plan of Removal submitted by the facility was accepted on 8/23/2025 at 7:50PM. Record review of the facility Plan of Removal reflected the following: [Facility Name] 8/23/20258/23/2025Plan of RemovalProblem: IJ F656 related to care planning called on 8/23/2025Interventions:1. On 8/23/2025, the Regional Compliance Nurse/ Administrator reviewed care plans for all residents who smoke and updated them with correct information related to the safe smoking assessments completed on 8/23/2025. This was to include any special safety equipment or procedures identified in those assessments.2. On 8/23/2025, off cycle QAPI with the medical director was done by the Administrator and Regional Compliance Nurse over the IJ and plan of removal.3. On 8/23/2025 Administrator and MDS case managers were in-serviced over assuring that care plans are reflective of resident conditions and preferences to include safe smoking. Monitoring:1. Beginning 8/25/2025 and 5 times weekly DON/Administrator and MDS case managers will review any changes to resident conditions or preferences to include safe smoking in the morning meeting.2. Weekly the regional compliance nurse will review 5 care plans to assure that care plans are current and reflective of resident conditions and preferences to include safe smoking.3. The Area Director of Operations and Regional MDS support staff will assure that monitoring and updating of care plans is being done according to this plan of correction. On 8/24/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record of facility an in-service dated 8/23/2025 revealed training on the facility will allow smoking only supervised and in designated smoking areas. There will not be any smoking or vaping devices, including cigarette lighters in resident rooms. If a resident seen with a lighter, request if from the resident and notify the Administrator immediately. Residents who wear O2 (oxygen) must leave oxygen tank inside the facility prior to enter smoking area had signatures 32 staff members. Record review of a facility in-service dated 8/23/2025 revealed training on the facility has changed today 8/23/25 to a supervised smoking facility. All smoke breaks are to be supervised, please see attachment for smoking schedule had 29 staff signatures. Record review of the off-cycle Quality Assurance Meeting document, dated 8/23/25, titled: ADHOC QAPI for identification of a system in need of immediate attention by QAPI committee. On 8/23/25 a failure was identified to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 residents) reviewed for accidents and supervision while smoking. Residents were identified on 8/23/2025 that the facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Monitoring will start 8/24/2025. Regional Compliance Nurse/Area Director of Operations will monitor during weekly visits and ask DON and Administrator about status of the smoking changes and any violations identified. Monitoring will start 8/24/2025 and will continue for at least 8 weeks and prn thereafter. The administrator / DON / ADONs will monitor 5 residents' rooms daily, 5 days a week to ensure residents do not have any prohibited smoking paraphernalia in the rooms, was signed by the ADM, Regional Compliance Nurse, and physician. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during the staff meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the MDS Coordinator. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADON. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADM. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was often caught smoking in her room. Resident #1 was a supervised smoker and needed a smoking blanket or apron when smoking, date initiated 8/23/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, if smoking materials are found on her, remove from her and continue to redirect her not to smoke in room, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, resident was notified via negotiated risk agreement (NRA) on 8/23/25 that smoking is only allowed supervised at designated times in designated areas, she may not store smoking materials in her room and must check these in at the nurse station, this resident requires a fire-resistant smoking apron while smoking, dates initiated 7/14/25, 8/14/25, and 8/23/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7. Resident shakes/has tremors while smoking, 8. Resident falls asleep while smoking, 9. Had past accidents/incidents with smoking materials, 10. Are there any visible burn marks on the resident's clothing or coat, 11. Does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2. This resident requires direct supervision while smoking, 3. this resident requires a fire-resistant smoking apron while smoking, 6. The evaluation has been discussed with the resident. Record review of care plans for Residents #2,#3, $4, #5, #6, #7, #8, #9, #10, #11, #12, #13 revealed they were updated with current smoking information on 8/23/25. During an interview on 8/24/25 at 9:55AM, the ADM said they completed in-services to ensure care plans were updated timely and were updated with residents most current information. They would discuss smoking assessments weekly and review care plans. He said they would document their monitoring on logs to ensure they were monitoring according to the plan of removal. During an interview on 8/24/25 at 1:10 PM, with Resident #3, stated he messed up when he took his oxygen tank in the smoking room, he owned it. He stated he was upset about the changes of the supervised smoking schedule and how the code to the front door was changed so they have to be let out by staff. He stated he was upset about the changes and felt like it was prison. During an observation and interview on 8/24/25 at 1:24PM, with HK O, stated staff were in-serviced about having a smoking schedule and the different departments would take turns and monitor the residents when smoking and all of the new smoking procedures and rules. Resident #1 was observed smoking and was wearing an apron. Three HK staff were watching her. Resident #1 was observed to be leaning over. A HK staff asked Resident #1 if she was falling asleep. Resident #1 said she was told she could not smoke when she wanted, it would be a schedule. Resident #1 stated staff come get her for smoke breaks. She said she felt claustrophobic with the apron but she would wear it. Resident #1 was observed dropping ash on herself. During an interview on 8/24/25, at 1:39PM, Resident #2 said he was told about the new rules for smoking. He said his vape was at the nurse station and he would be supervised while vaping. He said he was told about the new smoke schedule and that the front door code was changed. He said he was told staff would let him out after he signed out. He said he had no concerns to report. During an interview on 8/24/25 at 3:45PM, the Regional Compliance stated she provided in-services to staff on care plans. She said the ADON was trained to review care plans in service the ADON, MDS Coordinator, and ADM would review them once a week. She would train the new DON on those updates after they start. She said she would continue to in-service staff of changes in care plans. She said care plans should've been updated immediately because it could cause harm to residents. She said she would come once a week and review care plans to ensure they were updated. She would also train the new DON to check weekly to ensure care plans are updated. On 8/24/2025 between the 3:00 to 5:31PM interviews were conducted with the following staff members: CNAs D, K, L, RN A, LVNs B, C, E, I, MAs F, G, H, SW, DOR, RTs M, N, DS, HKs O, P, Q, AIT, and LS J. All staff members stated they were in-serviced on 8/23/25 and 8/24/25 on smoking policies including scheduled smoking and smoking schedule, and residents were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes.On 8/24/25 at 6:00PM, the ADM was informed the IJ was removed however the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. 2. The facility failed to ensure Resident #2 received direct supervision per his smoking assessment from staff while smoking a vape on 8/23/25. 3. The facility failed to ensure Resident #3 did not have his oxygen tank with him while smoking on 8/22/25 and 8/23/25. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 8/23/24 at 4:18 PM. While the immediate jeopardy was removed on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. The failures could place residents at risk for serious injury, serious harm, burns, and death. Findings included: Resident #1 Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room, was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessments dated 8/1/25, revealed under Section A Evaluation answered yes to the following questions, 7. resident shakes/has tremors while smoking, 8. resident falls asleep while smoking, 9. had past accidents/incidents with smoking materials, 10. are there any visible burn marks on the resident's clothing or coat, 11. does the resident have finger dexterity problems; and under Section B Summary the following options were checked, 2. This resident requires direct supervision while smoking, 3. This resident requires a fire-resistant smoking apron while smoking, and 6. The evaluation has been discussed with the resident. Record review of progress notes written by SW for Resident #1 dated 7/28/25, revealed staff spoke with the resident regarding the smoking policy and smoking in the hallways. Resident #1 stated she was confused and believed the CNA wheeled her into the smoking room. Reminded her that it was unsafe for her and the other residents to smoke inside. She understood and stated it won't happen again. Nurse and I (SW) asked her if we could hold the cigarettes and lighter at the nurses' station. Resident #1 said no, I'm not a child. Spoke with family member in person. Updated her and asked her if she would be willing to speak with the resident about the situation. The family member said yes and was understandable of situation. Record review of nursing progress notes, author unknown, for Resident # 1 dated 8/14/25, revealed Resident #1 was noted to be found smoking in the room. The resident stated she did not know she was in the building and said she thought she was in the smoking area. The resident was educated about fire hazards and a no smoking tolerance in the building. The family member was notified about the incident. Resident #2 Record Review of Resident #2's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a medical history of paraplegia unspecified (paralysis of the legs or lower body), quadriplegia, 5-C7 complete (paralysis of all four limbs, torso, and some organs), unspecified asthma uncomplicated (lung condition that causes trouble breathing), epilepsy unspecified not intractable without status epilepticus (brain disorder causing seizures), unspecified lack of coordination, muscle weakness (generalized), muscle wasting atrophy (loss of muscle tissue), cognitive communication deficit (difficulty with communication due to cognitive impairment), and dysphagia unspecified (difficulty swallowing). Record review of Resident #2's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 12 which indicated Resident #2 had moderate cognitive impairment. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Resident #3 Record Review of Resident #3's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had a medical history of acute and chronic respiratory failure with hypercapnia (build-up of carbon dioxide in the lungs), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar levels that cause nerve damage), obstructive sleep apnea (temporary pauses in breathing during sleep), acute diastolic (congestive ) heart failure with hypoxia (blood backed up in the lungs and insufficient oxygen delivery to the body), unspecified lack of coordination (difficulty controlling muscle movements), muscle weakness (generalized), tracheostomy status (surgical opening in the neck to provide an airway into the trachea), and cognitive communication deficit (difficulty with communication due to cognitive impairment). Record review of Resident #3's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 9 which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. Record review of the facility's smokers list dated 8/21/25 revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 smoked. During an observation on 8/22/25 at 8:54 AM, revealed a sign was observed next to the front door on the outside front porch area that indicated it was a no smoking area. During an observation and interview on 8/22/25 at 11:44 AM revealed there was sign posted on the wall outside of smoking room, that reflected, No oxygen beyond this point. Observed Residents #1 and #3 in the smoking room. Resident #3 was observed smoking a cigarette while sitting in his scooter with an oxygen tank in between his legs. Resident #3 was observed wearing a trach collar on his neck. Resident #1 was within arm's reach distance from Resident #3. Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when someone spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron while holding an unlit cigarette that she stated she was holding for later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he used oxygen as needed during the day. He said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room, but they never stayed to supervise her. He said staff or himself or other residents would light Resident #1's cigarettes for her. He said he had not seen Resident #1 burn herself while smoking. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but she was not asleep. During an interview on 8/22/25 at 2:46PM, Resident #9 said she smoked in the smoke room regularly. She had seen Resident #1 in the smoke room and had never seen staff supervise Resident #1 when she smoked. She said she had never seen Resident #1 wear an apron when she smoked. She said Resident #1 had fallen asleep while smoking. She said she had not seen Resident #1 get burned while smoking. During an interview on 8/22/25 at 2:48PM, Resident #12 said he occasionally saw staff bring Resident #1 outside but staff did not stay to supervise her. He said Resident #1 did not wear a smoking apron. During an interview on 8/22/25 at 3:25 PM Resident #4 said he saw Resident #4 smoke, staff brought her in the smoking room, staff did stay to watch her. He said he had never seen her wear a smoking apron. He said he was not aware of her burning herself. He said staff lit her cigarettes or other smokers would. During an observation on 8/22/25 at 3:31 PM, revealed staff CNA D rolled Resident #1 in the smoke room and exited at 3:33PM. Resident #1 stayed in the smoking room. During an interview on 8/22/25 at 3:36 PM, CNA D said she had worked at the facility for 2 weeks and worked 6am to 6pm. She said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to be in the room to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware if Resident #1 had to be supervised when she smoked or any other accommodations. She said she was not aware of any resident on her hall that had to be supervised while smoking. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. CNA D entered the smoking room and asked Resident #1 why she was in the corner. Resident #1 said she did not know where she was in the smoking room. Resident #1 said she was still trying to learn her way around the facility. CNA D moved her to the table and gave her an ashtray. She was observed to use the ashtray properly. Smoking aprons were observed to be hanging in the smoke room and a red container labeled fire blankets was hung up on the wall in the smoke room. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff went back inside, they did not watch her. She had not seen Resident #1 burn herself. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in in the building. He said staff were supposed to put Resident #1 in front of the table in the smoking room, she was still able to light her own cigarette, or he would light it for her. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear a protective apron when smoking. He was not aware of any residents on halls 1 and 2 that were required to be supervised while smoking or wear an apron. They tried to promote independence. He had no concerns of her smoking independently. He said he did not know if she had burned herself at the facility but had seen burn marks on almost all of her clothing. He was not aware if it happened before she moved to the facility. He said the only other cigarettes he kept at the nurse station was for Resident #13 who needed help rationing them. During an interview on 8/22/25 at 4:47PM, Resident #2 said he only smoked a vape in the front, he did not smoke in the smoking room because could not stand the smell. He said staff were not with him when he smoked, and he did not need a smoking apron to smoke a vape. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 9:13 AM, RN A sated there were no vapes being held at the nurse station for any residents. He said they only held Resident #1's cigarettes due to her smoking in her room and she accused people of stealing her cigarettes. He said he had not been told to supervise any residents while they smoked. He said residents were not supposed to take oxygen tanks in the smoking room. He said there were no residents in the facility they supervised when smoking. He said residents who vaped must still vape in the smoking room. During an observation on 8/23/25 at 9:23 AM, a sign was observed on the wall hanging next to the smoking-room entrance doors that reflected, No oxygen beyond this point. During an interview on 8/23/25 at 10:27 AM, a Family Member said Resident #1 had been blind for 7 years and smoked since she was 7 years old. The family member said Resident #1 caught a pillowcase and blanket on fire in the past, she had burned her fingers, ankle, knee, thighs, and clothing. No medical treatment was needed for any of the burns. The family member said the facility no longer allowed Resident #1 to keep her cigarettes or a lighter in her room. She had to get them from staff now. The staff would light the cigarette for Resident #1. She thought staff watched Resident #1 smoke but was not sure. She said she did not know if Resident #1 was required to wear an apron when smoking. The Family Member said when Resident #1 lived with her, she often fell asleep and the cigarette had fallen out of her hand before. The Family Member said Resident #1 denied being asleep and she would tell Resident #1 to wake up and Resident #1 would not know the cigarette had fallen out of her hand. She said the ADM told her they caught Resident #1 smoking in her room. She told them she would ask Resident #1 to let them hold her cigarettes at the nurse station for safety purposes. She now gave the cigarettes to nurse for them to hold and Resident #1 was okay with it. The Family Member said Resident #1 smoked 12 to 15 cigarettes a day. The Family Member said Resident #1 did not have neck muscles and held her neck down. She's had several falls over the years, she was never trained to walk with a walking stick, and she did not know how to do anything while being blind. During an observation and interview on 8/23/25 at 10:53AM, Resident #2 was observed sitting on the front porch smoking his vape. No staff were observed to be present. Resident #2 said he kept his vape in his room. During an interview on 8/23/25 at 10:57 AM, LVN B said she was the charge nurse on hall 2. She said Resident #3 was the only smoker on this hall and he was an independent smoker. LVN B said Resident #2 used an oxygen concentrator at night and used a portable oxygen tank as needed during the day. She said Resident #3 was not supposed to take the oxygen tank into the smoke room because it could start a fire and burn himself or others. She said the oxygen tank could ignite. LVN B said everyone was responsible to make sure he did not take it in there. LVN B said she had been asking for scheduled smoke breaks so they could check everyone on their way to the smoke room. She said no one vaped on hall 2. She said she was not sure if Resident #3 kept his cigarettes in his room because they held cigarettes for everyone at the nurse station on hall 1. She said she was not aware if residents were allowed to keep cigarettes and lighters in their rooms. She said there was no system in place to track when residents smoked. She said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and hopefully passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said Resident #3 went to dialysis on Tuesday, Thursday, Saturday, and took a portable oxygen tank with him. RT M said Resident #3 used the concentrator at night and as needed during the day and during the day he used room air and could use oxygen as needed when out of breath. RT M said Resident #3 knew he was not supposed to take the oxygen tank into the smoking room. RT M said the oxygen tank was flammable and could ignite and burn a resident or start a fire. She said no one on hall 2 vaped. She stated there was no system in place to track when Resident #3 went to smoke because there was no smoking schedule. RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes on a resident's smoke assessment. During an observation and interview on 8/23/25 at 11:16AM, Resident #1 was observed at the nurse station and asked for a cigarette. RN A was observed getting a cigarette out of a lock box and he gave it to Resident #1. RN A then rolled Resident #1 into smoking room, lit the cigarette, and exited room at 11:19AM. Resident #1 was observed smoking with no apron and sitting at table with an ashtray. She was observed to use the ashtray. She said she had never burned herself but had burned her clothes when she lived with her one of her family members. She said she had never started a fire with a cigarette. During an observation on 8/23/25 at 11:31 AM, Residents #3 and #8 were observed smoking outside on the front porch within arm's reach of each other. Resident #3 had a portable oxygen tank in between his legs on his scooter. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. SW said Resident #1 got upset and said they were trying to make her look bad when they tried to address it with her. The SW stated staff held Resident #1's cigarettes at the nurse station because she was an unsafe smoker, she had ashes in her hair, and she missed the ashtray. The SW stated Resident #1 had not burned herself while at the facility, but all of her clothing had burn holes, but Resident #1 reported they were from before she lived at the facility The SW said Resident #1 was lethargic and was hunched over and she looked like she fell asleep when she was smoking, but there was no confirmation of that. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments, but she thought the EHR prompted staff when they were due. The SW said per policy, residents were not supposed to keep cigarettes in their room, nurses were supposed to keep them. The SW said Resident #1 went on a pass with her family member and could bring cigarettes in without them knowing. The SW said she was not aware of residents that kept cigarettes in their rooms. She said she did not think residents were supposed to take oxygen tanks in the smoking room because residents could get burned or catch on fire, the oxygen tanks could explode, and it was a safety concerns. The SW said there was a fire blanket in the smoking room. She said they had not had anyone report burning themselves or their clothing. The SW said it wouldn't hurt for Resident #1 to wear an apron even if she denied getting the burn holes while at the facility, but she did not think Resident #1 would agree. Resident #1 said she did not want to be treated like a child. The SW said a potential negative outcome of not supervising resident were that they could get burned, ashes in their clothing, cigarettes may not be put out properly, and there would be cigarette butts everywhere. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans, she helped with therapies, PASRR, and helped on the floor if needed. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said there had been meetings with staff, resident council meetings, and with the ombudsman about smoking issues at the facility. The MDS Coordinator said residents go to the grocery store and could bring smoking materials in without them knowing. She said residents were not supposed to keep cigarettes or lighters in their rooms, they were kept at the nurse desk. She said she was not sure about vapes but she thought they would be treated like cigarettes. She said resident were not supposed to vape in their room or keep vapes in their rooms. She said there was a sign outside the smoking room that reflected, no oxygen beyond this point. She said she did not think residents could take oxygen tanks in the smoking room. She said residents were not allowed to smoke on the front porch and were not supposed to smoke outside next to someone with an oxygen tank. The MDS Coordinator said she saw Resident #3 smoking with another resident on the front porch this morning and she told them they were not allowed to smoke there; however, she did not notice Resident #3 had an oxygen tank between his legs. The MDS Coordinator said she was not sure if a person that vaped had to be supervised since there was no fire involved. She said she was not sure if there was a system in place to ensure staff were communicating changes in smoking restrictions. She said staff monitored the facility to see if they saw residents with cigarettes in their hands, but they could not do anything about the ones that hid them and took them into their rooms. She said all residents who smoked and used oxygen knew they could not take oxygen in the smoking room. She said there was no system to check resident's with oxygen before they enter the smoking room, there was not smoking schedule as resident's smoked whenever they wanted. The MDS Coordinator said a potential negative outcome could be that the oxygen tank could explode and cause a fire, that happened at the facility about 14 years ago. She said that was even possible even if they were smoking outside in close proximity to an oxygen tank. She said residents could burn themselves and they could catch themselves on fire if not supervised and not wearing an apron. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. She said she was not aware Resident #3 took his oxygen tank into the smoke room and outside while sitting with other people smoking. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next . He said residents who used oxygen should've left the oxygen in their room or somewhere safe, they were not allowed to take oxygen in the smoke room. He said the system to monitor that was the residents should tell staff they wanted to smoke and staff were supposed to remove the oxygen tank from their chairs. He said residents were not supposed to keep cigarettes and lighters in their rooms. He said residents were not supposed to smoke vapes or keep vapes in their room. They must vape in the designated smoking areas. He said the SW was responsible for completing smoking assessments. He said there was no policy on how often smoking assessments were completed and updated. He said an initial smoking assessment was completed during admission, and they would go from there to determine when to complete the next one. He stated himself and the DON were responsible to communicate changes in smoking assessments to staff. He said changes were currently communicated during morning meetings. The ADM said he believed a person that was an unsafe smoker and vaped should be supervised as well. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. The ADM said oxygen was combustible and could start a fire and burn residents. He said he was not aware a resident took an oxygen tank in the smoking room or that a resident was outside with an oxygen tank smoking with other resident. He said he was not aware of a resident that vaped that was not being supervised that should be supervised. He said he did not know any of the residents that vaped. He said he was aware there was a resident that should be wearing an apron and should be supervised but he was not aware that was not occurring. He said regardless of the age of documentation it should be followed until otherwise updated. He said care plans should have been updated with the updated smoking assessment results so everyone could know what was going on with residents because that was what staff referred to when they provided care to the residents. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates need to the MDS and care plan were to discuss them during morning meetings to ensure care plans were being followed. During an interview on 8/23/25 at 7:12 PM, LVN C said he completed the smoking assessment on Resident #1 because he observed her two or three times and observed her to be asleep with a cigarette in her hand, on her lap, in the smoking room. He said it was not a scheduled assessment. He said Resident #1 got mad and denied falling asleep. He said some of her clothes had burn marks on them and he did not believe her clothes had burn marks on them when she moved in. He said Resident #1 wanted to smoke as soon as she woke up. He said he did not believe she was fully awake but they could not tell her anything because she would holler and curse people out. He said she smoked every 30 minutes. He said last night she called her family member at 4:00AM to bring her cigarettes because she ran out. LVN C said Resident #1 accused him of stealing her cigarettes. He said he forwarded the smoking assessment to the ADON and he went and told the ADON that night he did it, as well. He said he did not know what the ADON was supposed to do with the assessment next. He said he would tell his aides of the changes and he would verbally pass it on to the nurse on the next shift. He said the aides he told no longer worked at the facility, but he told the new aide last night. He said he told RN A about it as well. He said RN A told him last night that the SW told him Resident #1 was to b

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 3 residents (Resident #50 and Resident #172) and 3 of 3 staff (CNA B, CNA C, and CNA D) reviewed for infection control. 1. CNA C failed to follow policy and procedure for handwashing while providing incontinent care for Resident #50, during observations of peri care on 04/15/2025 at 1:10 PM. 2. CNA B and CNA D failed to follow policy and procedure for handwashing while providing wound care for Resident #172, during observations of wound care on 04/15/2025 at 1:52 PM. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #50 Record review of Resident #50s face sheet undated revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), chronic kidney disease,. Record review of Resident #50's quarterly MDS dated [DATE] revealed a BIMS score listed as 6 meaning severe cognitive impairment. The MDS under bowel continence Resident #50 was listed as a 3 meaning always incontinent. Record review of Resident #50's Care Plan dated 04/24/23, revealed that Resident #50 was listed as having bowel and bladder incontinence with the goal listed as: Resident #50 will remain free from skin breakdown due to incontinence and brief use. Interventions listed as: apply barrier cream after each incontinent episode, incontinent care at least every 2 hours and apply moisture barrier after each episode. During an observation on 04/15/2025 at 1:10 PM CNA C, was observed coming out of another resident's room and began gathering supplies to provide peri care for Resident #50 without washing her hands first. CNA B gathered supplies. CNA C went into Resident #50's bathroom and washed hands prior to providing care by placing soap in hands and using friction for 10 seconds prior to rinsing hands under water. CNA C used a clean paper towel to dry hands and disposed in the trash. CNA C used a clean paper towel to turn off the faucet. CNA C put on clean gloves. CNA C laid out supplies. CNA C provided privacy by closing the blinds, curtain, and door. CNA C took off gloves and disposed of them in the trash. CNA C washed hands by turning on the water and placing soap in her hands using friction for 7 seconds before rinsing under running water. CNA C used a clean paper towel to dry hands and disposed in the trash. CNA C used a clean paper towel to turn off the water faucet. CNA C removed Resident #50's pants. CNA C removed gloves and disposed in the trash. CNA C washed hands by turning on the water and placing soap in her hands and using friction for 4 seconds before rinsing under running water. CNA C used a clean paper towel to dry hands and disposing it in the trash. CNA C used a clean paper towel to turn off the faucet and disposed in the trash. CNA C removed resident's brief. CNA C put on clean gloves. CNA C used one clean wipe to clean the right groin and disposed in the trash. CNA C used one clean wipe to wipe the left groin and disposing in the trash. CNA C used a clean wipe to wipe the center under the scrotum and the shaft of the penis and then disposing in the trash. CNA C turned the resident to the left side and used one clean wipe to wipe the entire buttocks area several times with one wipe. CNA C disposed of the wipe in the trash. Put on a clean brief on the resident and pulled his pants up. CNA C covered Resident #50. CNA C removed gloves and discarded in the trash. CNA C gathered trash. CNA C did not wash hands after providing care. During an interview on 04/15/2025 at 1:20 PM, CNA C stated that she had been trained in infection control practices and hand washing through in-services, monthly. CNA C stated that she had also been trained through [company] training and competency checks every few months. CNA C stated that she had a competency check for hand washing last week. CNA C stated that the policy stated that she should wash her hands with soap for 30 seconds before rinsing. CNA C stated that she was nervous and did not pay attention to her hand washing. CNA C stated that the negative potential outcome of not following the policy for hand washing would be the spread of infection and it could make others and herself sick. Resident #172: Record review of Resident #172s face sheet undated revealed a [AGE] year-old female with an admitted [DATE] with the following diagnoses: urinary tract infection. Record review of Resident #172's quarterly MDS dated [DATE] revealed a BIMS score was left blank and incomplete. The MDS under bowel continence Resident #172 was listed as a 3 meaning always incontinent. Record review of Resident #172's Care Plan date revised on 01/09/24, revealed that Resident #172 was listed as having bowel and bladder incontinence with the goal listed as: interventions listed as: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode. During an observation on 04/15/2025 at 1:52 AM, CNA B and CNA D provided peri care for Resident #172. CNA D washed her hands by tuning on the water, placing soap in hands, and using friction for 9 seconds before rinsing with water. CNA D used a clean paper towel to dry hands and disposed in the trash. CNA D used a clean paper towel to turn off the water faucet and disposed in the trash. CNA B then washed his hands by turning on the water faucet and putting soap in his hands, using friction for 12 seconds before rinsing under water. CNA B used a clean paper towel to dry hands and disposed in trash. CNA B used a clean paper towel to turn off the water faucet and disposed in trash. Both CNA B and CNA D put clean gloves on. CNA B uncovered the resident and unfastened the front of the resident's brief, rolling it and tucking it between the legs. CNA B used one wipe to wipe the left side and disposed of wipe. CNA B used a clean wipe to wipe the right groin and disposed in the trash. CNA B used a clean wipe to wipe the center groin and disposed in the trash. CNA B and CNA D turned Resident #172 to the left side. CNA B used a clean wipe to wipe Resident #172's buttocks once and disposing of wipe in the trash. Observed a large amount of BM on the wipe. CNA B used another clean wipe to clean Resident #172's buttock with BM still coming off on the wipe. CNA B disposed of the used wipe in the trash. Observed BM still on the resident's anus and buttocks when CNA B placed a clean brief on Resident #172. Surveyor asked to CNA B to check again to see if there was still BM. CNA B used a wipe and observed BM still on the resident. CNA B used a few more wipes and wiped until resident was clean. CNA B put a different clean brief on Resident #172 and placed pants on. CNA B covered resident and lowered bed. CNA D gathered trash. CNA B and CNA D disposed of gloves and did not wash hands after resident care. During an interview on 04/15/2025 at 11:15 AM, CNA B stated he had been trained in hand washing and infection control practices through in-services, every month. CNA B stated that he did observe the BM that he had failed to clean off the resident. CNA B stated he should have kept cleaning with a clean wipe until the resident was completely clean. CNA B stated that it was important to verify that all urine and BM was cleaned off the resident because it could cause infections, rashes, and skin breakdown. CNA B stated he was not sure why he did not continue to clean the resident. CNA B stated that for hand washing he believes that he was to wash hands for 30 seconds before rinsing and then dry hands thoroughly. During an interview on 04/15/2025 at 11:20 AM, CNA D stated that she had been trained in hand washing and infection control practices by in-services, every couple of weeks. CNA D stated that she was nervous. CNA D stated the policy stated that staff should wash hands before, during, and after care for 15 seconds. CNA D stated that the ADON and DON was responsible for overseeing the training. CNA D stated that the negative potential outcome was infections. During an interview on 04/15/2025 at 2:00 PM, The ADON stated that the policy stated that staff should wash their hands thoroughly for 20-30 seconds before, during, and after providing care to a resident. ADON stated that staff had been in-serviced last week for hand washing. ADON stated competency checks will be completed monthly. ADON stated that staff should have followed policy for infection control and hand washing. ADON stated the negative potential outcome for not following infection control practices or hand washing is the risk for spreading infection. During an interview on 04/15/2025 at 2:00 PM, The Administrator stated that staff should go by the policy. The Administrator stated she was not familiar with the policy due to being new to the facility. The Administrator stated she does expect staff to follow the policy. The Administrator stated the negative potential outcome of not following the policy for infection control or handwashing is the spread of infection. Record review of the facility-provided policy titled, Perineal Care, dated 05/11/2022, revealed: Objective: Use proper hand washing techniques to keep hands and exposed portions of the arms clean. Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure: 10. Perform hand hygiene 11. [NAME] gloves and all other PPE per standard precautions . Back Side: . 24. Doff gloves and PPE 25. Perform hand hygiene Important Points: Do not wipe more than once with the same surface Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use. Record review of the facility-provided policy titled, Infection Control Plan, date updated on 03/2023, revealed: Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Definitions: Hand Hygiene: is a general term that applies to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub. Hand washing: refers to washing hands with plain soap and water. Fundamentals of Infection Control Precautions: Hand Hygiene: hand hygiene continues to be the primary means of preventing the transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. When hands are visibly soiled (handwashing with soap and water); Before and after direct resident contact (for hand hygiene is indicated by acceptable professional practice). Before and after assisting a resident with personal care (oral care, bathing). Upon and after coming in contact with a resident's intact skin (when taking a blood pressure or pulse, and after lifting a resident) Before and after assisting a resident with toileting (hand washing with soap and water). After handling soiled or used linens, dressings, bedpans, catheters, and urinals. After removing gloves or aprons. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. It is necessary for staff to have access to proper hand washing facilities with available soap (regular or antimicrobial), warm water, and disposable towels and/or heat/ air drying methods. Alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques. Recommended techniques for washing hands with soap and water include wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a new disposable towel; and turning off the faucet on the hand sink with the disposable paper towel.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 Residents (Resident #172) reviewed for incontinent care in that: CNA B failed to clean BM completely off Resident #172 until Surveyor intervention. This failure had the potential to affect residents by placing them at an increased risk of infections and skin breakdown. Findings include: Resident #172: Record review of Resident #172s face sheet undated revealed an [AGE] year-old female with an admitted [DATE] with the following diagnoses: urinary tract infection. Record review of Resident #172's quarterly MDS dated [DATE] revealed a BIMS score was left blank and incomplete. The MDS under bowel continence Resident #172 was listed as a 3 meaning always incontinent. Record review of Resident #172's Care Plan date revised on 01/09/24, revealed that Resident #172 was listed as having bowel and bladder incontinence with the goal listed as: interventions listed as: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode. During an observation on 04/15/2025 at 1:52 AM, CNA B and CNA D provided peri care for Resident #172. CNA D washed her hands by tuning on the water, placing soap in hands, and using friction for 9 seconds before rinsing with water. CNA D used a clean paper towel to dry hands and disposed in the trash. CNA D used a clean paper towel to turn off the water faucet and disposed in the trash. CNA B then washed his hands by turning on the water faucet and putting soap in his hands, using friction for 12 seconds before rinsing under water. CNA B used a clean paper towel to dry hands and disposed in trash. CNA B used a clean paper towel to turn off the water faucet and disposed in trash. Both CNA B and CNA D put clean gloves on. CNA B uncovered the resident and unfastened the front of the resident's brief, rolling it and tucking it between the legs. CNA B used one wipe to wipe the left side and disposed of wipe. CNA B used a clean wipe to wipe the right groin and disposed in the trash. CNA B used a clean wipe to wipe the center groin and disposed in the trash. CNA B and CNA D turned Resident #172 to the left side. CNA B used a clean wipe to wipe Resident #172's buttocks once and disposing of wipe in the trash. Observed a large amount of BM on the wipe. CNA B used another clean wipe to clean Resident #172's buttock with BM still coming off on the wipe. CNA B disposed of the used wipe in the trash. Observed BM still on the resident's anus and buttocks when CNA B placed a clean brief on Resident #172. Surveyor asked to CNA B to check again to see if there was still BM. CNA B used a wipe and observed BM still on the resident. CNA B used a few more wipes and wiped until resident was clean. CNA B put a different clean brief on Resident #172 and placed pants on. CNA B covered resident and lowered bed. CNA D gathered trash. CNA B and CNA D disposed of gloves and did not wash hands after resident care. During an interview on 04/15/2025 at 11:15 AM, CNA B stated he had been trained through in-services, every month. CNA B stated that he did observe the BM that he had failed to clean off the resident. CNA B stated he should have kept cleaning with a clean wipe until the resident was completely clean. CNA B stated that it was important to verify that all urine and BM was cleaned off the resident because it could cause infections, rashes, and skin breakdown. CNA B stated he was not sure why he did not continue to clean the resident. During an interview on 04/15/2025 at 2:00 PM, ADON stated that staff had been in-serviced last week. ADON stated that staff should have followed policy. ADON stated the negative potential outcome for not following infection control practices or the risk for spreading infection. During an interview on 04/15/2025 at 2:00 PM, The Administrator stated that staff should go by the policy. The Administrator stated she was not familiar with the policy due to being new to the facility. The Administrator stated she does expect staff to follow the policy. The Administrator stated the negative potential outcome of not following the policy for infection control or the spread of infection. Record review of the facility-provided policy titled, Perineal Care, dated 05/11/2022, revealed: Introduction: It is essential that residents using various devices, absorbent products, external collection devices, etc. be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. Objective: Use proper hand washing techniques to keep hands and exposed portions of the arms clean. Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure: 10. Perform hand hygiene 11. [NAME] gloves and all other PPE per standard precautions 15. If required, use a towel or extra incontinence pad to protect the mattress cover from being soiled. 17. Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area-clean to dirty. Female resident-Working from front to back, wipe one side of the labia majora, the outside folds of perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. . Back Side: 21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal care. 24. Doff gloves and PPE 25. Perform hand hygiene Important Points: Do not wipe more than once with the same surface Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to close food spices stored on shelf in kitchen. This failure could place residents at risk for food contamination and foodborne illness. The findings included: Observation on 04/13/25 at 11:55 AM the following spices were stored open on the shelf: Italian Seasoning Oregano Garlic Salt Garlic Powder Observation on 04/14/25 at 12:31 PM the following spices were stored open on the shelf: Granulated Garlic Ginger Italian Seasoning Garlic Powder During an interview on 04/15/25 at 10:30 AM with [NAME] A, she stated all spices should be clean and closed when stored on shelf. She stated there was not a reason the spices should be stored open. She stated the potential negative outcome could be food poising, drying out and contamination. She stated she had training on proper storage of spice and food in the kitchen. During an interview on 04/15/25 at 10:42 AM with DM, she stated all spices should be closed when on storage shelf. She stated all staff were responsible for making sure spices and food were properly stored. She stated all staff had been trained. She stated the potential negative outcome could be rodents or insects getting in the spices and not being good anymore. During an interview on 04/15/25 at 11:00 AM with Interim ADM, she stated all spices should be closed when stored. She stated all staff have been trained. She stated all staff were responsible for closing spices before storing. She stated the DM was responsible for checking to make sure the spices were properly stored. She stated the potential negative outcome could be bug or something else getting in the spices and in the resident's food. Record review of the facility's undated policy, titled Dry Storage and Supplies dated 2012, reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: . 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 4 of 5 Residents (#1, #2, #3, and #4) reviewed for hospice care: 4 of 5 residents receiving hospice services did not have a physician's order for hospice care. These problems could result in residents not receiving needed care as ordered by their physician. These problems had the potential to affect any resident receiving hospice care services. The findings included: Resident #1 Record review of the admission record for Resident #1, dated 10/07/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Neuromuscular dysfunction of bladder (urinary problems), anemia (low red blood cells) and schizophrenia (chronic mental disorder). The face sheet revealed Resident #1 used Hospice Company A. Record review of the annual MDS for Resident #1, dated 07/05/24, revealed Resident #1 had a BIMS score of 06, which indicated severe cognitive impairment. Section O revealed Resident #1 was receiving hospice services. Record review of the care plan for Resident #1, last reviewed on 07/16/24, revealed a focus area for: Resident #1 has a terminal prognosis and/or is receiving hospice services, initiated on 01/15/24. Record review of the physician orders for Resident #1, dated 10/07/24, revealed no physician order for hospice care services. Resident #2 Record review of the admission record for Resident #2, dated 10/07/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: essential hypertension (high blood pressure), hyperlipidemia (too many fats in blood), and malignant neoplasm of bronchus or lung (lung cancer). The face sheet revealed Resident #2 used Hospice Company B. Record review of the quarterly MDS for Resident #2, dated 09/23/24, revealed Resident #2 had a BIMS score of 03, which indicated severe cognitive impairment. Section O revealed Resident #2 was receiving hospice care. Record review of the care plan for Resident #2, last reviewed on 09/26/24, revealed a focus area for: Resident requires hospice as evidenced by terminal illness, initiated on 10/07/24. Record review of the physician orders for Resident #1, dated 10/07/24, revealed no physician order for hospice care services. Resident #3 Record review of the admission record for Resident #3, dated 10/07/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: type 1 diabetes mellitus (chronic autoimmune disease), essential hypertension (high blood pressure), and dysuria (painful urination). The face sheet revealed Resident #3 used Hospice Company A. Record review of the quarterly MDS for Resident #3, dated 09/21/24, revealed Resident #3 had a BIMS score of 02, which indicated severe cognitive impairment. Record review of the physician orders for Resident #3, dated 10/07/24, revealed no physician order for hospice care services. Resident #4 Record review of the admission record for Resident #4, dated 10/07/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: COVID-19 (infection), chronic obstructive pulmonary disease (lung disease), and mood disorder. The face sheet revealed Resident #4 used Hospice Company A. Record review of the significant change MDS for Resident #4, dated 07/26/24, revealed Resident #4 had a BIMS score of 09, which indicated moderate cognitive impairment. Section O revealed Resident #4 was receiving hospice services. Record review of the care plan for Resident #4, last reviewed on 07/30/24, revealed a focus area for: Resident #1 has a terminal prognosis and/or is receiving hospice services with Hospice Company A, initiated on 08/01/24. Record review of the physician orders for Resident #4, dated 10/07/24, revealed no physician order for hospice care services. Record review of a facility document titled, Hospice Residents, provided on 10/06/24 revealed Residents #1, #2, #3, and #4 were listed. Interview on 10/07/24 at 11:44 AM, the DON stated residents and their families choose which hospice company to use and a hospice referral was made. The DON stated a physician order should be in the chart for hospice care services. The DON stated it was her responsibility to ensure residents receiving hospice care have a physician order for hospice. The DON stated she ran an order listing report every morning and reviewed the orders that were already in place. The DON stated she did not know why Residents #1, #2, #3, and #4 did not have a physician order for hospice care and stated it was not followed up on. The DON stated a potential negative outcome to the residents was not receiving hospice care when that was what the resident wanted. Interview on 10/07/24 at 12:09 PM, the Adm stated she expected a physician order to be in place for hospice services. The Adm stated the DON and the ADON's audit the charts and she did not know why these orders were missed. The Adm stated corporate nurses train the DON on their duties, so she does not know about the specific training for the DON. The Adm stated a potential negative outcome to the residents on hospice services were staff may not know which hospice company the resident used. Record review of the facility policy and procedure titled, Hospice Services, with a revised date of 02/13/07 reflected the following: As an end of life measure, the resident or responsible family member may choose to use hospice services within the facility . Procedures: 11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: Physician Certification of Terminal Illness

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 Residents observed for infection control for practices (Resident #1, Resident #2, and Resident #3) in that: 1. CNA A failed to use proper hand washing techniques before and after assisting with resident during wound care for Resident #1. CNA A washed her hands for 6 seconds with soap and friction before rinsing. 2. CNA A failed to use proper hand washing techniques before and after assisting with resident during wound care for Resident #2. CNA A washed her hands for 4 seconds with soap and friction before rinsing. 3. CNA B failed to use proper hand washing techniques before and after assisting with resident during wound care for Resident #3. CNA B put soap in hands, rubbing hands together under water and not allowing to lather. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #1: Record Review of Resident #1's face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of: urinary tract infection, anemia, paraplegia (paralysis of the legs and lower body), gastrointestinal hemorrhage (gastrointestinal bleeding), chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), acid reflux, weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), thrombocytopenia (low platelet level), type 2 diabetes, dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), metabolic encephalopathy (a series of neurological disorders not caused by primary structure abnormalities), high blood pressure. Record review of Resident #1's Annual MDS (Minimum Data Set) dated 08/29/2024, revealed Resident #1 had a BIMS Score of 06, meaning Resident #1 could not recall information. Record Review of Resident #1's Physician Orders dated 09/20/2024 revealed: Right Plantar foot: cleanse, pat dry, apply silver alginate and idosorb, skin prep peri wound, cover with gauze island bordered dressing once daily and PRN, one time a day related to pressure ulcer of other site, unstageable. Record Review of Resident #1 Care Plan dated 05/08/2024 revealed Resident #1 had an unstageable that had progressed to stage 4 on right plantar foot with interventions of administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered, replace loose or missing dressings PRN, access/record/monitor wound healing at least weekly, measure length, width, and depth where possible, access and document status of wound perimeter, wound bed, and healing progress, report declines to the MD, avoid positioning the resident on the location of the pressure ulcer. During an observation on 09/26/2024 at 10:26 am CNA A failed to wash her hands prior to putting gloves on and proceeded with removing Resident #1's boot and sock on the right foot. CNA A held right foot up while LVN C performed wound care. After the completion of wound care CNA A had placed the socks back on Resident #1's foot. CNA A removed gloves and discarded in the trash. CNA A proceeded to wash hands after LVN C coached her to do so. CNA A turned on water in Resident #1's restroom. CNA A wet her hands and applied soap. CNA A applied soap/friction for 6 seconds and then rinsed her hands. CNA A used three clean paper towels to dry her hands and discarded in the trash. CNA A used one clean paper towel to turn off the faucet. Resident #2: Record Review of Resident #2 face sheet revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), seizures (a burst of uncontrolled electrical activity between brain cells that cause temporary abnormalities in muscle tone), quadriplegia (paralysis of all 4 limbs), polyneuropathy (is damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body), acute respiratory failure (results from inadequate gas exchange by the respiratory system), heart failure, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), difficulty swallowing, polydipsia (excess thirst), urinary tract infection. Record review of Resident #2's Annual MDS (Minimum Data Set) dated 07/05/2024, revealed Resident #1 had a BIMS Score of 00, meaning Resident #2 had severe cognitive impairment. MDS indicated that Resident #2 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Under risk of pressure ulcers/injuries indicated that resident was at risk of developing a pressure ulcer. Under unhealed pressure ulcers/injuries indicated that Resident #2 had one or more unhealed pressure ulcers. Under current number of unhealed pressure ulcers/injuries at each stage indicated Resident #2 had 3 stage 3 pressure ulcers. Record Review of Resident #2 Care Plan dated 05/16/2024 revealed: Resident #2 had a stage 3 pressure ulcer to the sacrum and stage 3 pressure wound to the right upper back with interventions of: administer supplements per medical provider or dietician, administer treatments as ordered and monitor for effectiveness, replace loose or missing dressing PRN, access/record/monitor wound healing at least weekly, measure, length, width, and depth where possible, access and document status of wound perimeter, wound bed and healing progress, report declines to the MD, avoid positioning the resident on the location of the pressure ulcer, do not massage over bony prominences and use mild cleansers for peri/care/washing, educate the resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, ensure heels are floated with the use of pillows, follow facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record, notify nurse immediately of any new areas of skin breakdown, notify nurse immediately of any new areas of skin breakdown, open areas, redness, blisters, discoloration noted during bath or daily care, report loose or missing dressings to the nurse. Wounds to be managed by [NAME] wound physicians, treat per provider orders and notify for worsening or non-healing wounds. Date Initiated: 02/15/2024 During an observation on 09/26/2024 at 10:59 am CNA A failed to wash her hands prior to putting gloves on and proceeded with removing Resident #2's boot and sock on the left foot. After the completion of wound care CNA A had placed the socks back on Resident #2's foot. CNA A removed gloves and discarded in the trash. CNA A turned on water in Resident #1's restroom. CNA A wet her hands and applied soap. CNA A applied soap/friction for 4 seconds and then rinsed her hands. CNA A used three clean paper towels to dry her hands and discarded in the trash. CNA A used one clean paper towel to turn off the faucet. Resident #3: Record Review of Resident #3's face sheet revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnosis of: schizoaffective disorder (a mental health condition including schizophrenia and mood disorder), type 2 diabetes, morbid obesity, anxiety, quadriplegia (paralysis of all 4 limbs), high blood pressure, acute respiratory failure, contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), difficulty swallowing, muscle weakness, tracheostomy site. Record review of Resident #3's Annual MDS (Minimum Data Set) dated 08/18/2024, revealed Resident #3 had a BIMS Score of 12, meaning Resident #3 had mild cognitive impairment. MDS indicated that Resident #3 had a risk of a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Under unhealed pressure ulcers/injuries indicated that Resident #3 had one or more pressure ulcers/injuries. Under skin conditions indicated that Resident #3 had one stage 4 pressure ulcer and one stage 4 pressure ulcer that was upon admission. Record Review of Resident #3's Physician Orders, dated 08/09/2024, revealed Resident #3 had a stage 4 pressure ulcer to coccyx, cleanse, pat dry, apply collagen sheet and silver alginate, skin prep peri wound, cover with silicone bordered dressing and secure once daily PRN. Record Review of Resident #3 Care Plan dated 12/29/2023 revealed: Resident #3 had a pressure ulcer and the potential for additional pressure ulcer development with impaired mobility. Resident #3 had a stage 4 pressure ulcer to the coccyx with interventions of: Needs assistance to turn/reposition at least every 2 hours, requires a cushion to their wheel or Geri chair, requires the use of an air mattress, treat pain as per orde3rs to treatment/turning to ensure the resident's comfort, use lifting device, draw sheet, to reduce friction, wounds are to be managed by wound physicians, treat per provider orders and notify for worsening or non-healing wounds. During ana observation on 09/26/2024 at 11:20 am . CNA B turned on faucet and wet her hands. CNA B put soap in her hands and used soap/friction for three seconds and immediately rinsed her hands. CNA B grabbed two clean paper towels to dry hands and used the same paper towel used to dry hands to turn off the faucet. CNA B put on clean gloves and proceeded in aiding with turning of Resident #3 for LVN C to provide wound care. CNA B aided in turning Resident #3 twice and replaced wedge underneath Resident #3. CNA B covered Resident #3, removed gloves, and discarded in the trash. CNA B went into Resident #3 restroom to wash hands. CNA B turned on faucet and wet hands. CNA B put soap in hands and used soap/friction immediately under the water and not allowing soap to lather. CNA B completely rinsed hands. CNA B used two paper towels to dry hands and used the same paper towel to dry hands to turn off faucet. During an interview with CNA B on 09/26/2024 at 12:11 pm. CNA B stated she was trained in hand washing by competency checks and in-services monthly. CNA B stated hand washing should occur for 20 seconds, rinse, and then dry. CNA B stated the negative potential outcome of not washing hands properly would be to transfer germs and infections to others. During an interview with CNA A on 09/26/2024 at 1:01 pm. CNA A stated she read the policy for hand washing. CNA A stated the policy for hand washing stated to wet the hands with water, put soap on hands, wash hands for 20 seconds, rinse hands, and use clean paper towel to dry hands. CNA A stated she did not follow the policy for washing hands but did not know why she did not. CNA A stated she was not thinking about it. CNA A stated the policy had guidelines to stop the spread of infection. CNA A stated she worked in the facility since July and had not completed a competency check. CNA A stated she had been trained in hand washing by in-services, every two weeks. During an interview with the DON on 09/26/2024 at 1:10 pm. the DON stated hand washing was something that had been gone over multiple times and staff should know the process of washing hands. The DON stated accurate handwashing must be practiced for all residents, but especially those who are susceptible to infections such as trach/vent and wound residents. The DON stated the expectations for an effective infection control practices would be to follow the policy and the ultimate goal was to prevent the spread of infections. The DON stated hand washing competencies are done monthly as well as in-services. The DON stated the negative potential outcome for not using proper hand washing techniques would be the spread of infection and long term spread of infection could lead to death. During an interview with the Administrator on 09/26/2024 at 1:30 pm revealed the expectations of proper hand washing was to follow the policy and use proper infection control practices. The Administrator stated the staff had been trained in hand washing multiple times. The Administrator stated training for hand washing was by in-services and competency checks monthly. The Administrator stated the negative potential outcome of not using proper hand washing techniques would be the spread of infection. Record review of the facility skills competency for CNA B titled; Hand Hygiene Checkoff dated 07/09/2024 revealed the following expectations were met: Hand washing with soap and water: 1. Wet hands with water using temperature that is comfortable. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. 4. Rinse your well under clean, running water. 5. Dry your hands using a clean towel or air dry them. Turn faucet off using a dry paper towel to touch the handle protecting clean hands from the contaminated handle. Record review of the facility skills competency for CNA A titled; Hand Hygiene Checkoff dated07/11/2024 revealed the following expectations were met: Hand washing with soap and water: 1. Wet hands with water using temperature that is comfortable. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. 4. Rinse your well under clean, running water. 5. Dry your hands using a clean towel or air dry them. Turn faucet off using a dry paper towel to touch the handle protecting clean hands from the contaminated handle. Record review of the facility in-services titled; Hand hygiene dated 03/18/2024 revealed 91 staff members signed and attended, No evidence of CNA A or CNA B attending this in-service. Record review of the facility in-services titled; Hand hygiene dated 03/18/2024 revealed 91 staff members signed and attended, CNA B attended this in-service. Record review of the facility in-service training report titled; Infection Control dated 08/10/2024 with 24 staff members attended and signed, CNA A attended this in-service. Record review of the facility policy titled; Fundamentals of Infection Control Precautions date revised 03/2024 revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. .before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). Before and after assisting a resident with personal care. Upon and after coming into contact with a resident's intact skin (when taking a pulse or blood pressure and lifting a resident). After removing gloves or aprons. Recommending techniques for washing hands with soap and water include: Wetting hands first with clean, running water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a new disposable towel; and turning off the faucet on the hand sink with the disposable paper towel. Gloving: Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard. Record review of the facility policy titled; Infection Control Plan date revised 03/2024 revealed: The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 6 medication carts (Hall 200), in that: The facility failed to ensure that the Hall 200 medication cart was secured when unattended. These failures could result in the theft or misuse of medications. The findings include: Observation on 6/27/24 at 11:54 AM, revealed a medication cart was left unlocked and unattended in Hall 200 in the corridor between room [ROOM NUMBER] and the Hall 200 nurse's station. The cart was against the east wall with the unlocked drawers of medications facing the public access walkway of the hall. This cart was full of hall 200 resident medications. The surveyor alerted LVN A on 6/27/24 at 11:56 AM and he went to look for the nurse for Hall 200. RN A was observed leaving room [ROOM NUMBER] where he had been with a resident and returned to the cart on 6/27/24 at 11:57 AM. During this visit, cognitively impaired, independently ambulatory residents were observed ambulating the facility corridors at random times throughout the day on 6/27/24, which included Resident #1 at 9:52 AM and Resident #2 at 9:59 AM. On 6/27/24 at 11:59 AM an interview was conducted with RN A, nurse for nurse station 200. Regarding the unlocked medication cart, he stated, Sometimes I get in a rush and forget. I keep the key with me. He stated he left the cart unlocked because he was in a rush. He added, I should have locked it. He stated he had received training at the facility, a couple of weeks ago, regarding medication counts, securing the medication cart keys and locking the cart. He further stated he, and the nurses who have the (medication cart) keys, were responsible for ensuring the security of medications in the cart. He also stated, residents could come in and take medicine and staff too as a result of leaving the medication cart unlocked. On 6/27/24 at 5:22 PM an interview was conducted with the DON regarding medication security. She stated RN A was not following facility protocol and policies by leaving the medication cart unlocked. Regarding training on medication security, she stated, Yes, one (in-service) was done on 3/28/24 stating to lock the cart. Anytime it is locked the key should be in their pocket, and they should secure and lock the cart at all times. She stated every nurse and medication aide in possession of the cart was responsible for ensuring the security of the medications in the cart. She added the DON should ensure they follow the policy. She stated, residents could get in the cart and could have a reaction to the medication and pass away as a result of accessing medication on an unlocked cart. She further stated that the facility's population was younger and more active, and the active residents were more likely to be out and possibly see the unlocked medication cart. She stated, she and the ADON walked halls and conducted reeducation as a means of monitoring medication security. Record review of the In-Service Training Report dated 6/20/24 given by the Administrator, DON and ADON revealed a Subject documented as, Medication Misappropriation/Securement of Medication/Narcotic. The Summary of Subject Matter was documented as, Did you know that taking any medication that belongs to a resident from the cart is misappropriation and is punishable by actual prison time? Medications for long-term care residents are provided and paid for by Medicaid, which is funded by the State of Texas. Think before taking anything from a resident. When you receive keys, you are taking ownership of those narcotics. You must always keep narcotic key secure on person. If you leave the property on your lunch break, or you do not want to be disturbed on your lunch break, you MUST count with nurse covering and leave them the keys. You must always keep your cart locked anytime you are away from it. Documentation on the report revealed that RN A attended this in-service. Record review of the facility policy titled Pharmacy Policy and Procedure Manual 2003, PA 03-4.02, Revised 10/25/17 revealed the following documentation, Medication Administration Procedures . 5. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse 8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured .

Based on observation, interview and record review the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 1 of 28 residents (Resident #1) and 1 staff (SW) reviewed for infection control. The SW failed to wear appropriate PPE and practice hand hygiene before entering or exiting room [ROOM NUMBER] for Resident #1 who was on contact isolation for Carbapenem Resistant Pseudomonas Aeruginosa (bacteria resistant to certain classes of antibiotics). The SW removed a reusable cup from room [ROOM NUMBER] and carried it to the community water station at the nurse's station, refilled the cup and returned the cup to room [ROOM NUMBER]. The SW entered three additional residents' rooms with signed posted enhanced barrier precaution after exiting room [ROOM NUMBER]. An Immediate Jeopardy was identified on 6/12/24/at 4:35 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:50 PM. While the immediate jeopardy was lifted on 6/13/24 at 4:15 PM, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. These failures could place residents at risk for infection and cross contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization , or death. Finding include: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female with an initial admitted [DATE] and a readmitted [DATE] with the following diagnoses: acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood), chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), tracheostomy status (surgically created hole in the windpipe for breathing), dependence on respirator [ventilator status], and hypothyroidism (thyroid condition). Record review of Resident #1's Quarterly MDS dated [DATE] revealed resident #1 had a BIMS of 08, which indicated the resident's cognitive status was moderately impaired. Additionally, section H - Bladder and Bowel revealed Resident #1 had an indwelling catheter, section M - Skin Conditions revealed Resident #1 had a pressure ulcer, and section O - Special Treatments, Procedures and Programs revealed Resident #1 received tracheostomy care and uses an invasive mechanical ventilator. Record Review of Resident #1's Care Plan, dated 02/22/2024, revealed Resident #1 was on contact precautions related to Pseudomonas Aeruginosa in sputum (bacterial organism in lung secretions). Interventions were to have PPE readily outside of the resident's room, place sign in the resident's door to check with nurse prior to entering put gown, gloves, and to sanitize hands prior to entering and exiting the room. The Care Plan also revealed Resident #1 has Chronic Obstructive Pulmonary Disease (COPD), a tracheostomy related to respiratory failure, a Foley catheter, had oxygen therapy via trach collar secondary to respiratory failure, and was ventilator dependent related to respiratory failure. Record Review of Resident #1's Physician's Orders dated 06/12/2024 revealed an order dated 02/23/2021 for isolation protocol for Carbapenem Resistant Pseudomonas Aeruginosa - Staff will require gown and gloves while giving care. The physician's orders further revealed an order dated 10/06/2023 for Trach care, an order dated 04/27/2024 for Foley catheter care, and an order dated 01/30/2024 for a vent setting: AC/VT = 450, Rate = 18, Peep = 8 8/liters every shift. Record Review of Resident #1's Discharge Instructions Record dated 02/22/2024 revealed CRPA infections can occur in a wound or surgical incision. It can also occur in other areas of the body, such as the urinary system, blood stream, lungs, and abdomen. CRPA infections may cause severe illnesses such as: Gastrointestinal illness, Pneumonia, bone or joint infections, bloodstream infections, and invasive infections in other body organs. CRPA bacteria may colonize wounds, the respiratory tract of some patients, and medical devices that are in place for a long time. Healthcare facilities may utilize isolation precautions to prevent the spread of the bacteria to other patients. The most effective way to prevent the spread of bacteria is to wash your hands often. This condition is caused by Pseudomonas aeruginosa bacteria that no longer responds to carbapenem antibiotic medicines. This bacterium can be spread by: direct contact of an open wound of an infected person, having contact with a medical device that has the bacteria on it (is contaminated), and touching surfaces or items that have been in contact with an infected person. Those most at risk include patients in hospitals, especially if: you had a long-term hospital stay, especially in an intensive care or burn unit, you have been on antibiotics for the treatment of other conditions, you use a breathing machine (ventilator), you use urinary (bladder) catheters, or are on kidney dialysis, you have a short-term or long-term vascular access device, such as a catheter or IV, you have wounds from surgery or burns, or you have a weakened defense system (immune system). Pseudomonas aeruginosa infections are generally treated with antibiotics. Unfortunately, people in exposed to healthcare settings like hospitals or nursing homes, Pseudomonas aeruginosa infections are becoming more difficult to treat because of increasing antibiotic resistance. To identify the best antibiotic to treat a specific infection, healthcare providers will send a specimen (often called a culture) to the laboratory and test any bacteria that grow against a set of antibiotics to determine which are active against the germ. The provider will then select an antibiotic based on the activity of the antibiotic and other factors, like potential side effects or interactions with other drugs. For some multidrug-resistant types of Pseudomonas Aeruginosa, treatment options might be limited. During an observation on 6/12/24 at 10:43 AM, the SW was observed in the 200 hall, entering room [ROOM NUMBER], which had a sign posted outside of the door for Contact Precautions, and a clear three drawer cart with PPE in the cart. The SW entered room [ROOM NUMBER] without any PPE on and did not practice hand hygiene. SW walked to the bedside near Resident #1 and spoke with Resident #1. SW picked up the re-useable drinking cup for Resident #1 and exited the room. SW walked down the hall to the nurse's station and used the community water station to refill the cup for Resident #1. SW touched the spout for the community water pitcher to refill the cup. SW placed the cup on the counter at the nurse's station and walked over to talk with another staff. SW walked back to the nurse's station and picked up the re-usable cup and walked back down the hall to room [ROOM NUMBER] and entered the room. SW placed the re-usable cup on the BST and exited the room. SW did not Donn (put on correctly)PPE either time she entered the room, and she did not practice hand hygiene any time she entered or exited the room. SW entered three additional resident rooms after exiting room [ROOM NUMBER]. SW entered room [ROOM NUMBER], 205 and 204. SW was observed knocking on the doors and pushing the doors open with her hands. There was signed posted on the outside of the door for room [ROOM NUMBER], 205 and 204 for Enhanced Barrier Precautions. The SW did not practice hand hygiene prior to entering or exiting rooms [ROOM NUMBER]. During an observation on 6/12/24 at 10:43 AM of a facility sign posted outside of room [ROOM NUMBER] titled Contact Precautions reflected (Contact Precautions are in addition to Standard Precautions. See Standard Precautions for questions) Attention! Visitors must report to the nurse station before entering. Patient Placement: Private room, if possible. Ensure that patients are physically separated (i.e.,>3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for direct contact. Personal Protective Equipment (PPE) Don gown and gloves outside of the resident's room. Remove gown and gloves and observe hand hygiene before leaving the patient-care environment. Hand Hygiene (according to Standard Precautions) Avoid unnecessary touching of surfaces in close proximity to the patient. When hands are visibly dirty, contaminated with proteinaceous material, visibly soiled with blood or body fluids, wash hands with soap and water. If hands are not visibly soiled, or after removing visible material with soap and water, decontaminate hands with alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Preform Hand Hygiene: Before having direct contact with patients After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure or lifting a patient) If hands will be moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient After removing gloves Patient Transport When transporting or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contaminated and covered. Remove and dispose of contaminated PPE and preform hand hygiene before and after transporting patients on Contact Precautions. Patient-Care Equipment and Instruments/Devices If common use of equipment for multiple patient's is unavoidable, clean and disinfect such equipment before use on another patient. During an observation on 6/12/24 at 10:50 AM of facility sign posted outside of rooms 204, 205, 208 for Enhanced Barrier Precautions reflected: Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following: High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. During an interview on 6/12/24 at 10:54 AM, the SW stated she did not see the Contact Precaution sign posted outside the door for Resident #1 in room [ROOM NUMBER]. She stated she did not practice hand hygiene or Donn PPE before she entered room [ROOM NUMBER]. She stated she did not practice hand hygiene before she entered or exited rooms 208, 205 and 204. She stated the Enhanced Barrier Precaution sign posted outside of rooms [ROOM NUMBER] were posted so staff would know what to do when entering those rooms. She stated that Resident #1 had asked for more water, so she carried the re-usable cup down the hall to get more water and took it back. She stated that she had been trained and in-serviced on PPE and infection control and if the sign was posted staff should follow the instructions posted. During an interview on 6/12/24 at 11:57 AM, the Corporate RN stated that if the sign was posted for Contact Isolation, then staff should observe the proper PPE prior to entering the room. She stated even if a staff entered the room to talk with the resident, they would need to observe the proper PPE per the sign posted. During an interview on 6/12/24 at 2:35 PM, the DON stated the facility had trained and in-serviced staff over Infection Control, Enhanced Barrier Precaution, that the SW and other non-nursing staff would need additional education on infection control. She stated all staff should read the signs posted before they enter a room. She stated the SW should not have brought the re-usable cup out of the room, and the SW should get a foam cup and take the refill in the throw away cup in the room. The DON stated staff should not take personal belongings of a resident out of a room that is on isolation. She stated that SW did not follow the facility policy for contact precautions when she entered the room without PPE and took the resident's cup out of the room to refill it. She stated that SW placed other residents at risk for infection. During an interview on 6/13/24 at 11:52 AM, the Administrator stated the SW should have worn PPE and practiced hand hygiene before she entered Resident #1's room. She stated she expected staff to preform hand hygiene when they entered or exited a room, put on all needed PPE before they entered a room with contact isolation precaution, and equipment should be disposable. She stated the SW should not have carried the re-usable cup out of the room and down the hall to the community water station. She stated staff could have spread the bacteria to other residents, or staff. She stated that the DON would monitor staff and randomly pick staff to complete competency check offs on hand hygiene. She stated the DON had completed hand washing competency check offs and donning and doffing (take off correctly) PPE on all staff that had clocked in for work on 6/13/24. She stated the facility would discuss any area of concerns in the QA meeting. During an interview on 6/13/24 at 9:20 AM, the Corporate RN stated the facility knew they did not follow what was posted about contact isolation on 6/12/24. During an interview on 6/13/2024 at 1:31 PM with the NP whose office saw Resident #1, she stated she was familiar with Resident #1 as well as the resident's diagnosis of CRPA. She stated she was aware that Resident #1 was on contact precautions at the facility. The NP stated that in her professional opinion, a staff member removing a cup from the isolation room, carrying it down the hallway and using a community water station to refill it, then returning the cup to the isolation room, would place other residents on the hall at a huge risk for infection and/or cross contamination with CRPA. Record review of facility's resident roster for hall 200 dated 6/12/24 reflected 28 residents lived on that hall, 11 residents had active wounds, 12 residents received tube feeding, 22 residents had tracheostomies and 11 of those were ventilator dependent and 14 residents had catheters. Record review of facility provided policy titled, Fundamentals of Infection Control Precautions dated 2019, revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: o Before and after entering isolation precaution settings; o After handling soiled equipment or utensils; Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. 5. Gowns and protective apparel 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment. Record review of facility provided policy titled, Transmission-based Precautions dated 2010, revealed: Transmission-based precautions are used for residents who are known to be, or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measures to prevent transmission. It is essential both to communicate transmission-based precautions to all health care personnel, and for personnel to comply with requirements. A sign will be placed at the resident's room entrance to See Nurse Before Entering so to communicate to staff and visitors so that the nurse can communicate any precautions; in addition, it will be communicated to staff via verbal report what type of precautions are required to care for the resident. It is important to use the standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precaution determines the type of PPE to be used. Communication (e.g., verbal reports, signage) regarding the particular type of precaution to be utilized is important. When transmission-based precautions are in place, PPE should be readily available. Proper hand washing remains a key preventive measure, regardless of the type of transmission-based precaution employed. Contact Precautions Contact transmission risk requires the use of contact precautions to prevent infections that are spread by person-to-person contact. Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room. Prior to leaving the contact precaution room the PPE is removed and hand hygiene is performed. Depending on the situation, options for residents on contact precautions may include the following: a private room, cohorting, or sharing a room with a roommate with limited risk factors (e.g., without indwelling devices, without pressure ulcers and not immunocompromised). Implementation of Transmission-Based Precautions The Personal Protection Equipment (PPE) will be readily available near the entrance to the resident's room. Signage will be posted on the resident's door instructing visitors to see the nurse before entering. Record review of facility provided policy titled, Hand Washing dated 2012, revealed: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin. 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. c. Wet hands. d. Deliver soap in palm. e. Lather up soap. f. Cup the fingertips within the palms of the hands and rub vigorously. g. Interlock fingers and work them back and forth and side to side. h. Scrub back of hands, wrists and lower arms. i. Rinse hands, wrists, and lower arms thoroughly 3. Dry hands and arms with paper towel, then turn off the faucets with the paper towel. 4. Discard used paper towels in trash receptacle. 5. Food preparation sinks are not to be used for hand washing. This was determined to be an Immediate Jeopardy (IJ) on 06/12/2024 at 4:35PM. The Administrator, DON, and Corporate Nurse were notified. The Administrator was provided with the IJ Template on 06/12/2024 at 4:58 PM. The following Plan of Removal submitted by the facility was accepted on 06/13/2023 at 10:15 AM Record review of the facility Plan of Removal reflected the following: (Facility Name) Plan of Removal 06/12/2024 F880 ALLEGED ALLEGATION: Infection Control Staff did not wear correct PPE while entering the room of a resident on isolation Staff did not sanitize when entering and exiting the isolation resident room Staff removed a non-disposable beverage cup from the infected resident room and filled from the community water station and used hand to operate the spout. Staff placed infected resident cup on the nursing station contaminating the desk and placing immunocompromised residents at risk due to cross contamination. Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 6/12/2024: Any staff member not present or in-serviced on 6/12/2024, will not be allowed to assume their duties until in-serviced. o Staff will be Inservice on the following: In-service staff on Infection Control Overview In-service staff on proper PPE use for MDRO isolation and Enhanced Barrier Precautions In-service staff with return demonstration related to hand hygiene and donning and doffing PPE. In-service staff on management of multi- use or non-disposable items leaving isolation rooms In-service staff on Carbapenem-resistant pseudomonas aeruginosa (CRPA) In-service staff over management of all dietary items including beverage cups using disposable items only. o Community water station was removed from service and sanitized prior to continued use. o Nursing station was immediately sanitized to prevent cross contamination. o Disposable cups will be placed behind the nursing station for use with MDRO isolation residents. o All non-disposable cups were removed from the resident room. o Disposable blood pressure cuffs, thermometer, stethoscope to be kept in room to prevent cross contamination. o MDRO isolation signs will be printed in bright orange color to attract staff attention prior to entering resident rooms. The medical director was notified of the immediate jeopardy situation on 6/12/2024 at 1745. Monitoring The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts. The DON/designee will observe all MDRO resident rooms 3 times weekly to assure that non-disposable dietary items are not in resident room. The QA committee will review findings and makes changes as needed. During an observation on 6/13/24 at 10:25 AM revealed there was a bright orange contact precaution sign posted outside of room [ROOM NUMBER]. Staff observed donning PPE prior to entering the room. Disposable foam cups were observed in room [ROOM NUMBER]. The re-useable drinking cup was no longer in room [ROOM NUMBER]. During an observation on 6/13/24 at 10:30 AM revealed foam cups were at the nurse's station at the community water station for use. During an observation on 6/13/24 at 11:24 AM revealed disposable equipment was observed in room [ROOM NUMBER] for staff use. Record review of the facility in-service dated 6/12/24 titled Meal Service to isolated residents revealed: Absolutely no trays may enter isolation residents' rooms. One staff member may don gown, mask, gloves and enter the resident room. A second staff member is to hand the disposable containers with resident meals to the staff member in PPE to give to resident. (76 staff had signed). Record review of the facility in-serviced dated 6/12/24 titled Transfer Devices with Isolation Residents revealed: Multi use, non-Disposable patient care devices must be sanitized upon completion of use. (i.e. Hoyer Lifts, Geri chairs). *K-Quat is to be used on non-disposable items. Other multi use patient care devices must remain in the resident's room and be sanitized upon completion of use. (i.e. BP cuff, stethoscope, pulse oximeter, glucometer). *Sani wipes to be used on these items. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Hand Hygiene and policy revealed: Hand Hygiene, you may use alcohol-based hand cleaner or soap / water for the following: and examples of when to use. You must use soap/water for the following (alcohol-based hand cleaner is not recommended) examples given. (77 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Enhanced Barrier Precautions and policy revealed: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled MDRO Isolation revealed: Carbapenem Resistant Pseudomonas aeruginosa/Carbapenem resistant Acinetobacter baumannii. Residents are on contact isolation. Disposable medical equipment is required (stethoscope, blood pressure cuff, pulse oximeter, etc.). disposable cups for hydration (water is carried into the room in disposable cups). Donning and doffing PPE is required (Gown, mask and gloves). Rooms are clearly marked with bright isolation signage. Any staff attempting to enter these rooms must perform hand hygiene, and don masks, gloves, gowns. Prior to exiting the room masks, gloves, gowns are removed and disposed of, and hand hygiene preformed. All staff are required to follow all infection control policies. (74 staff signed). Record review of the facility in-service dated 6/12/24 titled Refilling isolation beverages revealed: Residents on contact isolation are served meals on Styrofoam plates and disposable utensils to prevent cross contamination to the dietary department or staff picking up trays. When managing a non-disposable drinking cups for these residents, they may not leave the room to be refilled. We may bring in a disposable cup with ice and water to refill the container. Those are disposed of inside of the resident room. If the non-disposable drink receptacle needs to be washed, and cannot be washed in the room, we will throw it away and get a new one. (71 staff signed). Record review of competency test dated 6/13/24 and titled Putting on and Removing Personal Protective Equipment (PPE) revealed 45 tests were completed for staff. Record review of competency test dated 6/13/24 and titled Hand Hygiene revealed 48 tests were completed for staff. During an observation interview on 6/13/2024 at 11:24 AM with Resident #1 and family member who was present in the room, revealed the resident was connected to a ventilator via her tracheostomy and was able to answer questions with a head shake or nod. When asked if all staff donned PPE prior to entering her room, Resident #1 nodded her head yes. When asked if staff were friendly with her while performing care, Resident #1 nodded her head yes. The family member also stated staff are very pleasant with the resident always. The family member stated prior to the foam cups being brought to the resident's room yesterday, the staff would bring drinks to the room in a disposable, clear cup. During an interview on 6/13/24 at 1:05 PM, the Dietary Aide stated she received in-serve on contact isolation precaution and the process that must be done before entering a resident room on those precautions. She stated she received in-service on EBP and when PPE would be needed. She stated there were signs posted outside the doors for EBP and bright orange signs posted for Contact precaution. She stated she was in-serviced on infection control and CRPA. She stated she was in-serviced on hand hygiene, and it must be performed prior to entering and exiting rooms; and how to preform hand hygiene, and staff completed competency check off for hand hygiene. She stated she was in-serviced on disposable containers used for residents on contact precautions, and that nothing could be removed from the room, as well as how a meal would be served, and that any items used that are not disposable must be cleaned and sanitized with K-quat sanitizer solution. She stated if she had any questions or concerns, she would ask staff before for assistance before she entered a room. During an interview on 6/13/24 at 1:36 PM, the MD Assistant stated the facility notified her of the IJ for infection control on 6/12/24 and the POR. She stated she informed the Medical Director and they agreed with the POR. She stated they followed up with the facility on 6/13/24. During an interview on 6/13/24 at 2:40 PM, the Activity Director stated she went in resident's rooms to provide activities. She stated there are signs posted outside of resident rooms when on isolation or EBP. She stated the facility in-serviced her on infection control, CRPA, donning and doffing PPE, hand hygiene, when to wash hands and when to use hand sanitizer, the bright orange sign posted for contact precaution, the PPE used for isolation and when to use it She stated the facility provided an in-service about staff using disposable cups for containers for residents that are on contact isolation precautions. That staff cannot remove items for the resident rooms if on isolation, staff needs to use foam cups to take water or ice in rooms and throw away in rooms. That staff should not bring items out of rooms for residents on isolation. That any non-disposable items that were used in an isolation room would need to be cleaned and sanitized with k-quat. During an interview on 6/13/24 at 2:45 PM, LVN A stated the facility provided in-service over contact isolation, infection control, EBP, equipment used in isolation rooms, cleaning and disinfecting those items before use in another room or with resident, disposable drinking cups, and meal containers, how to serve a meal to a resident on isolation, PPE used for isolation verses EBP and when to use PPE, hand hygiene, when to wash hands, when staff can use hand sanitizer, and to practice hand hygiene before entering rooms and exiting rooms. LVN A stated staff should use foam cups when refilling water for residents on isolation, to take the refill in the room and dispose of the foam cup, not bring items out of the room. The facility will use orange sign posted outside of resident rooms for contact isolation and signs for EBP will be posted outside of resident rooms. During an interview on 6/13/24 at 2:53 PM, the SW stated the facility provided an in-service on EBP and there were signs posted outside of the door and staff were to sanitize their hands before they enter the room and when they exit the room and if any care is provided PPE must be worn; contact isolation and an orange sign would be posted outside of the resident room, staff would have to perform hand hygiene then put on PPE, gown, gloves and a mask before they entered the room, remove the PPE before they exit the room and preform hand hygiene. If a resident was on contact isolation precautions staff cannot remove anything from the room like a cup. If the resident requested a refill or a drink staff would need to use a disposable foam cup and take the drink or refill to the resident in the room and throw away the cup in the room. The SW stated that the facility provided in-service over hand hygiene when to was hands and when sanitizer can be used and how to wash hands. The SW stated the facility provided in-service over infection control and CRPA and to follow the policy. She stated that any reusable item that had to be used in a resident room on isolation would need to be cleaned and disinfected with k-quat before it could be used with another resident or in another resident's room. During an interview on 6/13/24 at 3:15 PM, Housekeeper B stated she had been in-serviced on infection control. She stated she was in-serviced this morning on hand hygiene, abuse, how to clean resident with cotton balls. She stated she must wash hands and put on a gown, gloves before entering and remove PPE and sanitize hands before exiting for rooms on enhanced precautions. She stated rooms that have contact precautions have an orange sign outside the door. She stated for those rooms she must wash hands, put on a gown, gloves, and mask before entering and remove all PPE and sanitize hands before exiting. She stated she is not aware of any residents having falls recently. During an interview on 6/13/24 at 3:48 PM, the Physical Therapy Assistant stated she had worked at the facility for 2 years. She stated she has received several in-services today. She stated she washes her hands when working with residents on isolation precautions and wears PPE. She stated contact precautions mean she cannot take anything out of the resident's room and must use K-Quat to sanitize any equipment going in and prior to exiting the room. She stated rooms that have contac [TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure staff used good hygienic practices while preparing food. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 03/04/24 at 11:00 AM during observation of puree meal preparation: During an observation on 03/04/2024 at 11:00AM, Cook A was observed washing her hands then she picked up a pan of hamburger patties and tongs and placed the hamburger patties in the processor bowl using the tongs. She walked over and set the pan and tongs down. She covered a larger pan with hamburger patties in it with the foil wrap and placed oven mitts on both hands and opened the oven door and placed the larger pan in the oven. She removed oven mitts and walked over to the table where the puree machine was located and turned the puree machine on to puree the hamburger patties. She put her hand inside the center opening of the lid for the puree machine, while turning the lid to remove the lid. She touched plastic spoons and sampled the pureed hamburger patties. Cook A then picked up the lid and returned it to the bowl on the puree machine and placed her hand in the center opening of the lid. She turned the machine on and continued to puree the food. She turned the machine off and placed her hand in the center opening of the lid to remove lid and then touched plastic spoons and sampled the food. She walked away from the table where the puree machine was located and placed an oven mitt on her left hand then picked up a sauce pan from the stove top and poured broth in the puree bowl. She returned the sauce pan to the stove top and removed the oven mitt. She returned to the puree machine and placed her hand inside the center opening of the lid and replaced the lid on the bowl and turned the machine on. She placed her hand in the center opening of the lid and removed the lid. She touched plastic spoons and sampled the pureed food. She picked up a small pan and a spray bottle of vegetable nonstick spray and sprayed the pan. She picked up a spatula, then removed the puree bowl from the puree machine and poured the puree hamburger patties in the pan and covered the pan with foil. She then placed the puree bowl, lid, and blade in the dishwasher. She took the bowl, lid, and blade out of the dishwasher and returned it to the puree machine. She walked over to the table, put an oven mitt on her left hand, and picked up a pan of broccoli, carried it to the puree machine and scooped broccoli in the puree bowl. She carried the pan back to the table and placed it on the table and removed the oven mitt. She returned to the puree machine and placed the lid on the bowl and placed her fingers inside the opening of the lid. She turned the puree machine on and pureed the broccoli. She placed her hand on the lid and her fingers inside the opening of the lid and turned the lid to remove it. She picked up plastic spoons and sampled the pureed broccoli. She picked up a pan and sprayed the pan with the vegetable non-stick spray. She removed the bowl and blade from the puree machine and picked up a spatula and used the spatula to transfer the pureed broccoli from the puree bowl to the pan. She carried the pan of pureed broccoli to the table and covered it with foil wrap. She picked up the puree bowl and blade and placed it in the dishwasher. There was no observation of her washing hands during the pureed food process except when she first started. During an observation on 03/05/2024 at 12:05 PM, DS A use a food scoop to place bread pudding in bowls for the lunch meal. She was not wearing gloves and placed her left thumb on the outer edge of the pan, moving her left thumb along the outer bottom edge of the pan. Observed a piece of the bread pudding fall on the edge of the pan where her left thumb had been placed. She used the scoop to push the piece of bread pudding back into the pan and scooped it into a serving bowl. Observed DS A scoop bread pudding into scoop with her right hand then she turned around to serving window and picked up napkin and silverware with her left hand from another employee and walked to the other side of the kitchen with the scoop in her right hand with bread pudding in the scoop. She returned to the prep table where the pan of bread pudding was at with the scoop in her right hand and placed the bread pudding in a bowl. During an interview on 03/06/2024 at 2:28 PM, Cook A was asked about the observations made of the puree process for the lunch meal on 3/5/24 and when hand hygiene should be completed during the puree process. She stated, about every 20 minutes or so. She stated she did recall she touched several items yesterday and did not washing her hands in between tasks. She stated she was moving too fast during the process and did not wash her hands. She stated the potential negative outcome of not washing hands could be spread of bacteria or food poisoning. She stated she was trained on hand hygiene by the facility. During an interview on 03/06/2024 at 2:35 PM with the DM, she stated staff should have washed their hands between tasks. She stated staff have been trained as to when they need to wash hands. She stated DS A should have washed hands and not walked around the kitchen with the bread pudding in the scoop. She stated DS A should have left the scoop in the pan with the bread pudding, completed the other task then then washed her hands before returning to the task with the bread pudding. She stated the potential negative outcome of not washing your hands between tasks could be cross contamination, bacteria, food poisoning and illness to the residents. She stated staff are good at washing hands, not sure why they didn't. She stated all staff have been trained on hand washing. During an interview on 03/07/24 at 10:22 AM with the ADM, she stated dietary staff should wash hands between each task. She stated the DM was responsible for monitoring staff for compliance. She stated staff had been trained on hand washing. She stated the potential negative outcome could be spread of infection to the residents. She stated her expectation were for staff to wash hands between each task. Record review of facility policy titled Hand Washing dated 2012, revealed the following: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin .

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 3 of 4 residents (R#1, R#2, and R#3) reviewed for significant medication errors. The facility failed to ensure: R#1 received 22 doses of her Vimpat (Lacosamide) from 04/20/23 to 05/18/23. Resident #1 was prescribed Vimpat related to epilepsy and missed 22 doses and had seizure activity and was sent to the hospital on 05/17/23. R#2 received 4 doses of Vimpat (Lacosamide) between 05/05/23 to 05/13/23, and R#3 received 3 doses of Levetiracetam between 05/04/23 to 05/12/23. This failure could place residents at risk of complications from deterioration in health, potential for seizure activity, extended recoveries, and hospitalization s. Findings include: Record review of R#1's Admission Record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, quadriplegia, injury of cervical spinal cord, tracheostomy status, dependence on respirator (ventilator), anoxic brain damage, and epilepsy. Record review of R#1's Admission Minimum Data Set, dated dated dated [DATE], reflected Section C Brief Interview for Mental Status (BIMS) was not filled out, which indicated she could not complete the interview. Section G indicated R#1 required total dependence with two-person physical assist for bed mobility, locomotion on and off the unit, dressing, eating and toilet use. Record review of R#1's Care Plan dated 03/30/23 reflected focused area as seizure disorder, and interventions to give medications as ordered, and monitor and document for effectiveness and side effects; Give seizure medications as ordered by doctor, monitor labs and report any sub therapeutic or toxic to physician and follow up as indicated. Record review of R#1's Order Summary dated 03/29/23 reflected Nurse Practitioner NP A ordered Vimpat oral tablet 150 MG (Lacosamide) Controlled Drug Anticonvulsant, give 150 mg via g-tube two times a day related to epilepsy, unspecified, not intractable, without status epilepticus. Record review of R#1's Order Audit Report dated 05/18/23 reflected on 05/10/23 NP A ordered Vimpat oral solution 10 MG/ML (Lacosamide) Controlled Drug give 15 mg via g-tube two times a day related to epilepsy, unspecified, not intractable, without status epilepticus. Record review of R#1's, April 2023 Medication Administration Record (MAR) indicated Vimpat (Lacosamide) oral tablet, give 150 mg via g-tube three times a day related to epilepsy was not administered 04/20/23 at 9 pm, 04/24/23 and 9 pm. Record review of R#1's, May 2023 Medication Administration Record indicated Vimpat (Lacosamide) oral solution, give 15ml via g-tube two times a day related to epilepsy was not administered on 05/10/23 at 5 pm, 05/11/23 at 9 am and 7 pm, 05/12/23 at 9 am and 7 pm, 05/13/23 at 9 am and 7 pm, 05/14/23 at 9 am, 05/15/23 at 7 pm, and 05/17/23 at 9 am and 7pm. Record review of R#1's, May 2023 Medication Administration Record indicated Vimpat (Lacosamide) oral tablet, give 150 mg via g-tube three times a day related to epilepsy was not administered on 05/01/23 at 9 am, 05/04/23 at 9 pm, 05/05/23 at 9 am, 05/06/23 at 9 am, 05/07/23 at 9 am and 9 pm, 05/08/23 at 9 am and 9 pm, 05/09/23 at 9 am and 9 pm, and 05/10/23 at 9 am. Record review of R#1's Progress Notes indicated the following: 05/01/23 at 9:23 am LVN F noted Vimpat Oral Table 150 mg n/a, has been re-ordered from pharmacy. 05/05/23 at 9:51 am LVN F noted Vimpat Oral Table 150 mg n/a, has been ordered from pharmacy. 05/06/23 at 10:08 am LVN F noted Vimpat Oral Table 150 mg not available, ordered from pharmacy. 05/07/23 at 10:19 am LVN F noted Vimpat Oral Table 150 mg has not been delivered by pharmacy. 05/07/23 at 20:16 pm on order. 05/09/23 at 8:01 am Vimpat unavailable. 05/09/23 at 20:15 pm Vimpat unavailable. 05/09/23 at 21:17 pm Vimpat unavailable. 05/10/23 at 10:13 am LVN F noted Vimpat oral tablets 150 mg not available, have been ordered from pharmacy. 05/10/23 at 17:07 LVN F noted Vimpat oral solution 10 MG/ML not delivered from pharmacy. 05/11/23 at 11:49 am LVN F noted NA. 05/11/23 at 17:06 pm LVN F noted NA. 05/12/23 at 8:19 am LVN F noted NA. 05/12/23 at 17:30 pm LVN F noted NA. 05/13/23 at 9:45 am LVN F noted NA. 05/13/23 at 17:02 pm LVN F noted NA. 05/14/23 at 8:33 am LVN F noted NA. 5/16/23 at 17:07 pm LVN E noted NA. 05/17/23 at 9:44 am LVN F noted unable to reorder. 05/17/23 at 9:49 am LVN F noted not available. 05/17/23 at 16:45 pm LVN G noted one on hand, notified administration of need to refill 05/18/23 at 8:54 am LVN F noted NA, not available. 05/18/23 at 10:34 am, RN H noted upon return from the hospital and audit discovered R#1's Vimpat had not been received from the pharmacy, doses were missed, pharmacy notified, and an order is being process for delivery. 05/18/23 at 12:56 pm LVN noted on 05/17/23 R#1 was sent to the hospital related to presenting seizure activity. During an interview with R#1 on 05/22/23 at 2:30 pm indicated she could not recall concerns with her seizure medications. During an interview with LVN E on 05/23/23 at 5:02 pm indicated he noted on R#1's MAR number 9 because Vimpat (Lacosamide) was not available to administer to R#1. The 9 referred to his notes on R#1's Progress notes on the following dates: 05/01/23 at 9 am, 05/05/23 at 9 am, 05/06/23 at 9 am, 05/07/23 at 9 am, 05/10/23 at 9 am and 9 pm, 05/11/23 at 9 am and 5 pm, 05/15/23 at 5 pm, 05/16/23 at 9 am and 5 pm. LVN E indicated this medication in liquid form is not in the emergency kit. During an interview with LVN F on 05/23/23 at 5:30 pm indicated he noted on R#1's MAR a number 9 because Vimpat (Lacosamide) was not available to administer to R#1. The 9 referred to his notes on R#1's Progress notes on the following dates:05/08/23 at 9 am, 05/09/23 at 9 am, 05/12/23 at 9 am and 5 pm, 05/13/23 at 9 am and 5 pm, 05/14/23 at 9 am and 5 pm, and 05/18/23 at 9 am and 5 pm. LVN F indicated this medication in liquid form is not in the emergency kit. Review of R#1's Audit report dated 05/18/23 and conducted by RN-C indicated on 03/29/23 R#1 was discharged from the hospital to the facility with order for Lacosamide 150 mg via g-tube twice (BID), which reflected admission order to facility. On 05/01/23 an email was received for a medication refill for Vimpat oral tablet 150 mg 1 tab via g-tube bid, and medication sent to MD B for escript to Pharmacy D. On 05/10/23 an email was received for reorder for liquid Lacosamide, communication message sent to MD A for liquid dose 10mg/ml 15 ml via g-tube bid. On 05/17/23 email received for liquid and Pharmacy D was asked if this medication could be crushed and was it an acceptable route via g-tube. Pharmacist replied Lacosamide could not be crushed. A communication was sent to MD A to change Lacosamide to liquid form per pharmacy and pill form not to be given via g-tube. On 05/18/23 Liquid from was sent via eScript to Pharmacy D by MD A for 10mg/ml 15 ml via g-tube bid. On 05/18/23 pharmacy confirmed they had not informed facility that this medication could not be crushed and put in a g-tube. On 05/17/23 R#1 was transferred to the hospital then readmitted to facility on 05/18/23. Review of R#1's eTransfer Form dated 05/17/23 indicated she had seizure activity and was referred out to the hospital. During an interview with NP A on 05/23/23 at 2:02 pm indicated the pharmacy failed to send Vimpat in liquid form, instead it was sent in pill form. And not receiving this medication or in the right form could increase chances for seizure activity. Record review of R#2's Admission Record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses of respiratory failure and epilepsy. Record review of R#2's Admission MDS, dated [DATE], C Brief Interview for Mental Status (BIMS) was not filled out, which indicated she could not complete the interview. Section G indicated R#2 required total dependence with two-person physical assist for bed mobility, dressing, and toilet use. Record review of R#2's Care Plan dated 03/07/23 included focused area as seizure disorder, and interventions to give seizure medications as ordered by doctor, monitor labs and report results to physician and follow up as indicated. Record review of R#2's Order by NP A for Lacosamide Sol 10 MG/ML, dated 02/06/2023, give10 ml via PEG-Tube two times a day related to epilepsy. Record review of R#2's MAR for May 2023 indicated Lacosamide Sol 10 MG/ML, give10 ml via PEG-Tube two times a day related to epilepsy, was not administered by LVN F on 05/05/23, 05/06/23, and 05/07/23, and by LVN E on 05/13/23. Record review of R#3's Admission Record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses of other seizures. Record review of R#3's Admission MDS, dated [DATE], Section C Brief Interview for Mental Status (BIMS) was not filled out, which indicated she could not complete the interview. Section G indicated R#2 required total dependence with two-person physical assist for bed mobility, dressing, and toilet use. Record review of R#3's Care Plan dated 03/07/23 included focused area as seizure disorder, and interventions to give seizure medications as ordered by doctor, monitor labs and report results to physician and follow up as indicated. Record review of R#3's Order dated 04/13/23 by MD J for Leveiraceta tablet 500 mg, via G-Tube two times a day for convulsions. Record review of R#3's MAR for May 2023 indicated Leveiraceta tablet 500 mg, via G-Tube two times a day for convulsions, was not administered on 05/04/23 pm, 05/06/23 pm, and 05/12/23 pm. During an interview on 05/24/23 at 8:30 am Corporate Nurse indicated DON K was informed R#1 was receiving Vimpat (Lacosamide) in pill form instead of liquid form. DON K destroyed R#1's Vimpat (Lacosamide) and directed the nurses not to administer the pill form; however, the liquid form had not been delivered to the facility. MD B said it was ok to crush R#1's Vimpat, but Pharmacy D said this medication could not be crushed. The physician's office had issued a triplicate for tablets instead of liquid. Review of facility's Medication Orders policy 03/02/03 not dated but presented as current, included procedures for ordering medications. Reorder medications three to four days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special procession (e.g., Schedule II controlled substances VA prescriptions), order at least seven days in advance of need. The nurse who reorders the medication is responsible for notifying the pharmacy of changed in directions for use or previous ordering labeling errors. New Orders: If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery. Use the emergency kit when the resident needs a medication prior to pharmacy delivery. If not in the emergency kit, contact the pharmacy for possible local pharmacy to fill enough of the medication until the next scheduled delivery. The nurse that receives a new medication order, should be responsible for the following: Order received is accurate and includes all necessary information, documentation about resident's condition justifies a need for the new order received. Family and/or Responsible Party should be notified of the change of condition of the resident. Order must be transcribed accurately to the MAR sheet unless electronic MARs are used by the facility. MAR continues proper times scheduled with arrows for start times and duration of therapy when appropriate. Medication order from the pharmacy timely. Other functions that must be performed or verified by nursing staff includes Medication received in acceptable quantity indicated. Initial dose administered with effective results or no adverse effect. Doses charted accurately on the MAR as ordered and as administered. Medication dispensed accurately with proper labeling.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse for 5 (Confidential Resident #1, #2, #3, #4, & #5) of 28 residents reviewed for abuse in that: After Confidential Resident #1 reported to the Administrator (ADM) Resident #57 was bullying them, (yelling at them and grabbing their wheelchair). The Administrator failed ensure Confidential Resident #1, was free from abuse and failed to follow through with investigating the incident. After Confidential Resident #2 reported to the ADM Resident #57 was pulling their hair and calling them names, the Administrator failed ensure Confidential Resident #2, was free from abuse and failed to follow through with investigating the incident. The Facility Staff failed to ensure Confidential Resident #3 was free from unwanted contact (physical/ coming into their room without permission and verbally bothering them) with Resident #57. The facility Staff failed to report it to the abuse preventionist, grievance official and failed to ensure the resident was protected from Resident #57. After Confidential Resident #4 reported to the ADM Resident #57 was coming in their room repeatedly and having unwanted verbal contact with them, the Administrator failed ensure Confidential Resident #4 was free of unwanted verbal contact and failed to follow through with investigating the incident. After Confidential Resident #5 reported to the ADM Resident #57 was verbally bothering them and coming into their room repeatedly the Administrator failed to ensure Confidential Resident #5 was free from abuse and failed to follow through with investigating the incident. On 1/19/23 at 1:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1/20/23 at 10:45 AM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed Resident #1, #2, #3, #4, #5 & #6 at risk to further verbal and physical abuse by Resident #57 and placed the remaining 74 residents at risk of abuse (verbal, physical and emotional) by Resident #57. Findings Included: Record review of Resident #57's face sheet, dated 1/18/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of alcohol dependence with withdrawal, and abnormality of gait. Record review of Resident #57's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E: Behavior E0200. Behavioral Symptom- Presence & Frequency: No physical, verbal or other behaviors towards anyone. Record review of Resident #57's Annual Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E: Behavior E0200. Behavioral Symptom- Presence & Frequency: No physical, verbal or other behaviors towards anyone. E0600. Impact on Others: No identified symptoms of putting others at risk for physical injury, intruding on the privacy or activity of others, and no significant disruption of care or living environment. Record review of Resident #57's Care Plan dated 01/04/23 revealed the resident did not have a care plan for any documented behaviors. A confidential interview was conducted with Confidential Resident #4 who reported that Resident #57 came into their room, and they did not want him in their room . They said he flipped on her light and yelled I'm back! They said this has been ongoing and they did not like it. They stated she had reported this to the ADM and was told that this would be addressed . They said they reported this verbally at least two weeks before the date of the interview but did not know the exact date. They stated that Resident #57 was with another resident all the time and does not mind that resident coming into their room but does not want Resident #57 in their room. They stated he comes early in the morning and flips on their light, yelling, I am back. They said if they had the ability, they would hit him. They said he makes her uncomfortable, but they cannot do anything alone because they cannot get out of bed. Since they reported this to the ADM, they said no one has come to them and asked if this situation was resolved. They said they had not received any documentation from anyone about the situation. They said it makes them angry when Resident #57 comes to their room and wakes them up early. When they heard him on the hall, they tried to have the staff close her door, but sometimes this did not keep him out, and he will still open her door and look in their room, and this made them uncomfortable. A confidential interview was conducted with Confidential Resident #1, who initially did not want to talk. They stated that nothing would be done. They said that they was being bullied and that nothing had been done about it. They stated 3 or 4 days ago, when they was in the hallway, they was approached by Resident #57. They said Resident #57 was coming down the hall. They said Resident #57 yelled for him to get out of the way. They said they figured they did not get out of the way fast enough because Resident #57 cussed them out and grabbed their wheelchair. They said staff were there and told Resident #57 to return to his hall. Confidential Resident #1 said that they told the ADM about this 3-5 days before the interview, and the ADM said he would take care of it, and nothing has happened . They said when he goes to smoke, if Resident #57 goes to the room, they hurry and get out of the room because they was scared. He said they was afraid and did not feel they could defend themself if ever alone with Resident #57 because they had a stroke and could not do much for themself. They said he had witnessed Resident #57 bother not only them but also bother Confidential Resident #4. They said that Confidential Resident #4 would yell for him to get out of their room, and he would come down the hall yelling, I am back, taunting all of the residents on the hall. He said that even though residents have complained, Resident #57 can go all over the facility, telling everyone what to do. They said that they understood that Resident #57 had rights, but they had rights too, and they felt that their rights were being violated because they cannot feel safe anywhere but in their room. Confidential Resident #1 began to cry and explained that they was scared and did not want to move because this was the only place that fits their needs as far as the smoking schedule but that they did not want to be afraid to leave their room. He said other residents were afraid but won't say anything because nothing was being done about Resident #57. They stated that Resident #57 helps take care of another resident, which was why they believed Resident #57 was allowed to say anything to staff and other residents. Confidential Resident #1 stated since they reported this to the Administrator, no one has come to them and talked to him about the incident. They said they had not received anything in writing stating that this had been resolved. They stated they was scared not to be in their room because they did not know what Resident #57 will do to them. They said they has been called names and threatened by Resident #57. A confidential interview was conducted with Confidential Staff A said that they had observed Resident #57 negative interactions with other residents. They stated no resident has specifically come to them and complained about Resident #57 but that just from observations, they can tell that his behavior bothers other residents. They stated specifically Confidential Resident #3 had told Resident #57 to get out of their room and to leave them alone and they had heard this. They also stated they heard Confidential Resident #4 yell at Resident #57 to get out of their room. Confidential Staff A said they told Resident #57 to get out of Confidential Resident #4 room. They said Resident #57 said he was only playing with Confidential Resident #4. Confidential Staff A stated they did not report this to anyone and this was because she had addressed Resident #57. Confidential Staff A said they also heard negative interactions with Confidential Resident #2. For example, they said they heard Confidential Resident #2 tell Resident #57 to leave them alone. Confidential Staff A said that they had not reported this to the Administrator but had reported it to nurses but could not remember them specifically by name and did not want to say the wrong name. In addition, they said that they had not been trained in what to do about Resident #57 behavior. A confidential interview was conducted with Confidential Staff B. They stated no residents had come to them specifically to complain about Resident #57 but that they had observed behavior that bothered the other residents. They said Resident #57 would come down the halls at 6:00 AM, yelling for the other residents to get up. They said that the residents on Hall 300 preferred to sleep in and that they can tell that it bothered the other residents. They said you hear the residents talking about it. They mainly said the women resident complained the most. When asked for specific residents they knew that Resident #57 had bothered, they could name Confidential Resident #2, Confidential Resident #4, and Confidential Resident #6 . They said they knew those residents did not like how Resident #57 interacted with them because they constantly said that he bothered them, and staff heard them consistently telling him to leave them alone. They said she did not report this specifically to the Administrator or anyone because it happens all the time, and everyone sees it. They said the staff would eventually get tired of it and tell him to stop, but that was it. They said they had not been trained on what to do specifically for Resident #57 behaviors. A confidential interview was conducted with Confidential Resident #3 who reported that Resident #57 bothers them. She said Resident #57 had come into their room , and they had to yell at him to get out multiple times. They said they told him that he was not allowed in the room unless they were invited. They stated they had never invited Resident #57 in his room. They said Resident #57 responded that he would come in anyway, and if they were not in the room, he would come in and take what he wanted. They said that they had not reported anything to anyone because the staff saw it , people know that Resident #57 bothers everyone, and they felt like he does it to her the most. They said that they did not know if he was drunk or high but that he seemed to go to the extreme to bother others. They said some staff would tell Resident #57 to stop, but there were times when staff will just ignore it. They said Resident #57 would make sexual comments toward them. When asked what specifically they said, Resident #57 would say things that included statements about lubricant and if they wanted to do something. They said it makes them uncomfortable and sometimes scared, especially when he blocks them in the hall. They said when he blocks them in the hall, they say whatever he wants to hear so that he will move. A confidential interview was conducted with Confidential Resident #5, who stated that Resident #57 bothers them but that they yells at him to leave them alone . They said that Resident #57 will come in their room and yell at them and turn on her light in the morning. They said that they told the ADM and was told not to talk with him and that even if you do not speak to him, he would come to their room. They said it makes them angry at him when he comes by heir room. They said they did not want him in their room. A confidential interview was conducted with Confidential Staff C who said that they was aware that Resident #57 bothers some residents. They said they had observed him bothering other residents but could not specifically think of others by name. They said that Resident #57 picked on multiple residents. They said this was an ongoing issue and reported this to the Social Worker . They was unable to narrow down a specific date but said it was recent. They said the Social worker would just respond, ok. They said they noticed that Resident #57 would pick on residents that could not defend themselves. They said other staff would ignore Resident #57 because this was the norm for Resident #57. They said rather than correct Resident #57, they would try to distract him by asking if he needed something. They said they had been instructed not to argue with residents, and Resident #57 would argue with you if you entertained him. They said in the daily stand-up meetings that Resident #57's behavior had been discussed, but nothing has ever been done about it. Confidential Staff C said they had observed the resident going into other's rooms but had not observed the resident becoming upset. They said they had discussed with the ADM what they needed to do and said the ADM said all that they needed to do was document Resident #57 behaviors. They could not provide a specific date for this conversation but said this had happened in the past prior to the interview with the surveyor. They said Resident #57 has said ugly things to them, but they ignore it because they were a staff and he was a resident. They expressed concerns that Resident #57 was allowed to take care of another resident with lower functioning. They said he does not provide nursing services but Resident #57 follows the resident around guiding him and playing music. They had observed him become upset with the resident that he looks after and makes the resident go wherever he wants. They said they had observed Resident #57 stop staff from assisting and providing care to the resident that he follows around. When asked if what they observed could be considered verbal abuse, they stated that this, in their opinion, could be verbal abuse. They said no one wants to be told to shut up. They said no one should be talked to that way. They said when Resident #57 acts this way, it causes tension in the environment, and they observe other residents become uncomfortable and avoid him. A confidential interview was conducted with Confidential Resident #2 who said Resident #57 always bothered them. They said they reported their issues to the ADM, and the only thing that has stopped was Resident #57 had not pulled their hair in a while. They said they had told the ADM multiple times as incidents happen but unable to specifically tell the surveyor an exact date. They said the resident continued to call them names. They said he called them and their friends witches. They said they believed he wanted to call them bitches. They said he would yell at them on their hall to get out of the way because he takes care of another resident. They said he would sometimes push the other resident in front of them and block them. They said it was not the other resident's fault because he did not know any better. They said Resident #57 would come to their room early in the morning, as early as 6:30 AM, and flip on their light and yell, wake up, witch!. They said Resident #57 would tell the other residents not to look at them or their friends, or they would turn into frogs. They said this made them feel really down and bad about themselves. An observation on 1/18/23 at 3:30 PM of Resident #57 in his wheelchair on Hall 300 was made and he did not have any interaction with other residents. He was in his wheelchair listening to music and self-propelling behind another resident. An interview was conducted on 01/18/23 at 4:45 PM with the Social Worker , and she said that she has had many conversations with residents about Resident #57. She said that residents would say he was disturbing them. She said that she had never received a grievance from any residents, yet she considered the concerns from residents as conversations. She said she deciphers the difference between a conversation and an actual grievance when the resident uses the term grievance She said sometimes she would ask residents if they would like to file a grievance. She said no one has asked to file a grievance. She said some of the concerns that she would receive would be that he yells coming down the hall saying, I'm back!. She said there is a fine line between joking and bothering the other residents, and sometimes he may go a little far. She said residents might not like it when he jokes with them, which is when it is too far. She said she is responsible for grievances. She said grievances are more formal and come from staff and the resident council. She said all staff was trained to come to her as the grievance official. Record review the facility's policy titled: Abuse/Neglect, Revised 03/29/18 , revealed the following documentation: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. C. Prevention (3) All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. (4) The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. (6) The facility will designate an Abuse Preventionist to monitor tracking and trending data and completion of investigations as needed. D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. E. Reporting (1) Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. (2) When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. (3) Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation. Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred. An interview was conducted on 01/19/23 at 09:21 AM, and the Administrator said that he was the grievance official and that the Social Worker was his backup. He said other staff outside of the Social Worker and himself could also take grievances. When asked what the grievance process was, the Administrator obtained the grievance policy and read the grievance policy. He said the process was as follows: Include the part read. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Maintain the confidentiality of all information associated with grievances Issue written grievance decisions to the resident Coordinate with state and federal agencies as necessary When asked how he determines the difference between a grievance and a conversation, he said that it is difficult to decipher between the two and that it is his expectation for all grievances to be logged. When asked about reported behavior concerns with Resident #57, he stated that people have come to him about Resident #57 attitude and behavior towards other residents and some toward staff, but nothing physical has been reported or observed by the Administrator. He said people would just say he is mean or that they did not like the way Resident #57 joked. He said that no specifics outside of Resident #57 being mean were reported when this was reported. He said this statement was a matter of onion, not a statement of fact. He stated that everyone was entitled to their opinion. The Administrator stated that he did not log any grievances when it was brought to his attention that Resident #57 was mean because he attributed it to Resident #57 personality. He said there were no instances that amounted to grievance level. When asked how he would determine what a grievance was and if he had a tool that he used, he stated he did not. He described Resident #57 as having an A-type personality. He read from his computer and said an A-type personality refers to a particular behavior for a person with high achievement, competitiveness, and tend to be impatient. He said staff had reported to him that Resident #57 had been mean to them, but nothing more than that. He stated nothing specific had been said. He stated if anyone had reported physical abuse, he would have reported it. He said that he was aware that there were more types of abuse than physical but that nothing has been reported to him that rises to the level of abuse in his opinion as the abuse prevention and grievance official and in his experience as an administrator. He said no residents have come to him and reported any issues regarding Resident #57 pulling anyone's hair, threatening them, grabbing their wheelchair, or name-calling. He said he spoke with Resident #57 on the morning of the interview (01/19/23) because he was loud and yelling in the hallways. He stated that Resident #57 was not yelling about anything specific, but it was 6:30 AM, and he asked him to keep it down. He stated that Resident #57 may rub some people the wrong way. He said that anytime anything was brought to his attention, he evaluated the situation to see if it was a grievance or if it was Resident #57's personality. He said he had evaluated anything brought to his attention and stated that the resident who said Resident #57 was mean did not like him. When asked about Resident #57's behavior, he reported that since the resident's admission, there has been no major shift and that he has had the following behaviors: yelling, cussing, evading care, and yelling for people to get out of the way. He stated that there had not been a specific training or in-service addressing the resident's behavior. He stated that no additional interventions were taken outside of monitoring and reporting the resident's behavior. He said Resident #57 does use profanity. A confidential interview was conducted with Confidential Staff B, when asked if she considered the interaction with the residents and Resident #57 as abuse, she stated that Confidential Resident #3 and #4 might consider it abuse because they keep asking him to stop, and he does not. She said Confidential Resident #4 might consider it abuse when he pulls her hair. When asked if she had observed this hair-pulling behavior, she stated she had. She said it had not been recent, but it had occurred two or three months ago. She said she did not report it but told Confidential Resident #4 to report it. When asked why she did not report it she stated she did not report it because she had instructed Confidential Resident #4 to report it. When asked if there were concerns with Resident #57 she said no. She said Resident #57 She stated she had never seen him be rude to that resident. She stated she had never witnessed any sexual inappropriateness. A confidential interview was conducted with Confidential Resident #3 who confirmed that no sexual contact had occurred and that it had only been verbal. She said Resident #57 had touched them like a pat on the back, but that was it. They stated she was not comfortable with any contact with Resident #57. They stated that Resident #57 would block them in the hallway where they felt they could not get away. They said they had not reported it because the staff was around and did not think about it. They stated that they had never been talked to by staff about the actions of Resident #57. A confidential interview was conducted with Confidential Resident #4 who stated that all interactions with Resident #57 have been verbal and never physical. A confidential interview was conducted with Confidential Resident #2 who said Resident #57 always bothered them. They said they reported their issues to the ADM, and the only thing that has stopped was Resident #57 had not pulled their hair in a while. They said they had told the ADM multiple times as incidents happen but unable to specifically tell the surveyor an exact date. They said the resident continued to call them names. They said he called them and their friends witches. They said they believed he wanted to call them bitches. They said he would yell at them in the hall to get out of the way. They said he would block them in the hallway. They said Resident #57 would come to their room early in the morning, as early as 6:30 AM, and flip on their light and yell, wake up, witch!. They said Resident #57 would tell the other residents not to look at them or their friends, or they would turn into frogs. They said this made them feel really down and bad about themselves. They stated Resident #57 had not said anything sexual, and the only thing he had done was call them names. An observation on 1/19/23 at 12:00 PM of Resident #57 in his wheelchair in the dining room entry talking with staff. Resident #57 was not interacting with any of the confidential residents. He reported to staff that he had lost his phone and that he may have left it in another resident room when he was visiting other residents. On 1/19/23 at 1:10 PM the Administrator, Regional Nurse, and ADON were notified that the facility would be placed in immediate jeopardy status due to failure to keep the resident safe from abuse. The following Plan of Removal submitted by the facility was accepted on 1/20/23 at 08:47AM: Plan of Removal Problem: Abuse allegation Interventions: Alleged perpetrator interviewed and placed in 1:1 observation 1/19/23 at 1330 One on One in-service on grievances and abuse reporting completed with the Administrator/DON /Social Services 1/19/2023 by the Regional Compliance Nurse. Safe surveys conducted on interviewable residents by social services 1/19/2023 Immediate psychiatric services on call for identified residents in need 1/19/2023 1438 Psychiatric services referral ordered and initiated for alleged perpetrator at 1433. Visit completed 1/19/2023 at 1530. MD contacted on 1/19/23 at 1433. Discharge placement ordered for alleged perpetrator. Staff working with alleged perpetrator have been interviewed by regional compliance nurse. Resident safe surveys have been completed by social services. All cognitive residents will be interviewed by corporate staff. Grievance reporting posting was placed on each nursing unit. The following in-services were initiated on 1/19/23: Any staff member not present or in-serviced on 1/19/2023, will not be allowed to assume their duties until in-serviced. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Management of aggressive behavior Grievance reporting Monitoring Administrator to Investigate and submit findings of grievances to ADO and Risk Management for review Administrator will submit documentation of investigation with Resident and Staff interviews, as well as weekly follow up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with outcome of investigation ADO will monitor weekly x 4 weeks follow up on grievances and monitoring of quality of life rounds and resident and staff interviews. Quality of life rounds on a sample of at least 25% of the residents will be made by Administrator/ Regional compliance nurse weekly x 4 weeks. The QA committee will review findings monthly for no less than 60 days and makes changes as needed On 1/20/23 at 08:47AM the Final Plan of Removal was approved. On 01/20/23 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: A confidential interview was conducted with Confidential Resident #2 who reported that staff had spoken to her about how she felt and if she felt safe. She stated she could speak with staff about all that Resident #57 had been doing with her. She said she knows she was to report any further incidents to the Administrator and the Social Worker. She stated that she felt much better after the staff spoke with her. She thanked the surveyor for all that she did and became emotional. She said she was happy because now maybe Resident #57 won't call him names anymore. An interview was conducted on 01/20/23 at 09: 15 AM with Resident #57, he stated he was not prescribed any psych medications, he has participated in his care plans and during his care plan meetings there has never been any mention of any inappropriate behaviors. Resident #57 stated he had called some of the female residents witches, but he meant no harm. Resident #57 stated he had touched a resident's very long braid, picked it up and flopped it down, but he had never pulled her braid. Resident #57 stated he plays around with residents, that was how he survives being in the facility. Resident #57 stated he felt he has been unfairly judged; Resident #57 stated if he would have ever been told he had offended other residents he would have corrected the behavior. A confidential interview was conducted with Confidential Resident #3 who stated that the Regional Nurse came by and spoke with them. They said they felt safe now and knows they can go to the Administrator or the ADON if they needed to report anything. They said they realized they should have reported it but did not feel they could report it at first. They [TRUNCATED]