Every finding on record at The Heights of Bulverde

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services including procedures that assured accurate dispensing, administering, and timely documentation of medications given, to meet the needs of each resident for three (3) of twelve (12) residents (Resident #44, #69 and #86) reviewed for pharmacy services. 1. The facility failed to make sure Resident #44's self-administered eye drops GenTeal Tears Lubricant Eye Drops (Dextran 70 0.1%) and Ultra Lubricant Eye Drops (Polyethylene Glycol 400 0.4%) matched physician's orders. 2. The facility failed to ensure Resident #69 received the correct dosage of cyanocobalamin (vitamin B12) 1000 mcg when she was administered 1 tablet instead of the ordered 2.5 tablets by MA J on 8/12/2026 MA J also failed to ensure Resident #69 received senna oral table 8.6 mg two tablets on 8/12/2026. 3. The facility failed to ensure Resident #86 received Senokot S 8.6-50 mg and Zyrtec 10 mg on 8/12/2026 by MA J during medication pass. These failures could place residents at risk for not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. The findings included: 1. Record review of Resident #44's admission Record, dated 08/12/2026, reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Record review of Resident #44's Medical Diagnosis tab on her electronic medical record, undated and accessed on 08/12/2026 at 04:29 p.m., reflected diagnoses included dementia (a general term for impaired ability to remember, think, or make decisions), mixed hyperlipidemia (a condition with high levels of bad fats in the blood), and absolute glaucoma, bilateral (both eyes with the final stage of glaucoma in which elevated pressure on the optic nerve has caused irreversible damage leaning to permanent vision loss or blindness). Record review of Resident #44's Quarterly MDS Assessment, dated 06/11/2026, reflected the resident had a BIMS score of 06, which indicated she had severe cognitive impairment. Record review of Resident #44's Care Plan Report, undated and accessed 08/12/2026 at 05:00 p.m., reflected the following focuses and interventions: - Focus: I am risk for vision loss/impairment: glaucoma [sic] I wear Glasses, date initiated 02/24/2023 and revised 04/10/2023. - Interventions/Tasks: Medications as ordered., date initiated 02/23/2023. - Focus: I prefer to have my eye drops and Flonase [a nasal spray] at my bedside and administer on my own. Patient is able to identify medication use and administration ., date initiated 04/30/2024 and revised 03/21/2025. - Interventions/Tasks: Patient will notify nurse for reorders. Nurse to check and follow up with pt for med reorders/availability and continued need. Assist patient with administration as requested or needed., date initiated and revised 04/30/2024. Record review of Resident #44's Order Summary Report, dated active orders as of 08/12/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - May self administer [sic] medications every shift related to absolute glaucoma, bilateral [affecting both sides] .may self administer lumigan [eye drops for glaucoma], flonase, refresh [eye drops for glaucoma], artificial tears [eye drops for glaucoma], order status Active, order and start date 04/30/2024, and no end date. - May use a generic equivalent, order status Active, order date 02/23/2023, and no start or end date. - Lumigan Ophthalmic Solution (Bimatoprost); Instill 1 drop in both eyes at bedtime related to absolute glaucoma, bilateral .unsupervised self-administration [sic] may self administer [sic], order status Active, order and start date 03/11/2024, and no end date. - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes three times a day related to absolute glaucoma, bilateral . unsupervised self-administration [sic] may self administer [sic], order status Active, order and start date 02/23/2023, and no end date. - Systane Complete Ophthalmic Solution (Propylene Glycol (Ophth)) Instill 1 drop in both eyes three times a day related to absolute glaucoma, bilateral . unsupervised self-administration [sic] may self administer [sic], order status Active, order and start date 02/23/2023, and no end date. During an observation and interview on 08/12/2026 at 09:45 a.m., Resident #44 was observed to take a bottle of GenTeal Tears out of her pocket. She stated that she self-administered her eye drops and that one of her eye drop medications was different from the medication she was taking previously. She stated she had not been informed of a change in her medications. During an observation and interview on 08/13/2026 at 04:20 p.m., Resident #44 was observed to open her locked lockbox in her room and take out her eye drop medications for observation. She was observed to have three (3) eye drop bottles: - GenTeal Tears with the bottle contents indicating the active ingredient was Dextran 70 0.1%, - Ultra Lubricant Eye Drops with the bottle contents indicating the active ingredient was Polyethylene glycol 0.3%, and - Lumigan with the bottle contents indicating the active ingredient was bimatoprost. Resident #44 identified the GenTeal Tears bottle as the medication that she believed was incorrect or had been changed. GenTeal's active ingredient, Dextran 70 0.1% was observed to be different than Resident #44's order for Refresh Tears, which had an active ingredient of Carboxymethylcellulose Sodium. Record Review on 08/13/2026 at 04:40 p.m. of Systane Complete manufacturer's website https://systane.myalcon.com/products/systane-complete/, revealed Systane Completes active ingredient was noted as polyethylene glycol at 0.6%. The medication, Ultra Lubricant Eye Drops, Resident #44 was observed to have been issued to self-administer was noted to contain polyethylene glycol at 0.3%. During an interview on 08/14/2026 at 10:23 a.m., WM H stated she took over the reordering of over-the-counter medications around three weeks ago, but the current week was the first time she had been ordering the medications herself. She stated she was not sure why Resident #44 had GenTeal Tears instead of Refresh Tears. She stated it was the responsibility of the staff member that checked off the order and administered Resident #44 the refill to ensure Resident #44 received the correct medication. She stated for Resident #44's Systane Complete, the Ultra Lubricant Eye Drops might have been listed as a substitution with the lesser concentration having been an oversight. She stated the impact for these changes would depend on the exact reason the resident was taking the eye drops, but if the eye drop was just at a lower concentration, then the impact might be that the resident was not getting the relief expected from the medication. During an interview on 08/14/2026 at 11:55 a.m., the DON stated the nurses were responsible in giving the residents their medications. After being notified about the discrepancies in Resident #44's eye drops, the DON stated he would have to review Resident #44's medications. He stated he did not know how the discrepancies occurred. He stated the impact of the discrepancies was that it was possible the eye drops Resident #44 was taking were not as effective. During an interview on 08/14/2026 at 12:23 p.m., OD I stated she had Resident #44 on Refresh Tears and Systane for dry eye. She stated Resident #44 having received GenTeal versus Refresh would not impact Resident #44. She stated the eye drops might work in different ways and as long as Resident #44 was not reporting any discomfort, then one might make her more comfortable than the other. She stated that some people may develop allergies to the preservatives in eye drops and since Refresh was non-preserved, the chances were lower for people to experience any symptoms. OD I stated she did not believe Resident #44 having received Ultra Lubricant Eye Drops at 0.3% versus Systane Complete at 0.6% was a big deal, just the medication was not as strong. She stated that as long as Resident #44 was not showing symptoms, she felt Resident #44 was fine. During an interview on 08/14/2026 at 01:36 p.m., the Administrator stated he was unsure who specifically was responsible for ensuring self-administered medications were per physician's order but thought the responsibility would fall on the nursing team as a whole. He stated he believed the impact to Resident #44 for taking eye drops that were different from the physician's order was that Resident #44 could experience side effects. Record review of facility policy Medication Administration, dated implemented March 2019 and revised January 2024, reflected: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. Responsible Disciplines Licensed Nurses, C.M.A.s . 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved 6. Administer medications as ordered by the physician . 2. Record review of Resident #86's face sheet dated 8/14/2026 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: amnesia, mild dementia with mood disturbance (mild memory decline with mood changes) and disorders of brain (unspecified). Record review of Resident #86's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15. Record review of Resident #86's Care Plan dated 8/12/2026 revealed he had chronic health conditions and co-morbid conditions affecting his physical function and may affect his quality of life with interventions which included: Administer my medications.as recommended by physician. Record review of Resident #86's Order Summary Report dated 8/14/2026 revealed: -10/31/2024: Senokot S (Senna) oral tablet 8.6-50 mg (sennosides-Docusate Sodium, give two tablets by mouth one time a day for constipation, hold for loose stools -6/06/2026: Zyrtec allergy oral tablet 10 mg, give one tablet by mouth, one time a day for allergies. During an observation on 08/12/2026 at 7:35 AM of med-pass with, MA J did not give Resident #86 his Zyrtec 10 mg or Senokot 8.6/50 mg tablet, which were showing due on the electronic medical record, along with his other morning medications. During an interview on 08/12/2026 at 7:58 AM, MA J stated she was not able to administer Resident #86's Zyrtec or Senokot because the facility was out of both medications. She stated she had already looked in the medication storage area on both sides of the facility and was unable to locate any of the medication. She stated she would let her nurse know when she had completed all of her med pass unless it was critical medication. She stated her nurse today was RN M. She stated the DON was responsible for ordering over-the-counter medications. She stated she had notified an unknown nurse yesterday (8/11/2026) and had asked if she could substitute Zyrtec with loratadine (Claritin) and was told no because they were different medications. She stated it was important for the residents to get all their medications because it helps them. She stated the allergy medication was important, so the residents did not get itchy or have runny noses. 3. Record review of Resident #69's face sheet dated 8/12/2026 revealed a [AGE] year-old female admitted on [DATE] with readmission date of 2/05/2026 with diagnoses which included: chronic obstructive pulmonary disease (chronic lung disease causing breathlessness), mild protein-calorie malnutrition (mild malnutrition from inadequate nutrition) and constipation. Record review of Resident #69's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated she was cognitively intact. Record review of Resident #69's Care Plan initiated on 10/09/2023 revealed the resident had chronic health conditions and comorbid conditions that have affected physical function and may further affect quality of life. Interventions included administer medications, treatments .as recommended by a physician. Record review of Resident #69's order summary dated 8/12/2026 revealed orders: -2/02/2026: cyanocobalamin tablet (vitamin B12) 1000 mcg, give 2.5 tablets by mouth one time a day for anemia equal to 2500 mcg by mouth every day. - 2/27/2026: senna oral tablet 8.6 mg (sennosides), give two tablets by mouth two times a day for constipation, hold if resident has a loose stool. During an observation on 08/12/2026 at 8:11 AM of med-pass, MA J dispensed and administered one tablet of cyanocobalamin (vitamin B12) instead of the ordered 2.5 tablets. Further observation revealed MA J omitted Senna which reflected as due on the electronic medical record. Resident #69 asked what medications she was receiving. MA J told Resident #69 Senna was not available today. Resident #69 stated she really needed her Senna, so she did not get constipated. During an interview on 08/12/2026 at 11:57 AM, MA J stated she administered 1 tablet of B12 instead of 2.5 tablets as ordered by a physician. MA J stated she should have retrieved three tablets, cut one in half and administered 2.5 tablets. She stated she missed the correct dose. She stated she was trained to verify the resident's (identity), verify the order against the actual medication and dosage of medication to be given. She stated she just missed it today. She stated someone (unknown name) had instructed her that it was okay to give less of a medication if that was what was on hand, as long as she did not give more. She stated she was trained to administer what was ordered. She stated it was important to give the correct dosage, so the residents got what they needed. Record review of MA J Med Aid Competency Checklist dated 6/22/2026 revealed she had successfully met the standards for administration of medication per the 5 rights (of medication administration unspecified). The competency did not include ordering or notification of missing medication. During an interview on 8/12/2026 at 10:35 a.m., RN M stated she was informed by MA J today (8/12/2026) they were out of Zyrtec and Senna. She stated she alerted the supply nurse, LVN N and saw it on LVN N's list to reorder. During an interview on 8/12/2026 at 10:37 a.m., LVN N stated she was responsible for central supply. She stated her job was to ensure things ran smoothly, which included ordering over-the-counter medications. She stated she started the central supply position 2-3 weeks ago. She stated when she took over central supply, she first cleaned the supply room out and made herself a list of frequently used medications. She stated sometimes the nurses, or medication aides, brought her a list of needed items. She stated her ordering process included counting how many bottles of medication were on hand, what was needed and what she needed to order. She stated all over-the-counter medications were ordered from a designated medical supply vendor. LVN N stated the DON showed her how to do the ordering. She stated this past Monday (8/10/2026) was an ordering day. She stated multiple items needed were out of stock for ordering or on back order. She stated she went ahead and placed the order for those items anyway, knowing they would not come right away. She stated she placed orders on Mondays and Wednesdays. She stated typically items ordered on Monday, arrived on Wednesday, and items ordered on Wednesday arrived the following Monday, unless stock was unavailable. LVN N stated she had been notified the facility as out of both Senna and Zyrtec. She stated she ordered both on Monday (8/10/2026). She stated Zyrtec was listed as back ordered. She stated she did not know when the facility would get the Zyrtec. LVN N stated she was told again today (8/12/2026) that the facility was out of Senna and Zyrtec by a staff member. She stated the facility could potentially go to a local store to purchase it, but it was not her decision to make. She stated the DON was aware of the backorder. LVN N stated it was important to ensure adequate over-the-counter medication was available in the facility to ensure people (residents) did not go without their medications which could cause problems. During an interview on 8/12/2026 at 10:47 a.m., the DON stated the medication aides should contact the nurse or the DON directly if medications were not available and needed. The DON stated it was his responsibility to ensure over the counter medications were available. He stated they had some stock in the medication room or there was a local pharmacy right across the street if needed. The DON stated he had a supply person who was ordering over-the-counter medication, but they left approximately one month ago. He stated their scheduler, LVN N was also assuming the role of central supply and ordering over-the-counter medications, but it was very transitional. The DON stated last week he had shown LVN N how an order was placed and he monitored her doing the process. He stated no one had notified him that they did not have Senna or Zyrtec on hand. He stated they had a number of residents on Senna and had ordered some on Monday but did not know the status of the order. The DON stated it was important for residents to receive all of their ordered medications including over-the-counter medications because the physicians were using over-the-counter medications to treat medical conditions. During an interview on 8/14/2026 at approximately 9:45 a.m., the Administrator stated the facility did not have a policy for ordering of over-the-counter medications. Record review of the facility policy titled Medication Administration dated March 2019 revealed: Resident medications are administered in an accurate, safe, timely, and sanitary manner.

Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 5 errors out of 25 opportunities, which involved 3 of 6 residents (Resident #69, #86, and #101) reviewed for medication administration. 1. The facility failed to ensure Resident #101 received Debrox Otic ear drops, two drops in each ear on 8/11/2026 by MA K in a manner that ensured accurate delivery of the medication per manufacturer directions and according to professional standards. 2. The facility failed to ensure Resident #69 received the correct dosage of cyanocobalamin (vitamin B12) 1000 mcg when she was administered 1 tablet instead of the ordered 2.5 tablets by MA J on 8/12/2026 MA J also failed to ensure Resident #69 received senna oral table 8.6 mg two tablets on 8/12/2026. 3. The facility failed to ensure Resident #86 received Senokot S 8.6-50 mg and Zyrtec 10 mg on 8/12/2026 by MA J during medication pass. These failures could place residents at risk of not receiving the desired therapeutic effect of their medication, The findings were: Record review of Resident #101's face sheet dated 8/12/20206 revealed an [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with Chronic Obstructive Pulmonary disease (chronic lung disease causing breathlessness), dementia mild without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (mild decline in memory and thinking), and rheumatoid arthritis (joint inflammation causing pain and swelling). Record review of Resident #101's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. Record review of Resident #101's care plan initiated 4/17/2026 revealed he had chronic health conditions and comorbid conditions that have affected his physical function and may further affect his quality of life with interventions which included: administer medication, treatments .as recommended by physician. Record review of Resident #101's physician orders revealed an order dated 8/12/2026 for Debrox Otic (related to or intended for the ear) Solution (Carbamide Peroxide Otic), Instill 2 drops in both ears, one time a day for ear wax. During an observation of med-pass on 8/11/2026 at 4:59 p.m., performed by MA K and observed by ADON L revealed Resident #101 was seated in a wheelchair. MA K asked the resident to turn his head to the side for his ear drops but he was unable to move his neck and his head remained in an upright position. MA K placed the entire end of the bottle into the resident's ear canal, with his head upright and squeezed the bottle twice. The dropper tip could not be visualized for drop count. MA K handed Resident #101 a tissue and helped him place it on his ear to catch the medication run off and then exited the room. During an interview on 8/11/2026 at 5:09 pm MA K stated she was not able to visualize the end of the medication dropper to see the number of drops she placed in Resident #101's ears. She stated she knew she administered the correct amount of medication because she had squeezed the bottle twice. She stated she administered the ear drops with the resident in an upright position because that was how she was trained to do it. She stated she was not trained to have a resident lie down when instilling ear medication. MA K stated she was new to the facility and had only worked there for approximately one week. She stated this week was her first time administering medications by herself. She stated her training included following someone for 5 days and then having someone follow and watch her administer medication for two days (unknown staff). She stated during her training she instilled ear drops and another medication aide (unknown) did it in the same manner. During an interview on 8/11/2026 at 5:15 pm ADON RN L who was in attendance during the ear drop administration stated MA K was new to the facility and had just come off of training. She stated MA K had trained with another medication aide and a nurse on the floor (working with patients/residents). ADON RN L stated MA K went into the ear canal with the ear drops container too deep. She stated the squeeze was not a drop but a stream. She stated the technique was not correct and it was obvious MA K needed additional training. ADON RN L stated it was important to administer ear drops using the appropriate technique to ensure the right dose, and so the medication is not just washed out and wasted by not having the resident in the proper position. She stated it was also important for infection prevention to not place the medication tip inside the resident's ear. ADON RN L stated ear drop administration would be ineffective if the resident was not positioned correctly. During an interview on 8/12/2026 at 10:52 a.m., the DON stated Resident #101 was unable to tilt his head because of his pre-existing neck (structure). He stated his expectation of staff was to ensure ear medication was dropped into the ear canal. The DON stated medication could not be administered by drop when the head was upright. He stated it was easy to do while in bed. The DON stated some residents were able to turn their heads enough to put the drops in from a seated position, however, Resident #101 was not. Record review of MA K's Med Aid Competency Checklist dated 8/11/2026 revealed she had successfully met the standards for administration of medication per the 5 rights (of medication administration/unspecified). The competencies did not include positioning for medication administration or administration of ear drops. Record review of a website dailymed.nlm.nih.gov revealed: Debrox Otic directions per package insert: tilt head sideways, place 5-10 drops into ear. Tip of applicator should not enter ear canal. Keep drops in for several minutes by keeping head tilted or placing cotton in the ear. Record review of a website ncbi.nlm.nih.gov (open sources for nurses) viewed on 8/24/2026 revealed: Chapter 16.1: Administration of Medication via Other Routes: Ear Drops: .The patient should be positioned so the affected ear is tilted in the uppermost position.The nurse should squeeze the bottle so that the drops of medication fall onto the sides of the auditory (ear) canal.and should run towards the tympanic membrane (eardrum) after it is instilled. The patient should remain in this lying position for five minutes. After five minutes, the procedure can be repeated on the other ear, if ordered. 2. Record review of Resident #86's face sheet dated 8/14/2026 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: amnesia, mild dementia with mood disturbance (mild memory decline with mood changes) and disorders of brain (unspecified). Record review of Resident #86's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15. Record review of Resident #86's Care Plan dated 8/12/2026 revealed he had chronic health conditions and co-morbid conditions affecting his physical function and may affect his quality of life with interventions which included: Administer my medications.as recommended by physician. Record review of Resident #86's Order Summary Report dated 8/14/2026 revealed:-10/31/2024: Senokot S (Senna) oral tablet 8.6-50 mg (sennosides-Docusate Sodium, give two tablets by mouth one time a day for constipation, hold for loose stools-6/06/2026: Zyrtec allergy oral tablet 10 mg, give one tablet by mouth, one time a day for allergies. During an observation on 08/12/2026 at 7:35 AM of med-pass with, MA J did not give Resident #86 his Zyrtec 10 mg or Senokot 8.6/50 mg tablet, which were showing due on the electronic medical record, along with his other morning medications. During an interview on 08/12/2026 at 7:58 AM, MA J stated she was not able to administer Resident #86's Zyrtec or Senokot because the facility was out of both medications. She stated she had already looked in the medication storage area on both sides of the facility and was unable to locate any of the medication. She stated she would let her nurse know when she had completed all of her med pass unless it was critical medication. She stated her nurse today was RN M. She stated the DON was responsible for ordering over-the-counter medications. She stated she had notified an unknown nurse yesterday (8/11/2026) and had asked if she could substitute Zyrtec with loratadine (Claritin) and was told no because they were different medications. She stated it was important for the residents to get all their medications because it helps them. She stated the allergy medication was important, so the residents did not get itchy or have runny noses. 3. Record review of Resident #69's face sheet dated 8/12/2026 revealed a [AGE] year-old female admitted on [DATE] with readmission date of 2/05/2026 with diagnoses which included: chronic obstructive pulmonary disease (chronic lung disease causing breathlessness), mild protein-calorie malnutrition (mild malnutrition from inadequate nutrition) and constipation. Record review of Resident #69's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated she was cognitively intact. Record review of Resident #69's Care Plan initiated on 10/09/2023 revealed the resident had chronic health conditions and comorbid conditions that have affected physical function and may further affect quality of life. Interventions included administer medications, treatments .as recommended by a physician. Record review of Resident #69's order summary dated 8/12/2026 revealed orders: -2/02/2026: cyanocobalamin tablet (vitamin B12) 1000 mcg, give 2.5 tablets by mouth one time a day for anemia equal to 2500 mcg by mouth every day.- 2/27/2026: senna oral tablet 8.6 mg (sennosides), give two tablets by mouth two times a day for constipation, hold if resident has a loose stool. During an observation on 08/12/2026 at 8:11 AM of med-pass, MA J dispensed and administered one tablet of cyanocobalamin (vitamin B12) instead of the ordered 2.5 tablets. Further observation revealed MA J omitted Senna which reflected as due on the electronic medical record. Resident #69 asked what medications she was receiving. MA J told Resident #69 Senna was not available today. Resident #69 stated she really needed her Senna, so she did not get constipated. During an interview on 08/12/2026 at 11:57 AM, MA J stated she administered 1 tablet of B12 instead of 2.5 tablets as ordered by a physician. MA J stated she should have retrieved three tablets, cut one in half and administered 2.5 tablets. She stated she missed the correct dose. She stated she was trained to verify the resident's (identity), verify the order against the actual medication and dosage of medication to be given. She stated she just missed it today. She stated someone (unknown name) had instructed her that it was okay to give less of a medication if that was what was on hand, as long as she did not give more. She stated she was trained to administer what was ordered. She stated it was important to give the correct dosage, so the residents got what they needed. Record review of MA J Med Aid Competency Checklist dated 6/22/2026 revealed she had successfully met the standards for administration of medication per the 5 rights (of medication administration unspecified). The competency did not include ordering or notification of missing medication. During an interview on 8/12/2026 at 10:35 a.m., RN M stated she was informed by MA J today (8/12/2026) they were out of Zyrtec and Senna. She stated she alerted the supply nurse, LVN N and saw it on LVN N's list to reorder. During an interview on 8/12/2026 at 10:37 a.m., LVN N stated she was responsible for central supply. She stated her job was to ensure things ran smoothly, which included ordering over-the-counter medications. She stated she started the central supply position 2-3 weeks ago. She stated when she took over central supply, she first cleaned the supply room out and made herself a list of frequently used medications. She stated sometimes the nurses, or medication aides, brought her a list of needed items. She stated her ordering process included counting how many bottles of medication were on hand, what was needed and what she needed to order. She stated all over-the-counter medications were ordered from a designated medical supply vendor. LVN N stated the DON showed her how to do the ordering. She stated this past Monday (8/10/2026) was an ordering day. She stated multiple items needed were out of stock for ordering or on back order. She stated she went ahead and placed the order for those items anyway, knowing they would not come right away. She stated she placed orders on Mondays and Wednesdays. She stated typically items ordered on Monday, arrived on Wednesday, and items ordered on Wednesday arrived the following Monday, unless stock was unavailable. LVN N stated she had been notified the facility as out of both Senna and Zyrtec. She stated she ordered both on Monday (8/10/2026). She stated Zyrtec was listed as back ordered. She stated she did not know when the facility would get the Zyrtec. LVN N stated she was told again today (8/12/2026) that the facility was out of Senna and Zyrtec by a staff member. She stated the facility could potentially go to a local store to purchase it, but it was not her decision to make. She stated the DON was aware of the backorder. LVN N stated it was important to ensure adequate over-the-counter medication was available in the facility to ensure people (residents) did not go without their medications which could cause problems. During an interview on 8/12/2026 at 10:47 a.m., the DON stated the medication aides should contact the nurse or the DON directly if medications were not available and needed. The DON stated it was his responsibility to ensure over the counter medications were available. He stated they had some stock in the medication room or there was a local pharmacy right across the street if needed. The DON stated he had a supply person who was ordering over-the-counter medication, but they left approximately one month ago. He stated their scheduler, LVN N was also assuming the role of central supply and ordering over-the-counter medications, but it was very transitional. The DON stated last week he had shown LVN N how an order was placed and he monitored her doing the process. He stated no one had notified him that they did not have Senna or Zyrtec on hand. He stated they had a number of residents on Senna and had ordered some on Monday but did not know the status of the order. The DON stated it was important for residents to receive all of their ordered medications including over-the-counter medications because the physicians were using over-the-counter medications to treat medical conditions. During an interview on 8/14/2026 at approximately 9:45 a.m., the Administrator stated the facility did not have a policy for ordering of over-the-counter medications. Record review of the facility policy titled Medication Administration dated March 2019 revealed: Resident medications are administered in an accurate, safe, timely, and sanitary manner.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (1) of five (5) residents (Resident #73) reviewed for medication storage. The facility failed to ensure Resident #73 did not have his prescribed Fluticasone Propionate Nasal Spray on a counter in his room. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: Record review of Resident #73's admission Record on his electronic medical record, dated 08/11/2026, revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #73's Medical Diagnosis tab on his electronic medical record, undated and accessed on 08/11/2026 at 12:16 p.m., reflected diagnoses included muscle wasting and atrophy (shrinking of muscle or nerve tissue), osteomyelitis (bone infection) of vertebra, and acute respiratory failure with hypoxia (a sudden condition when the lungs cannot deliver enough oxygen to the blood). Record review of Resident #73's 5-Day MDS Assessment, dated 04/24/2026, reflected Resident #73 had a BIMS score of 14.0, indicating he was cognitively intact. Record review of Resident #73's Order Summary Report, dated active orders as of 08/11/2026, reflected the following order summary with order status, order date, start date, and end date if available: Fluticasone Propionate Nasal Suspension 50 MGG/ACT (Fluticasone Propionate (Nasal)) 2 spray in both nostrils one time a day for allergies, noted as Active, order date 04/18/2026, start date 04/19/2026, and no end date. There was not an order stating Resident #73 could self-medicate. Record review of Resident #73's Care Plan, undated and accessed 08/11/2026 at 12:11 p.m., reflected the following focuses and interventions: - Focus: Baseline / Initial Care Plan: I may be at risk for : self-care deficit, ., date initiated 04/18/2026. - Interventions/Tasks: 01. Medication / Treatment / Care Services: Administer & Provide medications, treatments, diet, care, and services as prescribed / recommended., date initiated 04/18/2026. - Interventions/Tasks: 14. Medication Monitoring: Monitor for and report any signs of adverse reactions to include but not limited to increase confusion, lethargy, double vision, bleeding, SOB, unstable vital signs, tremors ect [sic]. If identified report to the MD / NP., date initiated 04/18/2026.- Focus: I am allergic to Cephalexin [antibiotic], Erythromycin [antibiotic], Losartan [blood pressure medication], Lurasidone [antipsychotic], Penicillin [antibiotic], Lamotrigine [mood stabilizer], Latex [natural rubber used in products like gloves and b, date initiated and revised 04/24/2026. - Interventions/Tasks: Administer medication for allergies as ordered by MD, date initiated 04/18/2026. There was not a focus or intervention stating Resident #73 could self-medicate. Record review of Resident #73's Assessment Tab on his electronic medical record, undated and accessed 08/11/2026 at 12:11 p.m. did not reveal an assessment for Resident #73 to self-administer medications. Record review of Resident #73's Misc Tab on his electronic medical record, undated and accessed 08/11/2026 at 12:09 p.m. did not reveal an assessment for Resident #73 to self-administer medications. During an observation and interview on 08/11/2026 at 11:14 a.m., Resident #73 was observed sitting in his wheelchair next to his bed. A medication box, labeled Fluticasone Propionate Nasal Spray, USP 50 mcg with the pharmacy prescription for Resident #73 adhered to the box, was observed sitting on Resident #73's built-in cabinet in his room. The prescribed nasal spray bottle was observed to be present in the box when picked up and inspected. Resident #73's roommate was present and walking around his side of the room, but a staff member was not present. He stated his medication aide brought him his medications that morning while he was in the bathroom and told him she put them on the table in his room. He stated he came out of the bathroom, took his medications, including his nasal spray, and then because he wanted coffee, forgot to give his nasal spray back. He stated he did not believe it was a big deal for the staff member to have left his medications, including his nasal spray at his bedside. He stated the staff did not typically leave his medications without observing him take them. During an interview on 08/11/2026 at 11:54 a.m., LPN G stated the procedure for a resident to self-administer medications was that the nursing staff would complete an assessment and then educate the resident on the risks and side effects of the medication and if there were anything that might counter indicate (reason to not use or take a treatment or procedure) the medication. She identified MA F as the medication aide on the hall (Resident #73's) for the shift. She stated the risk for a resident to have a medication in their room when not approved for self-administration was that the resident could overuse the medication, someone else could get ahold of the medication, and since the Fluticasone Propionate Nasal Spray was in a glass container, the glass could become broken. During an observation on 08/11/2026 at 11:56 a.m., ADON A was observed entering Resident #73's room. Resident #73 was overheard stating It was my fault. ADON A was observed walking out of Resident #73's room holding Resident #73's Fluticasone Propionate Nasal Spray box. During an interview on 08/14/2026 at 10:01 a.m., MA F stated she knew if a resident was approved for self-administration because it would indicate on the resident's electronic medication administration record. She stated the expectation for residents that could not self-administer their medications was for her to stay present in the room while the medications are being administered. She stated for Resident #73, she would let him spray his own nasal spray in his nose. She stated she did not believe she had seen that he was cleared for self-administration on his medication administration record. She stated she let him spay his own nasal spray on Tuesday, 08/11/2026, but she thought she forgot to pick the box back up on the way out of his room. She stated the box was returned to her because it was left in his room. She stated she believed someone called her to go do another task and she forgot to pick up the box on the way out of the room. She stated she believed that was the first time she had left the nasal spray in Resident #73's room. She stated she did not believe leaving the nasal spray in Resident #73's room had an impact because Resident #73 was very self-aware, Resident #73 was always present in his room, Resident #73's roommate did not typically go on Resident #73's side of the room, and Resident #73 only took his nasal spray when it was scheduled. During an interview on 08/14/2026 at 11:00 a.m., ADON A stated for residents to self-administer medications the nurses would have to complete an assessment, notify the doctor, put in the order, and then put in a lock box in the resident's room to store the medication. She stated that if the resident did not have an order or assessment for self-administration, then the resident should not have a medication at bedside. She stated she would consider a resident to have medication at bedside without the order and assessment as unsafe. She stated that she considered Resident #73 as alert and aware. She stated that she would have to confirm that he did not have a self-administration assessment, but when she went into his room to pick up his Fluticasone Propionate, he stated it was his fault and he was alert. She stated she did not feel there was any risk for Resident #73 having had the Fluticasone Propionate in his room at bedside. During an interview on 08/14/2026 at 11:55 a.m., the DON stated for residents to self-administer medication, the staff would have to get a doctor's order, complete an evaluation, and monitor the resident to ensure they are administering the medication correctly. He stated for residents without an assessment; they should not be self-administering and should not have the medication in their room. He stated the impact of a resident having a medication in their room when not assessed for self-administration was that the resident could use the medication too frequently or administer it incorrectly. During an interview on 08/14/2026 at 01:36 p.m., the Administrator stated his expectation was for staff to make sure the residents were taking their medications. He stated he was aware that some residents preferred to self-administer their own eye drops or something like that, so as long as the residents were administering the medication right and the nurse was watching them. He stated he was aware Resident #73 liked to administer his own nasal spray and had demonstrated some behaviors when not allowed to. He stated if Resident #73 was self-administering medication, it might be care-planned or as long as the nurse was watching him administer. He stated he expected the staff to not leave the medication in the resident's room unless the resident was self-administering. He stated the risk of leaving the medication in the room was that another resident could get ahold of it. Record review of facility policy Medication Administration, dated implemented March 2019 and revised January 2024, reflected: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner.Responsible DisciplinesLicensed Nurses, C.M.A.s . 7. Avoid leaving medications with the resident to self-administer unless the resident is approved for self-administration of the medication. Record review of facility policy Medication - Self-Administration, dated implemented 03/15/2019 and revised January 2023, reflected: Compliance Guidelines:Each resident has the right to self-administer medications, if able. The interdisciplinary team evaluates each resident who expresses wishes to self-administer medications to determine if the resident is safe to do so, and if so provides the education and monitoring necessary to provide safe administration. Responsible DisciplinesLicensed Nurses, Therapists, Social ServicesGuidelines: . 2. If a resident desires to participate in self-administration, the clinical team team [sic] should assess the competence of the resident to participate, by completing a Self-administration of Medication Review. 3. The nurse should interview the resident to determine the resident's ability to identify, prepare, and self- administer medications. 4. Based on the self-administration review, a decision should be made as to whether the resident is a candidate for self-administration. This should be documented in the medical record; i.e [sic] Progrress [sic] notes/Self-administration of Medication UDA, and in the plan of care. 5. The nurse should obtain an order for self-administering medication. 7. Storage of self-administered medications should comply with state and federal requirements for medication storage.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #108) reviewed for care plans. Resident #108's care plan did not address individualized activity preferences that would attain or maintain the resident's highest practical quality of life. This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings include: Record review of Resident #108's face sheet, dated 8/13/26, reflected a 54 -year-old male who was admitted to the facility on [DATE]. Resident #108 had diagnoses which included: respiratory failure, cerebral infarction (stroke), Major Depression, Bi-polar disorder (mood swings), heart disease, chronic kidney disease, vascular dementia (a decline in thinking caused by a blockage in blood flow), and blindness. The RP was listed as: family member. Record review of Resident#1's Quarterly MDS Assessment, dated 7/14/26, reflected a BIMS score of 15, indicative of no impairment in cognition. The ADLs reflected: B/B was listed as always continent. Transfer and Mobility were listed as set up or supervision. The resident had no ROM impairment. The resident's assistive devices were a walker and wheelchair.Record review of Resident #108's Activity Assessment Note dated 6/12/26, authored by the Wellness (Activity) Director revealed: .Resident enjoys being around pets.Resident enjoys keeping up with the news.Resident enjoys doing things with groups of people.enjoys getting out in the fresh air.Resident prefers to have activities in.own room. Record review of Resident # 108's Activity Calendar dated July 2026 revealed the facility provided the resident with a group and in room activity on 7/2/26; and a room activity on 7/19/26.Record review of Resident#108's CP, undated, revealed interventions/tasks revealed: .Provide me with an activity calendar. The CP did not list activity preferences or include measurable objectives.During an observation and interview on 8/11/26 at 11:00 a.m., revealed Resident #108 was in his room lying in bed with no activities present. Observation of the room did not reveal an activity calendar meeting the resident's interest and needs. The resident stated that he had no activities or planned activities. The resident stated he was blind and the only activity he looked forward to was participating in rehab services. The resident stated the Activity Director had not discussed with him an individualized activity calendar or discussed his activity preferences. The resident state that bingo was not his preferred activity. He did not identify what his preferred activities were. During an interview on 8/12/26 at 10:30 a.m., LVN B stated she provided nursing care services to Resident #108 for the past three months. LVN B stated the resident only left his room to attend therapy, dialysis, and appointments. LVN B stated the resident's main activity in the room was listening to audio books. LVN B stated the resident was blind. LVN B stated activities that could improve the resident's quality of life and overall mood could include more social interactions, going outside to the patio to experience nature and feeling the sun on his skin. LVN B stated she was not aware of any individualized activity calendar in the resident's CP or posted in the resident's room.During an interview on 8/12/26 at 10:44 a.m., CNA C stated she had provided ADL services to Resident #108 for a couple of months. CNA C stated she provided ADLs to the resident that included: set-up for showers, eating, and appointments like dialysis. CNA C stated the resident was blind and kept the room dark. CNA C stated the resident sometimes wanted to go outside to the patio as an activity. She stated that the resident did not have a posted individualized calendar in his room or in his CP. CNA C stated the resident liked music and listening to movies. CNA C stated an individualized calendar would improve the resident's happiness. During an interview on 8/12/26 at 10:57 a.m., the MDS RN D stated at admission an activity assessment was completed on every new admission and captured in the CP. RN D stated Resident #108 was legally blind. RN D stated the CP only reflected the resident had visual impairment, and the activity CP intervention was for the resident to be provided with activity calendar. RN D stated she was not aware of the Activity Director giving Resident #108 an individualized activity calendar. During an interview on 8/12/26 at 11:26 a.m., the DON stated he was aware that certain residents required an individualized activity calendar because they remained in their rooms or were bedbound or were on hospice not leaving their room or had special needs like blindness. The DON stated the resident's activity preference should be in the CP. The DON stated a resident who was blind could benefit from music, going outside, and visitors. The DON stated the Activity Director was responsible for developing the individualized calendar and captured in the CP. The DON stated the Activity Director was responsible for explaining the sharing of the individualized activity calendar with the resident, RP, or family. During an interview on 8/12/26 at 11:42 a.m., the Administrator stated his expectation was on admission an activity assessment was done on every resident and the resident's activity preference or needs were captured in the CP. The Administrator stated the 3/18/26 activity progress note for Resident #108 noted that the resident expressed he enjoyed music and being around pets; liked being around people, fresh air; and socializing. The Administrator stated the resident preferred to have activities in his room. The Administrator stated he was not aware whether the CP provided specific activities or resident preferences. During an interview on 8/12/26 at 12:14 a.m., the Activity Director stated that Resident #108 was routinely offered activities and most of the time the resident refused activities or the resident was not available. The Activity Director stated based on her assessment of 3/18/26 the resident enjoyed music and being around pets; liked being around people, fresh air; and socializing. The Activity Director stated the activity calendar provided to the resident was the general calendar provided to all residents. The Activity Director stated she had not been doing specialized calendars to include in the CP for residents that required an individualized activity calendar like resident's who stayed in their rooms or had special needs or were blind. During an interview on 8/14/26 at 10:05 a.m., RN E stated in general from the activity assessment the CP was developed to document a goal and intervention for activity. RN E stated the CP activities needed to update after the activity assessment. RN E did not want to comment on whether the CP had to be individualized for Resident #108.During an interview on 8/14/26 at 10:15 a.m. RN D stated in general, at admissions the facility did an activity assessment for any resident and from the MDS assessment a baseline CP was developed (3 days) and then a comprehensive CP was developed in 21 days. The RN stated she did not read the activity policy around the need for an individualized activity CP. The RN stated the standard language put on the CP for residents was Provide me with an activity calendar. Record review of the facility's Activities Program policy, dated revised January 2023, revealed: . Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs.the activity care plan has been approved by the resident and his or attending physician.Individualized activity plans are integrated into the resident's total care plan and are reviewed at least quarterly.Residents who are confined or chose to remain in their rooms are provided with in-room activities and in-room projects they can work on independently.Record review of the facility's Care Plan development, Review, and Update Policy, dated revised January 2026, revealed: .Purpose: To ensure that each resident receives an individualized, person-centered care plan that reflects their assessed needs, goals, preferences.the care plan is developed, implemented and updated in accordance with federal regulations and RAI Manual guidance.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with professional standards for 2 of 8 medication carts (100 Hall cart and 300 Hall cart) reviewed for storage of drugs.The facility failed to ensure the carts for 100 Hall and 300 Hall were locked and secured.This failure could place residents at risk of medication misuse, medication errors, drug diversion or harm due to accidental ingestion of unprescribed medications.Findings included:During an observation on 03/31/2026 at 08:22 am, the medication cart on 300 Hall (secure memory care unit) by nurse station was unlocked, keys in the drawer containing the narcotics, and the nurse on duty was sitting 15 to 20 feet away at a dining room table administering medication to an unknown resident. The dining room area had 8 unknown residents, and 3 more unknown residents walking around. When LVN A finished administering medication, she walked over to medication cart to ask if this surveyor needed any assistance.During an interview on 03/31/2026 at 08:27 am, LVN A walked over to medication cart and surveyor asked if leaving the cart unlocked with the keys in it was normal practice for a memory care unit. LVN A stated no, the cart should be locked, however, she could see the cart from where she was and could stop any residents from approaching it. Surveyor asked what the potential outcome could be of residents getting into the unlocked medication cart if she were distracted. LVN A stated that the outcome could be bad.During an observation on 04/01/2026 at 07:51 am, the cart on 100 Hall was observed unlocked and unattended with the drawers facing a resident room. The nearest staff member was observed at nurses' station at the end of the hall on the phone. No other staff was observed. During an interview on 04/01/2026 at 08:30am, LVN B said he had left the cart unlocked and unattended to answer the phone at the nurse's station. LVN B stated it was not his normal practice to leave cart unlocked. LVN B stated the potential outcome if a resident opened the medication cart and took unprescribed medication could be very bad. LVN B stated that that had never happened to him.During an observation on 04/01/2026 at 08:09 am, the medication cart on 300 Hall (secure memory care unit) was observed to be unlocked, 2 residents were observed wandering 3 feet away from cart and in between the cart and the nurse was sitting 15-20 feet away at a table with an unknown resident obtaining a blood pressure. During an interview on 04/01/2026 at 08:12 am, LVN C stated she normally did not leave the cart unlocked and she knew the medication cart should be locked at all times when not in use. LVN C stated she could see the cart from where she was and could prevent residents from getting into it by calling to them. Surveyor asked nurse if there was a possibly, she could be distracted or pulled away and forget to lock the cart. LVN C said she did not think that that would happen. LVN C stated if a resident were to get into cart and take unprescribed medications it could affect them negatively.During an interview on 04/01/2026 at 1:30 pm, DON stated that the expectation is that medication carts should be locked at all times when they are not in use. The DON stated that the nurse observed earlier on 100 hall had informed him of what had happened and he had started an in-service for staff. Record review on 04/01/2026 of Medication Cart Policy dates 03/04/2024, states that staff should 'Keep the cart locked when unattended'.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control in that: Resident #1 had an open wound and did not have an EBP sign on Resident #1's room door and did not have a physician order for EBP.This failure could affect residents on enhanced barrier precautions and place them at risk for infection.The findings were:Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (when the body does not make or use insulin well) and chronic kidney disease (a reduction in kidney function).Record review of Resident #1's quarterly MDS assessment, dated 11/24/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG- Functional Abilities revealed Resident #1 was dependent on staff for ADL care, bed mobility, and transfers.Record review of Resident #1's January 2026 physician orders revealed an order, wound to coccyx cleanse with wound cleanser or NS, pat dry, apply Cal alginate and cover with dry dressing QD and PRN till healed, start date 12/18/2025. Resident #1 did not have a physician order for enhanced barrier precautions related to Resident #1's wound to her coccyx.Record review of Resident #1's comprehensive care plan revealed a care plan that revealed, I am at risk for significant infections and/or recurrent infections r/t compromised medical condition. Actual, date initiated 05/15/2024. An intervention revealed, enhanced barrier precautions practices as clinically indicated, date initiated 06/25/2025.During an observation, on 01/12/2026 at 11:39 a.m., Resident #1's room door was observed with a PPE supply cart outside of the room and no EBP sign on the door or doorway entrance to Resident #1's room.During an observation, on 01/12/2026 at 3:12 p.m., Resident #1's room door had 2 signs on the wall that indicated Resident #1 was on EBP and required specific PPE to be worn during care.During an interview with Resident #1, on 01/12/2026 at 11:40 a.m., Resident #1 stated she had a wound on her buttocks that was being treated by the nurses. Resident #1 stated nurses put cream and a dressing on the wound daily. Resident #1 stated staff wear a gown and gloves when performing wound care.During an interview with LVN A, on 01/12/2026 at 11:54 a.m., LVN A stated residents with wounds were on EBP and were identified by a sign outside of the resident door that indicated the resident was on EBP. LVN A stated staff were required to wear a gown and gloves when a resident was on EBP precautions. LVN A stated she had received training on EBP and stated everyone was responsible for ensuring a resident on EBP had a sign outside of their door to notify visitors and staff that the resident was on EBP. LVN A stated Resident #1 was on EBP and should have had a sign on Resident #1's door. LVN A stated it was important for residents on EBP to have signs posted on their door, for the safety of the residents and the staff to prevent further infection.During an interview with LVN G, on 01/13/2026 at 9:25 a.m., LVN G stated she was the wound treatment nurse and was responsible for performing wound care for Resident #1. LVN G stated Resident #1 was on EBP for a wound to the coccyx and stated residents on EBP were identified by a sign on their door indicating the need for EBP precautions. LVN G stated all facility staff were responsible for ensuring the proper signage was in place and stated, for residents with wounds, LVN G tried to make sure the signs were in place. LVN G stated residents on EBP would have a physician's order for EBP and stated it was important for a resident on EBP to have a physician order, to follow the orders for the benefit of the resident and prevent the spread of cross contamination. LVN G stated it was important for a resident on EBP to have a sign on their door, so anyone that goes in that room is following protocol including family members and staff. LVN G stated she had received training on EBP.During an interview with the Administrator, on 01/13/2026 at 12:00 p.m., the Administrator stated residents on EBP had a sign outside their room door that indicated the resident was on EBP precautions and had a physician order for EBP. The Administrator stated staff had received training on the placement of EBP signs and physician orders and stated a resident on EBP had care plans for EBP and EBP was reflected in a resident's Kardex(instructions) that revealed information from a resident's physician orders and care plan. The Administrator stated it was important for a resident on EBP to have a physician order, so it's in the chart and important for the EBP signs to be posted at a resident room doorway, so the staff know who is on EBP.Observation, on 01/12/2026 at3:12 p.m., of the enhanced barrier precaution sign posted outside of Resident #1's room revealed 2 large stop signs in the top corners and revealed, providers and staff must also: wear gloves and 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.Record review of a facility policy titled, Infection Prevention and Control, date implemented 03/13/19 and date revised April 2024, revealed, Compliance Guidelines: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Section II: Categories: Types of Isolation Precautions revealed, In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. Residents/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing; excluding simple skin breaks or tears that are covered with an adhesive bandage (e.g., Band-Aid) or similar dressing.

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for two of six residents (Resident #1 and Resident #3) reviewed for clinical records. 1. The facility failed to ensure Resident #1's medical record included an initial physician visit note when reviewed greater than 90 days (09/22/2025) after admission [DATE]). 2. The facility failed to ensure Resident #3's medical record included an initial physician visit note when reviewed greater than 90 days (09/22/2025) after admission [DATE]). 3. The facility failed to document wound care was provided to Resident #3 on three (3) occasions (Friday, 08/22/2025, Sunday, 08/24/2025, and Sunday, 08/31/2025) on Resident #3's August Treatment Administration Record (TAR). These failures could place residents at risk of not receiving the care and services needed due to inaccurate or in-complete clinical records. The findings included:1. Record review of Resident #1's admission Record, dated 09/22/2025, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1. Resident #1 discharged on 09/01/2025. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/22/2025 at 03:37 p.m., revealed diagnoses including Alzheimer's Disease (a progressive disease that affects memory and other important mental functions), muscle wasting and atrophy (shrinking of muscle or nerve tissue), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body). Record review of Resident #1's admission MDS, dated [DATE] and signed 07/03/2025 as completed, reflected a BIMS score of 09, indicating moderate cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Resident #1's functional abilities were documented as requiring partial/moderate assistance to set up or clean-up assistance. Record review of Resident #1's discharge MDS, dated [DATE] and signed 09/06/2025 as completed, reflected Resident #1 wandered 1 to 3 days. Resident #1's functional abilities were documented as requiring supervision or touching assistance to being independent. Record review of Resident #1's progress notes dated 06/01/2025- 09/01/2025 did not reveal a progress note written by a physician or MD. A MD, NP Progress Notes, dated 07/26/2025 and signed by NP F was the only note noted in the progress notes written by the NP. Record review of Resident #1's MD, NP Progress Notes, dated 07/26/2025 and signed by NP F reflected Resident #1 was seen by NP F on 07/26/2025. Record review of Resident #1's EMR Misc tab on 09/25/2025 did not reveal documentation of a physician or MD note apart from referral documentation. Resident #1 was unavailable for observation or interview.During an interview on 09/26/2025 at 03:06 p.m., Resident #1's family member and emergency contact #1 stated she was unaware of and didn't know if Resident #1 had seen a physician while at the nursing facility. 2. Record review of Resident #3's admission Record, dated 09/22/2025, revealed an [AGE] year-old male admitted on [DATE]. Resident #3 was noted as on hospice. Resident #3 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1. Record review of Resident #3's Medical Diagnoses, undated and accessed 09/22/2025 at 06:08 p.m., revealed diagnoses including chronic obstructive pulmonary disease (a type of progressive lung disease), dementia (a general term for impaired ability to remember, think, or make decisions), and adult failure to thrive (a condition where an older adult loses appetite, weight, and interest in activities). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 06/22/2025 as completed, reflected Resident #3 had a BIMS score of 03, indicating severe cognitive impairment. Resident #3 was noted as dependent for all self-care and mobility needs, except substantial/maximal assistance with rolling left or right on the bed. He was at risk for developing pressure ulcers/injuries but documented as not having a current skin condition, including a pressure ulcer/injury. He was noted to have a pressure reducing device for his chair and for his bed.Record review of Resident #3's progress notes dated 03/08/2025- 04/21/2025 did not reveal a progress note written by a physician or MD. Record review of Resident #3's EMR Misc tab on 09/25/2025 did not reveal documentation of a physician or MD note apart from initial referral, hospice, and physician orders documentation. During an observation of Resident #3 on 09/22/2025 at 04:35 p.m., he was noted to be asleep in bed. Attempted interview with Resident #3 revealed he was not interviewable. During an observation on 09/24/2025 at 12:07 p.m., Resident #3 was noted to not be present in his room. His bed was noted to have a pressure reducing mattress with scoop sides. Attempted interview with Resident #3's [family member] and emergency contact #1 on 09/26/2025 at 03:29 p.m. but they did not return the call. During an interview on 09/26/2025 at 05:52 p.m., the DNS revealed the physicians were notified immediately when a resident was admitted . He stated the physicians had a nurse practitioner in the facility multiple times a week and the physicians would come weekly to do rounds, sometimes in the morning, and sometimes on the weekend. He stated the medical records staff member was responsible for monitoring and ensuring the physician documentation was present in the resident records. He stated they would audit the records for the physician's history and physicals. He stated the physician's history and physical documentation would either be found in the resident's progress notes or under the miscellaneous tab of the EMR. He stated he did not know why there was not initial physician documentation for Resident #1 and Resident #3. He stated Resident #3 was on hospice, so it was possible the physician documentation was in his hospice binder. He stated he did not believe the lack of physician documentation would have impacted the residents' care due to both residents having been frequently seen and followed by the nurse practitioner. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed it was the medical records department's responsibility to upload and monitor the physician's documentation. He stated the physician's documentation was usually saved under the miscellaneous tab of the resident's EMR. He stated the physicians might email their notes to medical records, and the medical records staff member would upload them. He stated this might be done months later in some cases. He stated the delay or lack of the physician notes did not really impact the resident's care because the nurse practitioners were in the facility multiple times a week to provide care. During an interview on 09/29/2025 at 03:32 p.m., MD D returned call for attempted interview on 09/26/2025. MD D stated he messed up and forgot to send his history and physical documentation to the nursing facility for both Resident #1 and Resident #3. MD D did not reveal the dates he had initially seen Resident #1 and Resident #3. Requested a policy for Physician Services from the ADMIN on 09/26/2025. He provided policy titled, Physician Services: Medical Director. Record review of policy titled, Physician Services: Medical Director, date revised January 2023, revealed .The medical director's responsibilities include but are not limited to:.participating in establishing policies, procedures, and guidelines designed to ensure the provision of adequate, comprehensive services; participating in the resident care management system; developing written rules and regulations for all attending physicians; .consulting in the development and maintenance of an adequate medical record system; .acting as the organization's medical representative in the community.3. Record review of Resident #3's care plan, dated 08/05/2025, revealed Resident #3 had actual or was at risk for skin impairment, with an actual impairment on his sacrum (the triangular bone at the base of the spine). The interventions included *Apply treatment as ordered and *Skin Risk: Keep clean & dry and apply skin barrier cream as indicated. The care plan focus was created and initiated on 05/05/2025 and revised on 09/17/2025. Record review of Resident #3's EMR revealed a Skin & Wound Evaluation., dated 06/23/2025 and signed 06/25/2025. Resident #3 was noted to have a shear (a wound resulting from downward pressure and friction) on his sacrum, present on 06/23/2025. The wound was noted as 5.6 cm, length by 3.1 cm, width and without depth. Record review of Resident #3's EMR revealed a Skin & Wound Evaluation., dated 08/29/2025 and signed 08/29/2025 by LPN A. Resident #3 was noted to have a stage 3 (full-thickness skin loss) pressure wound on his sacrum, present on 06/23/2025. The wound was noted as 1.8 cm, length by 1.2 cm, width and without depth. The wound was documented as stable.Record review of Resident #3's Order Summary Report, dated as Active Orders As Of: 09/22/2025, reflected the order: Wound Care: Cleanse sacrum with normal saline, pat dry, apply Cal alginate&silver [sic] cover with dry dressing. every [sic] day shift for wound care till healed. Order noted as Active with order date, 07/25/2025, and start date, 07/26/2025.Record review of Resident #3's Treatment Administration Record, printed on 09/22/2025 and revealing treatments from 08/01/2025- 08/31/2025, reflected the order: Wound Care: Cleanse sacrum with normal saline, pat dry, apply Cal alginate& [sic] silver cover with dry dressing. every [sic] day shift for wound care till healed, start 07/26/2025 0700 [07:00 a.m.]. The treatment for the order was scheduled at Day 0 and was found to be blank on the treatment administration record for Friday, 08/22/2025, Sunday, 08/24/2025, and Sunday, 08/31/2025. Other medications and treatments scheduled at Day 0 revealed the following staff provided Resident #3 care during the shift the wound care treatment was scheduled: LPN B on 08/22/2025, RN H on 08/24/2025, and LPN C on 08/31/2025. Record review of Resident #3's SBAR Communication Form, dated but unsigned 09/23/2025, reflected Resident #3 had a change in his Skin wound or ulcer, which started on 09/23/2025. Under skin evaluation, wound deteriorating was noted. Under appearance, Stage 3 pressure wound not healing, deteriorating. Hospice aware & changed Tx noted. Record review of Resident #3's progress notes and skin and wound evaluations, revealed no documentation as to why the treatment was not done on 08/22/2025, 08/24/2025, or 08/31/2025. No other documentation was presented.During an interview on 09/26/2025 at 04:48 p.m., Resident #3's hospice RN revealed she observed initial problems, in June 2025, with the nursing facility staff regarding Resident #3's dressing, but the concerns were investigated and had been addressed. She revealed she felt the facility wound care had improved since the initial concerns. She revealed Resident #3's wound had been difficult to treat due to his complex medical conditions. She was unable to provide specific dates or state if wound care treatments had been missed. During an interview on 09/26/2025 at 12:32 p.m., LPN A stated the blanks in Resident #3's treatment records indicated the treatment was not checked off, indicating the treatment might have been completed but the nurse forgot to document the treatment completion. LPN A stated she believed she was out on planned leave on 07/22/2025 and 08/22/2025 and did not work on the weekends (08/31/2025 was a Sunday). She stated the nurses on the floor would cover wound care treatments when she was not at the facility. She stated the nurses had access to the treatment records and the treatments would have stayed open until someone clicked them off, indicating the treatments would have shown as due until a nurse noted they were completed. She stated she could not state what occurred on those dates, but she would have known if the treatment was not provided because the patches on the residents would have been dated and she would have noted a missed day. She stated she could not recall the dates in question. She stated she did not believe the residents were impacted by the nurses having not clicked off on the treatment record that they provided care because the care would have still been done. Attempted interview with MD E, Wound Care Specialist, on 09/26/2025 at 03:31 p.m., no return call received.Attempted interview with LPN B on 09/26/2025 at 05:05 p.m., no return call received.Attempted interview with LPN C on 09/26/2025 at 05:45 p.m., no return call received.Requested a policy for Wound Care from the ADMIN on 09/26/2025. He provided policy titled, Skin and Wound Prevention and Management. Record review of policy titled, Skin and Wound Prevention and Management, date revised January 2023, revealed .Each resident will receive the care and services necessary to retain or regain optimal skin integrity.Guideline: . 5.The licensed nurse should then document the notifications [sic] and any orders provided within the electronic health record. 6. The licensed nurse should communicate and collaborate with the IDT regarding the associated risks, identified wounds, skin concerns, and implement appropriate interventions.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry room reviewed for infection control. The facility failed to properly store clean resident clothing and mechanical lift slings in the facility clean laundry room.These failures could place the residents at risk of cross-contamination and development of infection.The findings included:During an observation of the clean side, noted on door of laundry room, of the nursing facility laundry room on 09/22/2025 at 04:52- 04:53 p.m., observed a bag of clean resident clothing, stored in a large clear bag with a hole in the bottom of the bag resulting in clothing spilled out and touching the laundry room floor. Observed approximately 5 mechanical lift slings hanging off the side of a trash can with straps of the slings touching the floor. During an interview on 09/26/2025 at 11:07 a.m., the LAM revealed he had been working as the manager for the facility's laundry for two weeks. He revealed the facility had been having issues with the laundry prior to his start and that he was still working to ensure all the resident clothing was cleaned and returned. He did not mention proper clothing or equipment storage for sanitation. During an interview on 09/26/2025 at 05:52 p.m., the DNS revealed the laundry services had been improving but he wouldn't say they were perfect yet. He revealed the department head for laundry was new. He did not mention proper clothing or equipment storage for sanitation. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed the facility had lost the prior laundry manager and had to let go of around 4-5 people in the laundry department recently due to not performing their job duties correctly. He revealed due to those changes the contracted laundry company had to send other people in to help with laundry and a new manager, the LAM, just started around 2 weeks ago. He did not mention proper clothing or equipment storage for sanitation. Requested policies for Laundry and Infection Control from the ADMIN on 09/22/2025. He provided policies titled, Routine Resident Care.Record review of policy titled, Routine Resident Care, date revised January 2023, revealed Residents should receive the necessary assistance to maintain good grooming and personal/oral hygiene.Care is taken to maintain resident safety at all times.f. Multi-patient use equipment should be cleaned/disinfected after patient use.

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for 1 of 6 (Resident #1) residents reviewed for involuntary seclusion.The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked unit, prior to Resident #1's move to the secured unit on 06/24/2025.This failure could place residents who resided on the secure unit at risk for feelings of isolation and anxiety.The findings included:Record review of Resident #1's admission Record, dated 09/22/2025, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1. Resident #1 discharged on 09/01/2025. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/22/2025 at 03:37 p.m., revealed diagnoses including Alzheimer's Disease (a progressive disease that affects memory and other important mental functions), muscle wasting and atrophy (shrinking of muscle or nerve tissue), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body). Record review of Resident #1's Census data, undated and accessed 09/22/2025 at 03:37 p.m., revealed Resident #1 was moved into the secure unit on 06/24/2025. Record review of Resident #1's admission MDS, dated [DATE] and signed 07/03/2025 as completed, reflected a BIMS score of 09, indicating moderate cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Resident #1's functional abilities were documented as requiring partial/moderate assistance to set up or clean-up assistance. Record review of Resident #1's discharge MDS, dated [DATE] and signed 09/06/2025 as completed, reflected Resident #1 wandered 1 to 3 days. The timeframe for Resident #1 having wandered was not specified within the assessment, except for the date of the assessment, 09/01/2025 and the noted end date of the observation for the assessment, 09/01/2025. Resident #1's functional abilities were documented as requiring supervision or touching assistance to being independent. Record review of Standard Assessment tab on Resident #1's EMR, undated and accessed on 09/22/2025 at 03:45 p.m., did not reveal an Elopement Risk Evaluation. Assessments noted as documented from the date of admission, 06/22/2025 through to the date of transfer to the secure unit, 06/24/2025 included: - Nrsg: Admission/Readmission., dated 06/22/2025, noted as In Progress, - SS: Social Services - Admission/Readmission., dated 06/23/2025, noted as Complete, and - IDT: Care Plan Conference & Advanced Care Planning Review., dated 06/24/2025, noted as Complete. Record review of Resident #1's Nrsg: Admission/Readmission. assessment, dated 06/22/2025, revealed No was selected for .does the resident display exit seeking behavior?. The Exit Seeking Careplan section did not include noted care plan focuses or interventions.Record review of Resident #1's SS: Social Services - Admission/Readmission., dated 06/23/2025, did not reveal need for secure unit placement or noted history of behaviors, including wandering or attempted elopements. Record review of Resident #1's IDT: Care Plan Conference & Advanced Care Planning Review., dated 06/24/2025, revealed 4. Psychiatric/Psychological Status and or Behaviors selected for under C. Advanced Care Plan: Care Choices Elected; however, additional comments not provided and secure unit placement not noted as an intervention. Record review of Resident #1's Order Recap Report, dated 09/25/2025 for order dates: 06/01/2025 - 09/30/2025, reflected no orders for secure unit placement. Record review of Resident #1's care plan, undated and accessed 09/22/2025 at 03:48 p.m., did not reveal mention of secure unit placement, risk for elopement, or wandering interventions. Record review of Resident #1's progress notes, dated 06/22/2025 (day of admission) to 06/24/2025 (day of transfer to secure unit), indicated no documentation about why a room change to the secure unit was made. No progress notes were found mentioning Resident #1 had tried to elope, ask where the exit was, or had wandering behaviors. Resident #1 was unavailable for observation or interview. During an interview on 09/26/2025 at 03:06 p.m., Resident #1's family member and emergency contact #1 stated the facility notified her of Resident #1's move to the secure unit and stated the move was due to Resident #1 having been exit seeking. She revealed she did not consent to Resident #1's move and stated she did not feel the facility attempted alternate interventions such as redirecting and providing activities to Resident #1 while he settled in at the nursing home. She revealed, upon moving Resident #1 to the secure unit, the facility staff removed some of Resident #1's personal property from his initial room. She stated the family were then notified he could not have specific items, those items removed, while he resided in the secure unit due to safety. She did not reveal if Resident #1 had a decline resulting from his secure unit placement, only mentioned Resident #1 was unable to perform some self-care tasks he typically did, such as cutting his own nails, while in the secure unit. She revealed Resident #1 was discharged home from the nursing facility per family request. During an observation and interview on 09/26/2025 at 05:52 p.m., the DNS revealed the only reason for a resident to have been placed in the secure unit was if the resident had a tendency for elopement or attempted elopement. He stated the exit seeking behavior determined the resident's need for secure unit placement. He stated an assessment would be done on the resident for exit seeking and if the resident was appropriate for secure unit placement, a consent from the family with an order from the physician would be obtained. The DNS was observed to review Resident #1's assessments to identify the exit seeking assessment and stated the assessment should have been there but he could not find it. The DNS revealed he could not recall the reason behind Resident #1's transfer to the secure unit but did not believe Resident #1 had a decline or was negatively impacted due to the transfer. He revealed there should have still been an assessment in Resident #1's EMR and the consent for transfer was a part of the assessment documentation. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed he recalled Resident #1's transfer to the secure unit was due to Resident #1 attempting to leave the nursing facility and asking where the exit door was located. The ADMIN stated Resident #1 was moved to the secure unit due to his attempt to elope. The ADMIN stated he did not know if the attempts or behaviors were documented but was sure the family was notified of the transfer. The ADMIN stated he was unaware of the family expressing any concerns or requests for Resident #1 to not be placed in the secure unit. The ADMIN stated he did not believe Resident #1 was negatively impacted by his secure unit placement. During an interview on 09/29/2025 at 03:32 p.m., MD D returned call for attempted interview on 09/26/2025. MD D stated he was unaware if he was required to put in a physician order for a resident to be placed in the secure unit. Record review of policy titled, Criteria for Memory Support Unit, date revised January 2023, revealed Residing on the Memory Support Unit (MSU) should be the least restrictive course of action in that it allows the resident's free movement in a safe environment. The following criteria will serve as a guide for admission to and discharge from the memory care support unit (MSU).Admission- The interdisciplinary team review should review each resident's condition, need and risks when considering admission to the memory support unit.- The attending physician should be consulted as part of the IDT and should provide an order for admission to the MSU.- Must be self-mobile by foot or wheelchair or another device.- Family/RP accepts the admission, transfer, and discharge criteria of the community.

Based on observation, interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's electronic clinical record had Hospice A Physician I's handwritten order for the indwelling urinary catheter, that had been in place for 95 days and did not discontinue the order for Hospice A when the resident admitted to Hospice B. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #1's admission Record, dated 10/04/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included high blood pressure, diabetes (chronic elevated levels of blood sugar which can affect other organs and bodily tissues), Parkinson's disease (progressive neurological disorder that affects, movement, balance and coordination), hypothyroidism (low blood levels of thyroid hormones) and systemic Lupus Erythematosus (a chronic autoimmune disease where the body's immune system attacks healthy tissues and organs, causing damage). Record review of Resident #1's Quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 15 out of 15, indication her cognitive skills for daily decision making were not impaired, and it was not marked the resident had an indwelling urinary catheter. Record review of Resident #1's care plans dated 10/05/2025, revealed a care plan for the focus area of At risk for infection or recurrent/chronic infection related to compromised medical condition: foley cath, initiated 05/23/2025 and revised on 10/04/2025. Record review of Resident #1's electronic clinical record Physician's Order Summary Report dated 10/04/2025 revealed an order to admit Resident #1 to Hospice A dated 06/20/2025 with no discontinue date, and another order to admit to Hospice B dated 8/21/25 with diagnoses of Parkinson's disease; and there was no order for an indwelling urinary catheter. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a New Order Form dated 06/30/2025 with a handwritten order from Hospice A Physician I to Place Foley [urinary] cath [catheter] for [urinary] retention and an order for an antibiotic (Cipro 500 mg) to be administered by mouth twice a day for 10 days for diagnosis of Urinary Tract Infection, and was signed by Hospice A Physician I. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a Hospice A Meeting Review note, dated 07/01/2025, which noted on 06/30/2025 Resident #1 was complaining of symptoms of urinary retention. Resident #1 wanted an in-and-out catheter which was placed and left for urinary retention. Resident #1 had over 1 L [Liter] of urine retention. Her urine was cloudy. Cipro 500 mg bid [twice a day] x 10 days started.Record review of Resident #1's Hospice A Nursing Clinical Notes, dated 07/02/2025, 07/07/2025, and 07/10/2025 revealed Resident #1 had an indwelling urinary catheter.Record review of Resident #1's Hospice B admission Orders, dated 08/19/2025, revealed she was admitted with hospice diagnosis of Parkinson's disease, and an order for the indwelling urinary catheter was not listed. Record review of Resident #1's Hospice B Facility and Hospice Delineation of Duties Plan of Care, dated 08/19/2025, revealed both Hospice B and the facility were responsible to provide indwelling urinary catheter care, insertion, and change the catheter.Record review of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling urinary catheter and drainage system; and supplies Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter.Record review of Resident #1's nurses' notes from 06/30/2025 to 10/04/2025 revealed the resident did not have any further urinary tract infections and she was not hospitalized . Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. Record review of Resident #1's nurses' note dated 10/03/2025, created on 10/04/2025 at 4:24 PM by RN A revealed Hospice B nurse came into facility per resident request to replace foley [indwelling urinary catheter]. Foley 16fr [size of catheter inserted] was placed successfully by hospice nurse. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. RN A stated, it was replaced yesterday by Hospice B [nurse] and I flushed it today and it looked good. When asked where she documented it, RN then asked the surveyor if she should have documented it and before the surveyor could respond, RN A stated she would write a late note about the indwelling urinary catheter being replaced by hospice services. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON stated the harm of not having an order for an indwelling urinary catheter or not documenting catheter care was that the care could be missed. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the harm of not having an order for an indwelling urinary catheter was that it could potentially be missed for monitoring for changes to the catheter. The Administrator said they have daily clinical meetings in the morning and weekly interdisciplinary team meetings to review residents' care to ensure accuracy of orders. Record review of the facility's policy Medical Records, revised January 2023, revealed A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. The medical record consists of but not limited to the following: information to identify the resident, a record of the resident's assessments, the plan of care and services provided.

Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #1) whose assessments were reviewed. The facility failed to indicate Resident #1's had an indwelling urinary catheter on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's admission Record, dated 10/04/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included high blood pressure, diabetes (chronic elevated levels of blood sugar which can affect other organs and bodily tissues), Parkinson's disease (progressive neurological disorder that affects, movement, balance and coordination), hypothyroidism (low blood levels of thyroid hormones) and systemic Lupus Erythematosus (a chronic autoimmune disease where the body's immune system attacks healthy tissues and organs, causing damage). Record review of Resident #1's Quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 15 out of 15, indication her cognitive skills for daily decision making were not impaired, and it was not marked the resident had an indwelling urinary catheter. Record review of Resident #1's care plans dated 10/05/2025, revealed a care plan for the focus area of At risk for infection or recurrent/chronic infection related to compromised medical condition: foley cath, initiated 05/23/2025 and revised on 10/04/2025. Record review of Resident #1's electronic clinical record Physician's Order Summary Report dated 10/04/2025 revealed an order to admit Resident #1 to Hospice A dated 06/20/2025 with no discontinue date, and another order to admit to Hospice B dated 8/21/25 with diagnoses of Parkinson's disease; and there was no order for an indwelling urinary catheter. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a New Order Form dated 06/30/2025 with a handwritten order from Hospice A Physician I to Place Foley [urinary] cath [catheter] for [urinary] retention and an order for an antibiotic (Cipro 500 mg) to be administered by mouth twice a day for 10 days for diagnosis of Urinary Tract Infection, and was signed by Hospice A Physician I. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a Hospice A Meeting Review note, dated 07/01/2025, which noted on 06/30/2025 Resident #1 was complaining of symptoms of urinary retention. Resident #1 wanted an in-and-out catheter which was placed and left for urinary retention. Resident #1 had over 1 L [Liter] of urine retention. Her urine was cloudy. Cipro 500 mg bid [twice a day] x 10 days started. Record review of Resident #1's Hospice A Nursing Clinical Notes, dated 07/02/2025, 07/07/2025, and 07/10/2025 revealed Resident #1 had an indwelling urinary catheter. Record review of Resident #1's Hospice B admission Orders, dated 08/19/2025, revealed she was admitted with hospice diagnosis of Parkinson's disease, and an order for the indwelling urinary catheter was not listed. Record review of Resident #1's Hospice B Facility and Hospice Delineation of Duties Plan of Care, dated 08/19/2025, revealed both Hospice B and the facility were responsible to provide indwelling urinary catheter care, insertion, and change the catheter. Record review of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling urinary catheter and drainage system; and supplies Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter that was to be changed every 30 days and as needed. Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/06/2025 at 1:57 PM, MDS Nurse RN H said when she completes the resident's MDS assessments, she would review the resident's clinical record, the Point of Care record, documents in the clinical record and interview the resident. MDS Nurse RN H reviewed Resident #1's Quarterly MDS assessment dated [DATE] and stated she did not mark the resident had a catheter because the resident did not have a catheter based on the resident's clinical record, the Point of Care charting completed by the CNAs. The MDS Nurse RN H was asked to review the nurse's note dated 09/14/2025 which indicated Resident #1's indwelling urinary catheter had been replaced; RN H verified the nurse noted the hospice nurse had changed the catheter and stated it was an overlook. MDS Nurse RN H stated that if she had seen the note about the urinary catheter being changed, she would have questioned the note since there was no order for the indwelling urinary catheter before marking on the MDS the resident had a urinary catheter. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON looked at Resident #1's MDS Quarterly assessment dated [DATE] and stated it was not marked the resident had an indwelling urinary catheter, it should have been marked and the harm of not having the MDS completed accurately could result in the MDS being inaccurate and would need to be revised or amended. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the facility had weekly interdisciplinary meetings to ensure residents' MDS assessments were completed accurately and the harm of an inaccurate MDS could result in care not being monitored. Record review of the facilities policy titled Comprehensive Assessments, revised January 2023, revealed The community conducts frequent and different types of assessments, depending on the resident's condition and need.The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental & physical functional status. The community uses a variety of sources to obtain the information needed for the RAI, including direct observation and communication with the resident, communication with licensed and non-licensed team members on all shifts, review of the resident's previous medical history and physical and medical record obtained from the referring community.Accuracy of Assessment. Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and area of decline. Record review of CMS's RAI Version 3.0 Manual, October 2025, page H-1 to page H-2, revealed under Steps for Assessment was 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Under Coding Instructions was Check next to each appliance that was used at any time in the past 7 days.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents (Resident #1) reviewed for urinary catheters. The facility failed to ensure Resident #1's Hospice A Physician I's handwritten order for the indwelling urinary catheter that had been in place for 95 days was on the electronic physician orders; and did not document when urinary catheter care was provided or if the urinary catheter had been replaced every 30 days as ordered by Hospice B. This failure could place residents at risk for a decline in their health status.The findings included: Record review of Resident #1's admission Record, dated 10/04/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included high blood pressure, diabetes (chronic elevated levels of blood sugar which can affect other organs and bodily tissues), Parkinson's disease (progressive neurological disorder that affects, movement, balance and coordination), hypothyroidism (low blood levels of thyroid hormones) and systemic Lupus Erythematosus (a chronic autoimmune disease where the body's immune system attacks healthy tissues and organs, causing damage). Record review of Resident #1's Quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 15 out of 15, indication her cognitive skills for daily decision making were not impaired, and it was not marked the resident had an indwelling urinary catheter. Record review of Resident #1's care plans dated 10/05/2025, revealed a care plan for the focus area of At risk for infection or recurrent/chronic infection related to compromised medical condition: foley cath, initiated 05/23/2025 and revised on 10/04/2025. Record review of Resident #1's electronic clinical record Physician's Order Summary Report dated 10/04/2025 revealed an order to admit Resident #1 to Hospice A dated 06/20/2025 with no discontinue date, and another order to admit to Hospice B dated 8/21/25 with diagnoses of Parkinson's disease; and there was no order for an indwelling urinary catheter. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a New Order Form dated 06/30/2025 with a handwritten order from Hospice A Physician I to Place Foley [urinary] cath [catheter] for [urinary] retention and an order for an antibiotic (Cipro 500 mg) to be administered by mouth twice a day for 10 days for diagnosis of Urinary Tract Infection, and was signed by Hospice A Physician I. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a Hospice A Meeting Review note, dated 07/01/2025, which noted on 06/30/2025 Resident #1 was complaining of symptoms of urinary retention. Resident #1 wanted an in-and-out catheter which was placed and left for urinary retention. Resident #1 had over 1 L [Liter] of urine retention. Her urine was cloudy. Cipro 500 mg bid [twice a day] x 10 days started. Record review of Resident #1's Hospice A Nursing Clinical Notes, dated 07/02/2025, 07/07/2025, and 07/10/2025 revealed Resident #1 had an indwelling urinary catheter. Record review of Resident #1's Hospice B admission Orders, dated 08/19/2025, revealed she was admitted with hospice diagnosis of Parkinson's disease, and an order for the indwelling urinary catheter was not listed. Record review of Resident #1's Hospice B Facility and Hospice Delineation of Duties Plan of Care, dated 08/19/2025, revealed both Hospice B and the facility were responsible to provide indwelling urinary catheter care, insertion, and change the catheter. Record review of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling urinary catheter and drainage system; and supplies Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter that was to be changed every 30 days and as needed. Record review of Resident #1's July 2025 MAR/TAR revealed Resident #1 received the antibiotic Cipro 500 mg twice a day by mouth for 10 days and there was no documentation of indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's August 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's September 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's October 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care from 10/01/2025 to 10/04/2025. Record review of Resident #1's nurses' notes from 06/30/2025 to 10/04/2025 revealed the resident did not have any further urinary tract infections and she was not hospitalized . Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. Record review of Resident #1's nurses' note dated 10/03/2025, created on 10/04/2025 at 4:24 PM by RN A revealed Hospice B nurse came into facility per resident request to replace foley [indwelling urinary catheter]. Foley 16fr [size of catheter inserted] was placed successfully by hospice nurse. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. RN A stated, it was replaced yesterday by Hospice B [nurse] and I flushed it today and it looked good. When asked where she documented it, RN then asked the surveyor if she should have documented it and before the surveyor could respond, RN A stated she would write a late note about the indwelling urinary catheter being replaced by hospice services. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/05/2025 from 2:25 PM to 2:41 PM, NAIT B said Resident #1 had an indwelling urinary catheter that she would empty the collection bag about five times a day and clean the catheter when pericare was provided to the resident. In an interview on 10/05/2025 from 4:31 PM to 4:52 PM with CNA C and CNA D, who was translating for CNA C, revealed when CNA C provided incontinent care to Resident #1, he would empty the urinary catheter bag and perform catheter care. In an interview on 10/05/2025 from 4:57 PM to 5:14 PM, LVN E stated she would check Resident #1's urinary catheter and bag, empty the bag several times during the shift and would clean the catheter tubing. LVN E stated the hospice nurse would change Resident #1's indwelling urinary catheter. In an interview on 10/06/2025 from 1:40 PM to 1:55 PM, MA G stated he had been a MA for 1 week and previously was a CNA who had cared for Resident #1. MA G said when he provided care to Resident #1, he would empty the urinary collection bag, and clean the catheter tubing when pericare was provided to the resident. In an interview on 10/06/2025 at 9:04 AM, Resident #1's Private Sitter F stated she has been the resident's private sitter for about 1 year before the resident was admitted to the facility and had been coming to the facility for about four months for 12 hours a day. Private Sitter F stated the nurses and CNAs would come in to clean up the resident and take care of the resident's indwelling urinary catheter. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON stated the harm of not having an order for an indwelling urinary catheter or not documenting catheter care was that the care could be missed. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the harm of not having an order for an indwelling urinary catheter was that it could potentially be missed for monitoring for changes to the catheter. The Administrator said they have daily clinical meetings in the morning and weekly interdisciplinary team meetings to review residents' care to ensure accuracy of orders. Record review of the facility's policy Incontinence and Catheterization Assessment and Evaluation, revised January 2023, revealed Assessments are based on the resident's RAI, history, and physical, and other information such as physician orders, progress notes, nurses' notes, pharmacist reports, lab reports, and any flow sheets used to document the resident's voiding history.For a resident who was admitted to the community with an indwelling urinary catheter or who had one placed after admission, the community will: Recognize and assess factors affecting the resident's urinary function and identified the medical justification for the use of an indwelling urinary catheter; Define and implement pertinent interventions consistent with resident conditions, goals and recognized standards of practice to try to minimize complications from an indwelling urinary catheter and remove it if clinically indicated; Monitor and evaluate the resident's response to interventions; Revise the approaches as appropriate.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure trays of prepared and poured glasses of beverages were dated and labeled. 2. The facility failed to ensure soup warmer with soup was returned to kitchen after meal and not left out all night. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 06/22/2025 at 9:27 AM revealed during the initial tour of the kitchen 4 trays with beverages prepared in the standing refrigerator not dated or labeled: *1 tray of 8 large glasses of milk, *1 tray of 5 large glasses of juice and water, *1 tray of 20 small glasses of orange juice and, *1 tray of 12 small glasses of milk. The [NAME] stated the trays were from breakfast and she had placed them back in the refrigerator but did not put dates on the trays. The [NAME] stated the date was, so the kitchen staff know when things are put in the refrigerator, so things would not go bad. The [NAME] was observed removing the trays of beverages from the refrigerator and placing the date on them. Observation on 06/24/2025 at 5:30 AM revealed a soup warmer on the counter in the main dining room with soup. The soup warmer did not feel warm to the touch and was not plugged in, the lid to the soup was partially opened due to ladle sticking out there was no date or label on the soup. Observation on 06/24/2025 at 5:36 AM revealed in the standing refrigerator held 6 trays thta were not dated or labeled: *One tray was observed to have 10 large glasses of tea. *Two other trays stacked on each were observed to have glasses of orange juice with the bottom tray being full and top tray almost full. *2 trays of milk stacked on one another with bottom tray full and 11 glasses on the top tray. *A cup was observed to be sitting in the fridge that look to be chocolate milk, and * a tray with 2 dates on it for 06/22/2025 and 06/23/2025 having 2 glasses of cranberry juice, 6 glasses of milk and 1 glass of water on the tray. During an interview on 06/24/2025 at 5:39 AM the [NAME] stated the beverage trays had been placed by whoever worked last night. The [NAME] further stated the trays with the beverages should have been dated and that she had explained it to them after we came in the first day reminding the other kitchen staff. The [NAME] stated regarding the tray with the two dates was because the 06/22/2025 was not taken off and when the new date was placed. The [NAME] stated the tray of tea she stated should have been dated last night when they put it back in the refrigerator. The [NAME] stated the soup in the dining room was not brought in last night and it should have been. The [NAME] further stated the soup was put out at lunch yesterday. The [NAME] stated she was not sure how long the soup could be out but by not being brought back in to the kitchen the residents could be put at risk of being burned if they were not supervised with the soup or it could make them sick by leaving it out too long. During an interview on 06/24/2025 at 7:02 AM the Administrator stated the soup was usually brought out from the kitchen right before lunch, but there was not a set time they bring it back in to the kitchen, but it should have been after lunch. The Administrator further stated by leaving the soup out bacteria could form, and people could get sick. The Administrator stated items are to be dated and labeled to know when they might go bad. The Administrator stated the kitchen was responsible for removing the soup from the dining room and the labeling of items in the fridge. During an interview on 06/25/2025 at 11:08 AM the DM stated the kitchen the evening of 06/23/2025 should have pulled the soup from the dining room when they closed the kitchen for the night before they left. The DM stated residents could get sick from food borne illness. The DM stated the evening kitchen staff did prep the breakfast items and the beverage trays should have been labeled and dated. The DM further stated anything prepped or opened in the refrigerator should be dated and labeled, so, staff understood it was not old and to know when to pour things out. The DM stated somebody could get sick if the items were left too long in the refrigerator and not thrown out. The DM stated the person placing items in the refrigerator was responsible for labeling and dating the items. During an interview on 06/25/2025 at 5:38 PM the Administrator stated stored and refrigerated items should be labeled and dated so they know it was still okay to serve and prevent food borne illness. The Administrator further stated the kitchen as a whole was responsible for labeling and dating. Record review of in-service training dated 10/16/2024 revealed, staff had been in serviced regarding Labeling and Dating. Record review of in-service training dated 05/20/2025revealed, staff had been in serviced regarding Refrigeration & Dry Storage of Food. Review of facility's policy, Food Storage, no date, read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the stated, federal and US Food Codes and HACCP guidelines. Procedure: #2. Date, label and tightly seal all refrigerated foods using clean, no absorbent, covered containers that are approved for food storage.

Based on interview and record review, the facility failed to ensure the Resident has the right to be informed of, and participate in, his or her treatment, including: the accurate communication and implementation of code status for 1 of 4 residents (Resident #53) reviewed resident rights and advance directives. Resident #53 had a discrepancy in code status, as evidenced by contradictory records found in the medical chart. This failure to ensure consistency in the resident code status violates their autonomy and places them at risk of receiving treatment contrary to their expressed wishes. Findings included: Record review of Resident #53's face sheet revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included Senile Degeneration of the Brain (a decline in cognitive function, particularly memory and thinking skills), Dementia (progressive or persistent loss of intellectual functioning) Depression (mental health disease of high and low mood swings), Anxiety (intense, excessive, and persistent worry and fear). Record review of Quarterly MDS assessment dated [DATE] revealed BIMS (Basic Interview of Mental Status) Score of 8 indicating moderate cognitive impairment and required supervision with self-feeding, toilet hygiene, dressing, bed mobility, bathing and gait. Record review of Resident #53's medical record revealed a discrepancy was found between Resident #53 face sheet, care plan (dated 06.20.2025), OOH-DNR (dated 02.14.2025), and orders (no orders for DNR in EHR). The profile reflected Resident #53 was a full code; the care plan reflected the resident was a full code; and the Misc. Documents revealed an OOH- DNR signed by the physician dated February 2025. Resident #53's orders reflected hospice and contradictory (RN to pronounce) information for Full Code. During an interview with Resident #53 on [DATE] at 3:27 p.m., Resident #53 was asked what his wishes were if he were to stop breathing and needed CPR. He replied that he believed he would want CPR to keep on living. During an interview with the Social Worker on [DATE] at 1:52 p.m., the SW was able to see and verify the discrepancy noted in Resident #53' s chart. The face sheet showed a full code, and there was a signed OOH- DNR order found in EHR under Misc. Documents . The SW was not aware if Resident #53 had an Ad Litem (someone appointed by the court to represent the interests of someone who cannot represent themselves ) but verified that the two physicians who admitted Resident #53 to hospice were also the ones who signed the OOH- DNR. Resident #53 did not sign any consents to hospice or OOH-DNR. The last care plan meeting was 06.12.2025 and Resident #53 was not present . During an interview with the DON on [DATE] at 4:50 p.m., the DON stated that she did see a concern with the discrepancy and that the Social Worker would be the one to ensure that Resident #53's wishes had been updated during the care plan meeting. She understood the concerns with the discrepancy would be that his Resident #53 wishes were not followed. During an interview with the ADM on [DATE] 05:38 PM, the ADM stated he was aware of the discrepancies in the advance directives for Resident #53. That Resident #53 should be informed and make decisions regarding his treatment plan. The ADM stated that resident records should be updated at care plan meetings, and the SW was responsible for ensuring accuracy of wishes and code status. Review of the facility policy titled, The Facility Manual, revised [DATE], reflected Resident Rights, Exercise of Rights, Residents will have the right to exercise their rights as residents of the community and as citizens or residents of the United States. Residents will have the right to be free of interference, coercion, discrimination, and reprisal from the community in exercising his or her rights.

Based on interview and record review, the facility failed to ensure the residents right to request to formulate an advance directive and accurate documentation of advance directives was maintained and implemented for 1 of 4 residents (Resident #53). Resident #53's OOH-DNR was signed and in misc. documents while face sheet and care plan were listed as full code. This deficient practice could place the resident at risk of receiving care inconsistent with their wishes. The findings were: Record review of Resident #53's face sheet revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included Senile Degeneration of the Brain (a decline in cognitive function, particularly memory and thinking skills), Dementia (progressive or persistent loss of intellectual functioning) Depression (mental health disease of high and low mood swings), Anxiety (intense, excessive, and persistent worry and fear). Record review of Quarterly MDS assessment dated [DATE] revealed BIMS (Basic Interview of Mental Status) Score of 8 indicating moderate cognitive impairment and required supervision with self-feeding, toilet hygiene, dressing, bed mobility, bathing and gait. Record review of Resident #53's medical record revealed a discrepancy was found between Resident #53 face sheet, care plan (dated 06.20.2025), OOH-DNR (dated 02.14.2025), and orders (no orders for DNR in EHR). The profile reflected Resident #53 was a full code; the care plan reflected the resident was a full code; and the Misc. Documents revealed an OOH- DNR signed by the physician dated February 2025. Resident #53's orders reflected hospice and contradictory (RN to pronounce) information for Full Code. During an interview with Resident #53 on [DATE] at 3:27 p.m., Resident #53 was asked what his wishes were if he were to stop breathing and needed CPR. He replied that he believed he would want CPR to keep on living. During an interview with the Social Worker on [DATE] at 1:52 p.m., the SW was able to see and verify the discrepancy noted in Resident #53' s chart. The face sheet showed a full code, and there was a signed OOH- DNR order found in EHR under Misc. Documents . The SW was not aware if Resident #53 had an Ad Litem (someone appointed by the court to represent the interests of someone who cannot represent themselves ) but verified that the two physicians who admitted Resident #53 to hospice were also the ones who signed the OOH- DNR. Resident #53 did not sign any consents to hospice or OOH-DNR. The last care plan meeting was 06.12.2025 and Resident #53 was not present . During an interview with the DON on [DATE] at 4:50 p.m., the DON stated that she did see a concern with the discrepancy and that the Social Worker would be the one to ensure that Resident #53's wishes had been updated during the care plan meeting. She understood the concerns with the discrepancy would be that his Resident #53 wishes were not followed. During an interview with the ADM on [DATE] 05:38 PM, the ADM stated he was aware of the discrepancies in the advance directives for Resident #53. That Resident #53 should be informed and make decisions regarding his treatment plan. The ADM stated that resident records should be updated at care plan meetings, and the SW was responsible for ensuring accuracy of wishes and code status. Record review of the facility policy, Advanced Directives, reviewed [DATE], revealed, The medical record and resident's plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #19) reviewed for infection control. LVN A poured two different over the counter bulk facility medications into her bare hand to administer to Resident #19 and put the pills she did not need back into the bottle during a medication administration observation. This failure could place residents at risk of cross contamination, health complications, and illness. The findings were: In an observation and interview on 6/24/25 at 6:36 a.m. during a medication administration observation for Resident #19, LVN A poured several cyanocobalamin (Vitamin B12) 1000mcg oral tablets from a bulk facility stock bottle (unknown amount) into her bare left hand and tilted her left hand against the bottle and put all the tablets back in the bottle except one that she had in her creased palm to administer to Resident #19. LVN A stated she should not have poured the medications into her bare hands and put the remainder medication back into the bottle. LVN A discarded the bottle and the pill in her hand in the trash on the medication cart. LVN A poured several iron 325mg tablets from a bulk facility stock bottle (unknown amount) into her bare left hand and tilted her left hand against the bottle and creased her palm to hold one tablet and began putting the other tablets back into the bottle, she paused, and placed all pills back in the bottle and discarded the bottle in the medication sharps container and asked another staff member to bring her a new bottle. LVN A stated pouring the medications into her hand and putting them back in the bottle was not a habit for her and she was nervous. LVN A stated she should not have poured the medications into her bare hand and returned them back in the bottle. LVN A stated the possible consequences of doing so could be exposing the resident to germs and contaminates the entire bottle. In an interview on 6/25/25 at 10:23 a.m. the DON stated LVN A should not have put the medications in her hand nor returned them to the bulk bottle after touching them and should have used the inside of the lid to the bottle to separate them to 1 pill to administer to the resident. The DON stated the possible consequences of putting the medications in her bare hand and returning them to the bottle could be introducing bacteria. The DON stated there was not a facility policy specific to the medication error rate. Review of LVN A's competencies checklist revealed she had met the medication administration competency and infection control practices on 2/17/25. Review of the facility policy on medication administration revised January 2024 indicated . 1. Follow safe sanitary practices . d. Do not touch oral medication, topical ointments, or creams .

Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 4 residents (Resident #53) reviewed for accuracy of records. The facility failed to ensure Resident #53 expressed Full Code status and the code status documented in the electronic medical record, placing the resident at risk of receiving improper treatment. These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #53's face sheet revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included Senile Degeneration of the Brain (a decline in cognitive function, particularly memory and thinking skills), Dementia (progressive or persistent loss of intellectual functioning) Depression (mental health disease of high and low mood swings), Anxiety (intense, excessive, and persistent worry and fear). Record review of Quarterly MDS assessment dated [DATE] revealed BIMS (Basic Interview of Mental Status) Score of 8 indicating moderate cognitive impairment and required supervision with self-feeding, toilet hygiene, dressing, bed mobility, bathing and gait. During a record review on [DATE] at 11:42am of Misc. Documents section of the clinical record indicated Resident #53 had an OOH- DNR signed by physician dated February 2025. During an interview with Resident #53 on [DATE] at 3:27 p.m., Resident #53 stated he believed he would want CPR to keep on living. During an interview and observation with the social worker on [DATE] at 1:52 p.m., the SW confirmed the discrepancy noted in the chart. The SW was not aware if Resident #53 had an Ad Litem (someone appointed by the court to represent the interests of someone who cannot represent themselves ) but verified that the two physicians who admitted Resident #53 to hospice were also the ones who signed the OOH- DNR. Resident #53 did not sign any consents to Hospice or OOH-DNR. The last Care Plan meeting was 06.12.2025 and Resident #53 was not present. During an interview with the DON on [DATE] at 4:50 p.m., the DON stated there was a concern with the discrepancy in Resident #53s records and the social worker would be the one to ensure his wishes had been updated during the care plan meeting. She stated the discrepancy would be that Resident #53's wishes were not followed. During an interview with the ADM on [DATE] 05:38 PM, the ADM stated he was aware of the discrepancies in advance directives for Resident #53. He stated Resident #53 should be informed and make decisions regarding his treatment plan. ADM stated Resident Records should be updated at care plan meetings and SW was responsible for ensuring accuracy of wishes and code status. Record review of the facility policy, Resident Rights, reviewed [DATE], revealed, Residents have the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect their well-being.

Based on observations and interviews, the facility failed to store medication with the expiration date on packaging in compliance with state laws and regulations for 1 of 2 medication rooms (300/400 hall) observed for medication storage. The medication room on the 300/400 hall had a box with an [NAME] boot stored without an expiration date. This failure could affect residents prescribed medications and result in less potent medications provided and could result in decreased health response or misuse of medication. The findings included: Interview and observation of medication storage room for 300/400 halls on 06/23/25 at 09:00 AM revealed the date was torn off a box with an [NAME] boot (a wet compression dressing used in the treatment of venous ulcers and dries semirigid similar to a cast) and no date was on the foil package with the [NAME] boot. The DCO took the box with the [NAME] boot and discarded it in the trash. She said she did not know why the package date was torn off that way and she did not know why it was in the medication room. The DCO said it should not have been stored that way. Interview on 6/25/2025 at 4:30PM the Administrator said expiration dates were needed on medications for nurses to know because expired medications could lose its potency and effectiveness over time. Interview on 6/25/2025 at 5:0PM the DON said it was important for medication to have expiration date so the nurse would know when not to use it. She said it was important not to use expired medication because it would not have the same benefits of what was needed to use the medication. Record review of the facility policy titled, Pharmacy Services dated February 2017 stated under Labeling of medications and biologicals: The critical elements of the drug label include: expiration dates.

Based on observation and interview the facility failed to ensure medication error rates are not 5 percent or greater for 1 of 4 residents (Resident #19), reviewed for pharmacy services in that the automatic calculation of the medication error rate in the Long-Term Care Survey Process (LTCSP) after 25 opportunities with 2 errors was 8%. LVN A poured two different over the counter bulk facility medications into her bare hand to administer to Resident #19 and put the ones she did not need back into the bottle during a medication administration observation. This failure could place residents at risk of cross contamination, health complications, and illness. The findings were: Record review of Resident #19's face sheet dated 6/25/25 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Her diagnoses included unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands), and immunodeficiency due to conditions classified elsewhere (medical condition where an individual's immune system is weakened or not functioning optimally due to another underlying health issue). Record review of Resident #19's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 1 out of 15 indicating the resident was severely cognitively impaired. Record review of Resident #19's care plan with a last reviewed date of 6/22/25 revealed a focus revised on 6/18/25 for nutritional deficits related to malnutrition. Interventions included to provide food, fluids, including supplements as ordered. Another focus initiated on 1/16/25 for chronic health conditions that included malnutrition. Interventions included to Administer medications as ordered. Record review of Resident #19's order summary dated 6/25/25 revealed an order with a start date of 12/10/24 for cyanocobalamin (Vitamin B12) Oral Tablet 1000 mcg once daily. Record review of Resident #19's order summary dated 6/25/25 revealed an order with a start date of 4/19/25 for Ferrous Sulfate (iron) tablet 325 mg once daily. In an observation and interview on 6/24/25 at 6:36 a.m. during a medication administration observation for Resident #19, LVN A poured several cyanocobalamin (Vitamin B12) 1000mcg oral tablets from a bulk facility stock bottle (unknown amount) into her bare left hand and tilted her left hand against the bottle and put all the tablets back in the bottle except one that she had in her creased palm to administer to Resident #19. LVN A was asked if she should have poured the medication into her bare hand and or put them back in the bottle prior to her placing the contaminated vitamin B12 tablet in the medicine cup with Resident #19's other meds and she stated she should not have. LVN A discarded the bottle and the pill in her hand into the trash on the medication cart. During this same medication observation LVN A poured several iron 325mg tablets from a bulk facility stock bottle (unknown amount) into her bare left hand and tilted her left hand against the bottle and creased her palm to hold one tablet and began putting the other tablets back into the bottle and paused and then placed them all back in the bottle and discarded the bottle in the medication sharps container and asked another staff member to bring her a new bottle. LVN A stated pouring the medications into her hand and putting them back in the bottle was not a habit for her and she was nervous. LVN A stated she should not have poured the medications into her bare hand and returned them back in the bottle. LVN A stated the possible consequences of doing so could be exposing the resident to germs and contaminates the entire bottle. Review of LVN A's competencies checklist revealed she had met the medication administration competency on 2/17/25. In an attempted interview on 6/25/25 at 6:45 a.m. Resident #19 would smile when asked questions and did not respond to questions. In an interview on 6/25/25 at 10:23 a.m. the DON stated LVN A should not have put the medications in her hand nor returned them to the bulk bottle after touching them and should have used the inside of the lid to the bottle to separate them to 1 pill to administer to the resident. The DON stated the possible consequences of putting the medications in her bare hand and returning them to the bottle could be introducing bacteria. The DON stated there was not a facility policy specific to the medication error rate. Review of the facility policy on medication administration revised January 2024 indicated . 1. Follow safe sanitary practices . d. Do not touch oral medication, topical ointments, or creams .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to ensure Resident #55 was provided a pad type call light which was care planned as an intervention for the resident. This deficient practice places residents at risk for not receiving proper care and services due to not implementing care plan interventions. The findings were: Record review of Resident #55's face sheet, dated 06/23/2025, revealed he was admitted on [DATE] with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, multiple sclerosis ( a chronic, often disabling, disease of the central nervous system that affects the brain and spinal cord) , other lack of coordination, chronic pain syndrome, and muscle weakness (generalized). Record review of resident #55's Quarterly MDS assessment, dated 06/19/2025, revealed the resident's BIMS score 07 for moderate cognitive impairment. The Quarterly MDS assessment further revealed Resident #55 required substantial/maximal assistance (helper does more than half the effort) for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. Record review of Resident #55's care plan, initiated date 03/19/2025, revealed Resident #55 had a focus of I use a specialized call light: Unable to push the button on the traditional call light and intervention/tasks Provide Pad type call light. During observation and interview on 06/22/2025 at 11:24 AM Resident #55 stated she had trouble with her call light. Resident #55 further stated she relied a great deal on her roommate to call when she needed something. Resident #55 was observed lying flat in the bed with the call light within reach however when she attempted to push her call light using one finger, she only pressed the side of the call light not the red button. The call light did not turn on due to resident had not manage to push the call light button. During observation and interview on 06/24/2025 at 7:28 AM revealed Resident #55 was up in her wheelchair at bedside with the over bed table in front of her and a traditional call light sitting on the side of bed within reach. Resident #55 was observed being able to this time to push the button of the call light, turning on the call light. Resident #55 stated she got shaky sometimes and had trouble with her call light. During an interview on 06/25/2025 10:15 AM the DON stated she was not aware of Resident #55 not being able to use her call light and they would get her the pad call light (call light requiring the resident only to tap). The DON further stated she was not aware it had been care planned for Resident #55 to have a pad call light. The DON stated Resident #55 had never complained to her that she was calling, and nobody was coming. The DON stated by not having the proper call light the resident would not be able to get a hold of them for what she needed. The DON stated she had personally answered her call light and was not aware the roommate was pushing the button for Resident #55. The DON stated the light outside of the room alerting staff did not tell them which bed pushed the light but, just that the room needed assistance. During an interview on 06/25/2025 11:21 AM the MDS Coordinator stated when the care plan was done back in March 2025 Resident #55 had a touch pad call light. The MDS Coordinator stated she was not sure what had happened and was not aware Resident #55 no longer had it. The MDS Coordinator stated she was not sure if Resident #55 had complained about the touch pad call light. The MDS Coordinator further stated the DON was going to put it back and it was going to stay the same. The MDS Coordinator stated she did not feel by not having the touch pad it would have been an issue because Resident #55 used the roommate many times to use the call light, and further stated Resident #55 would wheel herself out of the room to get staff and had used the call light before when it was a push call light. The MDS Coordinator stated in June 2025 when the care plan was reviewed, she was not aware Resident #55 did not have the touch pad call light. During an interview on 06/25/2025 at 5:09 PM the DON stated the care plan directed the care for the residents and by not following the care plan it could disrupt the continuity of care. The DON further stated nursing as a whole was responsible to ensure staff were aware of the care plan needs of the residents. The DON stated the staff were aware of the interventions for care or the care plan by the use of the Kardex system and the nurses had access to the view both the Kardex and the care plans. The DON was not sure if the specialized call lights were part of the Kardex. The DON further stated the Kardex was more regarding the care, but the Kardex was customizable. During an interview on 06/25/2025 5:35 PM the Administrator stated nursing was responsible for the implementation of the care plan. The Administrator stated by not following the interventions of the care plan and providing resident with the pad call light Resident #55 might not be able to alert staff to answer the call light. Record review of facility's Care Plans policy, revised date January 2023, read, Guidelines: Care Plans: The community develops a comprehensive care of each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs medical condition, preventative measures. The care plan may also include expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of facility's Routine Resident Care policy, revised date January 2024, read, Compliance Guidelines: Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene and safety. Steps are taken to provide that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to maintain resident safety at all times. Guidelines: #11 Team members should follow the resident plan of care and update with identified resident changes.

Based on interview, and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 23 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide that Resident # 1's environment remained as free of accident hazards as is possible when Resident #1 swallowed wet wipes, choked and expired. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. The failure placed all residents at risk for serious injury, harm, and/or death. Finding include: Record review of Resident #1's Admission Record dated [DATE] documented a [AGE] year-old male admitted to the facility [DATE] with diagnoses that included dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings and withdrawal from reality), depression (a mental condition characterized by feelings of severe despondency and dejection), neuromuscular dysfunction of bladder (a condition that occurs when the nerved controlling the bladder are damaged), and benign prostatic hyperplasia (enlarged prostate potentially squeezing the urethra and causing urinary problems). Record review of Resident #1's PPS Discharge Assessment MDS dated [DATE] revealed a BIMS score of 13 indicating he was cognitively intact. The PHQ9 score evaluating mood was 0 indicating no evidence of depression. Under Functional Abilities, Resident #1 was able to walk unassisted, transfer himself in and out of bed and to the toilet, and only required setup or clean-up assistance with ADLs. Record review of Resident #1's Care Plan dated [DATE] revealed Focus that included: - that he required a catheter and interventions were in place to provide catheter care - at risk for psycho-social issues, emotional distress or behaviors related to schizophrenia with interventions that noted behavior triggers: mood disorder, delusion and hallucinations and to keep environment calm, quiet and avoid loud noises as much as possible - Required anti-psychotic medication related to schizophrenia which included the need to monitor/document/report to MD signs and symptoms of psychotropic drug complications, altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation and withdrawal . Record review of Nurses Progress Notes dated [DATE] by RN B documented that Resident #1 was last seen at approximately 6:00 pm sitting on the side of his bed alert and oriented. CNA called for this nurse at approximately 7:10 pm. Resident lying in bed not responding to verbal stimuli, pale in color, and no pulse noted. Code Blue called. Resident was assisted to the floor by this nurse and two CNAs and CPR was initiated. 911 called by CNA at approximately 7:13 pm. CPR continued until EMS arrived .Time of death called by EMS MD at 7:48 pm. Record review of the EMS Report dated [DATE] revealed that during attempts to intubate Resident #1, EMS discovered a stack of wet wipes lodged in esophagus, wet wipes continued to be removed, approximately 15 wet wipes were removed . During an interview with LVN A on [DATE] at 1:12 pm, nurse reported that Resident #1 appeared to be in a good mood, participated in activities and had talked with a family member who was coming to visit. LVN A stated Resident #1 accidentally pulled out his foley so she easily reinserted it. LVN A stated Resident #1 was not complaining of pain. LVN A stated she had seen Resident #1 in the hall after that and there were no apparent signs of suicide. When asked if she had ever seen Resident #1 writing notes, LVN A stated he had asked for paper before but she had never seen him writing. LVN A was asked about the availability of wipes and she stated residents used to have access to wipes but they don't now. LVN A stated that getting rid of wipes was a plan of correction for a variety of reasons. During an interview with CNA D on [DATE] at 1:52 pm, she stated they were getting residents ready for bed. CNA D stated Resident #1 and his roommate would remind each other about going to the dining room to get their medications from the nurse. His roommate reported that he couldn't wake up Resident #1. CNA E went to check on Resident #1 and discovered he was non-responsive and got the nurse. CNA D stated she and the other CNA and the nurse got Resident #1 off the bed and onto the floor so CPR could be started until EMS arrived. CNA D stated she didn't see anything in Resident #1's mouth but later saw EMS pull something out of his mouth. CNA D stated she was in shock and never thought he would do anything like that. CNA D stated the wipes and gloves were always stored in the resident's bathrooms but now everything is either on the cart or will be locked up in a storage closet. CNA D stated staff was given an inservice by the DON about where these items will be kept. CNA D noted there are other things with which residents can hurt themselves like call light cords, miniblind cords and phones with cords - why not take those away? CNA D stated she always checked on her residents about every ,d+[DATE] minutes and makes sure the doors are open so I can see if they have fallen and they are OK. During a phone interview with CNA E on [DATE] at 2:11 pm, CNA E stated she had just seen Resident #1 earlier drinking some water. CNA E was present when EMS took the wipes out of Resident #1's throat but the wipes could not be seen prior to EMS taking them out. CNA E stated the DON inservices staff about abuse and neglect and keeping everything away from residents that are not safe. CNA E stated she worked in another facility before coming here and everything was locked up. CNA E stated that one of the girls told me Resident #1 had been seen with the bed remote cord around his neck one time. CNA E stated Resident #1 seemed fine the night before and he came out for a snack and water and was watching a movie. During an interview with RN B on [DATE] at 2:20 pm, the nurse stated she had seen Resident #1 sitting on the side of his bed when she arrived at 6:00 pm for her shift. RN B stated that when she was getting ready to give out medications, his roommate told staff Resident #1 was not waking up. RN B stated, After CNA E notified me that resident was unresponsive we lowered him to the floor and began CPR. RN B stated she first tried a sternal rub and then began compressions. Another staff member used the ambu bag and it appeared that air was going in. RN B stated the EMT showed her what he had taken from Resident #1's mouth which appeared to be multiple wipes. RN B stated Resident #1 was the most alert resident in the unit and was fully aware of what was going on. RN B stated she never saw Resident #1 do anything outside the norm. RN B stated she did know that Resident #1 wrote everything down but he never showed her what he was writing. RN B stated that the DCO, DON, ADM, SW, MDS Nurse and Treatment Nurse all were present during this incident and did an inservice with staff on abuse and neglect and maintaining the safety of residents. During an interview with the ADM, DON and DCO on [DATE] at 2:41 pm, the ADM explained why they had not reported the death. The ADM stated that Resident #1 never had a history with anything out of the ordinary. The ADM stated Resident #1 was in the Memory Care unit since this had been recommended by the hospital since Resident #1 had been found wandering around his neighborhood naked. The ADM and DON discussed the fact that wipes have always been available on the unit and that Resident #1 and his roommate were able to use them. The ADM stated that we have removed all the wipes and paper towels in the building and at mealtimes we have changed to cloth napkins. We did a full sweep of all the rooms. We also removed all the toiletries in the unit and they are now in a supply closet. The DCO stated they had also done a 4 Step Assessment as part of their QAPI to review any safety concerns for residents in the Memory Care Unit. Environmental rounds were made with Maintenance Dir on [DATE] between 8:30 - 9:00 am in the Memory Care unit. All drawers and cabinets in the resident rooms were observed for wipes and gloves and all rooms had been cleared of these items. A couple of rooms were found with items that were immediately removed including 1 silicone cream tube in the bathroom and 1 small body lotion tube in a dresser drawer. During a phone interview with Dr H, psychiatrist, on [DATE] at 11:43 pm, Dr H stated he was treating Resident #1 with antidepressants. Dr H stated that when he had seen Resident #1 earlier in March, he was a little withdrawn but denied sad mood or suicidal ideations. So I treated him with a mood stabilizer. Dr H stated he had a few sessions with Resident #1 and although he was found to have cognitive impairment it was not severe enough that he would confuse wipes and snacks but added it would be hard to say for sure. Dr. H stated he did see the psychologist at quarterly meetings they held with staff and he felt if she had a concern about Resident #1 she would have informed him. During an interview with SW on [DATE] at 3:26 pm, SW stated his last BIMS score was 13 and his PHQ-9 score was 0. SW stated she was not aware that resident heard voices. SW called LVN C to her office since LVN C was over the Memory Care Unit. LVN C stated the psychologist had mentioned Resident #1 hearing voices but that the psychologist was not concerned he would be a harm to himself or others. LVN C stated his only change in behavior was that he seemed to forget he could walk and would take other residents' wheelchairs. LVN C said she reminded Resident #1 he could walk on his own so he would readily give up the wheelchair. On [DATE] at 6:22 pm, the complainant returned my call and I informed him about our investigation. The complainant stated he could not say whether or not there was foul play involved so suggested I call the detective investigating the case. During an interview on [DATE] at 9:47 am, EMT HH reported that when EMS arrived staff were doing chest compressions and using an AED. EMT HH stated EMS took over with their life pack. EMT HH stated the EMTs noticed they were unable to get Resident #1's oxygen level so made the decision to intubate him. EMT HH said he then noticed vomit in the airway so started suctioning him. EMT HH stated he then used a scope to investigate the airway and he noticed a film. EMT HH then said he had to use his fingers to pull out a group of bath wipes. EMT HH stated the wipes were in 2 wads and did not appear to have been chewed but were rolled up and appear to have been shoved in there. EMT HH stated he looked at Resident #1's medications and didn't see anything unusual. Due to the unusual circumstances, the Crime Scene Investigator unit was called out. During a phone interview with Dr. I, psychologist, she stated the last time she saw Resident #1 he was not having suicidal ideations. Resident #1 did say he had audio hallucinations and they were critical voices like God but they were not telling him to hurt himself. Dr I said she last saw Resident #1 on February 12 and he was seated at a table and did not appear to be more depressed. Dr I stated Resident #1 would refer to himself in the third person. When surveyor asked Dr I about the fact that he frequently wrote about clouds on his papers, she said this was a delusion but not an indicator of depression. Surveyor interviewed LE L at the police department where he opened the evidence bag that had gathered about 25 pages of ,d+[DATE] x 11 paper found in Resident #1's room. On one paper he had written Resident #1 swallowed a napkin. On another paper he had written that [family member] was coming to see him. Most of the notes were very disjointed and since there were no dates on any of the papers it is unknown when they were written. LE L stated an autopsy was being done and if the solution from the wet wipes was found under Resident #1's fingernails then the conclusion would be suicide or at least self-harm. A phone interview on [DATE] at 12:40 pm with NP II revealed he had not been informed about Resident #1's death although he did see Resident #1 on behalf of the primary care physician who is also the facility Medical Director. NP II stated he would try to get a message to Dr J. During a phone interview with Dr. J on [DATE] at 2:11 pm, Dr. J stated he was aware of the death and the circumstances after being informed by the DON. Dr J stated Resident #1 was a walking and talking patient. He was in a locked unit so couldn't elope. Dr. J stated that the wipes should be in a designated area. Dr J also stated that this is very rare and he was being followed by a psychiatrist and was on medication including an anti-psychotic. Dr. J added people with schizophrenia used to be in State Hospitals but now they are in nursing homes so the psychotic behaviors have to be managed. Personnel records were reviewed for staff involved in administration of CPR including RN B, CNA D, CNA E and CNA JJ. CPR certifications and all other personnel records were current and in order. Interviews conducted with 25 staff members out of 96 regular staff and 31 contracted staff by surveyors on [DATE] between 8:35 am and 10:30 am and from 4:55 pm to 7:55 pm to verify they had received inservices on Abuse and Neglect, Preventing Accidents, Plan of Care/Kardex, and to ensure all wipes, gloves or personal items were locked in storage closet until use by staff with residents. The Administrator and DON were notified on [DATE] at 4:11 pm that an Immediate Jeopardy situation had been identified on [DATE] due to the above failures and were presented with an Immediate Jeopardy Template. A Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 8:34 pm and reflected the following: Immediate Response: Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse immediately assessed the identified resident and initiated emergency response care. Outcome: Resident pronounced deceased post EMS emergency response care provided. Date completed: [DATE] Notifications: PCP notified Responsible party notified DNS and Admin notified Director of Clinical Operations /Director of Nursing Services/Assistant Director of Nursing Services/IDT conducted an assessment of current residents in order to validate their safety and well-being. Outcome: No negative outcomes identified. Date Completed: [DATE] Risk: All residents with cognitive impairment especially those who currently reside on the memory care unit can be affected by the deficient practice. Out of an abundance of caution the IDT Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse/Designee immediately inspected all resident room to identify and removed any items such as patient care items for added safety. Outcome: There were no negative outcomes identified. Any briefs/wipes identified in bathrooms (cabinets) were immediate removed and disposed of. Date Completed: [DATE] The [NAME]/Director of Nursing Services/Assistant Director of Nursing Services conducted rounds and staff interviews to identify any residents with poor cognition and who is at risk for ingesting nonfood items. Outcome: No negative outcomes identified. Date Completed: [DATE] The IDT /Director of Nursing Services/Assistant Director of Nursing Services commenced with an audit of all residents with cognitive impairment to review and update the plan of care as indicated in order to validate the plan of care for accuracy and will update as needed to ensure the appropriate intervention/interventions are noted on the plan of care/Kardex as well as accurately identified. Outcome: No negative outcomes identified. Date completed: [DATE] IDT conducted an audit of all residents with a diagnosis of schizophrenia recent change of condition concerning new onset of behaviors, worsening behaviors, or s/s of being withdrawn within the last 30 days to ensure that appropriate plan of care. Completed: Initially completed on [DATE] and on going IDT conducted an audit of all residents with a recent change of condition concerning new onset of behaviors, worsening behaviors, or s/s of being withdrawn within the last 30 days and reviewed/updated the identified residents' care plan. Completed: Initially Completed [DATE] and on going IDT conducted a depression screen for all resident identified with behavioral concerns changes in condition and all positive screens to be to the mental health provider for evaluation and treatment in order to identify any potential risks for harm to self, specifically reviewing any concerns with potential safety issues such as ingesting non-edible food items. Outcome: No negative outcomes identified. Completed: [DATE] System Response: DCO re-educated Admin/DNS/ADNS regarding: o Abuse & Neglect Preventing, Identifying, and Reporting all suspicions or allegations. o Preventing Accidents/Incidents & Fall Prevention. o Plan of Care/Kardex should be reviewed by direct care team to ensure the staff member is aware of the necessary care to be provided. o IDT to ensure any safety concerns and appropriate interventions are noted on the plan of care and Kardex. Date Completed:[DATE] Community will ensure all staff on leave/agency staff /PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Administrator/Director of Nursing/Assistant Director of Nursing re-educated staff regarding: o Abuse & Neglect Preventing, Identifying, and Reporting all suspicions or allegations. o Preventing Accidents/Incidents & Fall Prevention. o Plan of Care/Kardex should be reviewed by direct care team to ensure the staff member is aware of the necessary care to be provided. o IDT to ensure any safety concerns and appropriate interventions are noted on the plan of care and Kardex. Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. IDT will conduct interviews with family, review of health records and evaluate any newly admitted resident for consideration on the memory care unit in order to identify any behavioral concerns that would pose risk of harm to self by ingesting non-food items. Date implemented and ongoing: [DATE] Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits/rounds to validate the safety and well-being of our residents and resident rooms at random times on random halls in order to identify any safety concerns. This audit will be conducted ,d+[DATE] days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs. Date Initiated: [DATE] Director of Nurses/Assistant Director of Nurses will review all admission/re-admission care plan and Kardex to ensure any safety risks are accurately noted on the plan of care and Kardex Will review progress notes and risk management reports to identify and safety risks / concerns. accordingly. This will take place ,d+[DATE] days a week for the next 2 months. Date Initiated: [DATE] This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will complete all audits and they will be placed in a binder and kept for review by HHSC for the revisit to validate for compliance. The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented. The facility's POR verification was as follows: Record review with ADM and DON conducted at 5:00 pm on [DATE] to ensure assessment of residents was conducted to assure their safety and well-being. No other residents identified as being in danger of self-harm. Surveyor and Maintenance Director had conducted search of Memory Care Unit rooms on [DATE] from 8:30 am to 9:00 am to ensure all patient care items such as wipes and gloves had been removed from rooms and were secured. Record review of Plan of Care review conducted on [DATE] at 8:30 pm to ensure anyone with cognitive impairment was not at risk of ingesting non-food items. Record review of Plan of Care with all residents with cognitive impairment conducted on [DATE] at 8:30 pm to ensure accuracy of care plans. Reviewed list of residents with schizophrenia and their plan of care on [DATE] at 8:35 pm. 5 residents were listed with this disorder. Record review of 4 Step Assessment was conducted by facility staff with each resident in the facility as of [DATE] is and ongoing. Review verified with DON on [DATE] at 8:40 pm. These steps included reviewing the care plan including diagnoses and related medications, monitoring behaviors and related documentation of any changes, and determining any safety concerns as each resident room was observed. Information will be discussed in the monthly QAPI meeting. Facility did chart review for residents with behavioral concerns who are already see by psychological services and no new changes were identified. Discussed procedures and outcomes with ADM and DON on [DATE] at 8:40 pm. Record review of inservice conducted by DCO with ADM, DON and ADON regarding Abuse and Neglect Preventing, Identifying and Reporting; Preventing Accidents and Incidents and Fall Prevention; and Plan of Care/Kardex to be reviewed by direct care team to ensure the staff member is aware of the care to be provided and the need for the IDT to ensure any safety concerns and appropriate interventions are noted on the Plan of Care/Kardex. The ADM, DON and ADON then re-educated staff on these topics and education acknowledged on [DATE] at 8:45 pm. Training reviewed for all staff and reviewed signatures on inservices. Verified 96 regular staff and 31 contracted staff for a total of 127 staff members. 25 staff interviews were conducted by surveyors on [DATE] between 8:35 am and 10:30 am and from 4:55 pm to 7:55 pm to verify that the above inservices were conducted and staff had an understanding of the contents of each inservice. The interviews, that covered all shifts, were as follows: 8:35 am - LVN A - was working on nights but moved to day shift; she did receive the in-services; is aware that the gloves and wipes can no longer be in the resident rooms; the Nurse stated that the foley was pulled out accidentally by the resident; the Nurse stated that resident Resident #1 was acting at his baseline and did not observe any unusual behavior 8:50 am - CNA G - she confirmed that she had received the in-services on abuse and Kardex and that wipes and gloves cannot be in the resident rooms; she advised if she saw unusual behavior she would tell the nurse; 9:00 am - CNA O - he advised that he did receive the in-services on Kardex and abuse; he was aware that wipes and gloves are not to be accessible to the residents; he stated that if he sees a resident acting unusually he would advise the nurse; 9:10 am - LVN C - she had received the in-services on abuse and Kardex and aware of no gloves/wipes in resident rooms; she was working on the unit on [DATE] and stated resident Resident #1 acting at baseline; he sat in someone else's wheelchair, she advised if staff or she would observe unusual behavior she would report it; 9:40 am - LA CC - she did receive the in-services, is aware of no wipes/gloves in resident rooms on Memory Care Unit; was not on unit when resident expired; she would report unusual behavior. 9:45 am - LA DD - she did receive the in-services, is aware of no wipes/gloves in resident rooms in Memory Care; She would report unusual behavior 9:50 am - Hsk Dir - she did receive the inservices, is aware of no wipes/gloves in resident rooms in Memory Care hall; she would report unusual behavior 10:10 am - [NAME] V - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am- DA W - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am - DA X - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am - DA Y - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:25 am - FSD - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:30 am - SW - did receive inservices on Kardex, falls/accidents, is aware of no wipes/gloves being allowed in Memory Care Unit resident rooms, had not observed unusual behavior for Resident #1 but would report if behaviors were noted. 4:55 pm - CNA M - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 4:55 pm - CNA N - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 6:10 pm - CNA T - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 6:20 pm - CNA E - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual; she worked the night of the incident with Resident #1 but did not observe anything unusual in his behavior 6:35 pm - RN B - she received the inservices on abuse, Kardex, falls, safety and is aware of the protocol for no wipes/gloves allowed in the Memory Care Unit; she would report any changes in behavior; she did not see any unusual behavior for Resident #1 on the night of the incident 7:00 pm - LVN U - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:05 pm - CNA P - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:05 pm - CNA Q - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:15 pm - LVN Z - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:15 pm - CNA R - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:20 pm - RN BB - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:55 pm - CNA S - has had inservices on abuse, Kardex, falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 3 new residents in the past week were evaluated and not appropriate for Memory Care Unit. This was verified with ADM on [DATE] at 8:57 pm. Monitoring form reviewed that will be used by ADM, DON, ADON and SW to make weekly random audits to validate the safety and well-being of residents on [DATE] at 8:54 pm. Monitoring tool reviewed for DON and ADON to review admission/readmissions' care plans and Kardex to ensure safety risks are addressed. Tool reviewed on [DATE] at 8:54 pm. The binder in which all audits will be kept was reviewed on [DATE] at 9:00 pm. On [DATE] at 10:00 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on [DATE] at 10:00 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal.

41937 Based on observations, interview, and record review the facility failed to ensure residents' environment remained as free of accidents and hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 6 of 20 residents (#1, #3, #27, #39, #46 and #185 ) reviewed for assistance with safe mechanical lifts and falls. 1. On 05/05/2024 at 03:54 PM CNA R transferred Resident #39 from her bed to her wheelchair with the assistance of 1 person and caused Resident #39 discomfort and pain. 2. On 04/16/2024 The facility assessed 4 residents (#1, #3, #27, and #46) with the need for a mechanical lift and planned for residents to receive assistance with mechanical lifts with the aid of 1 person. 3. Resident #185 fell multiple times and on 4/21/24 sustained a laceration which required multiple sutures to the left side of her head. Staff failed to implement fall mats upon admission even though she was assessed to be a high fall risk and had a fall history prior to her admission and failed to ensure the mats were in place after implementing as a safety device. These deficient practices could place residents at risk for harm by not provideing sufficient staff to operate the lift and stabilize residents and by not implementing necessary assistive devices to help residents from sustaining injuries. The findings included: 1.A record review of Resident #39's admission record dated 05/04/2024, revealed an admitted [DATE] with diagnoses which included morbid obesity (a severe and complex disease involving having too much body fat, which increases the risk of many other health problems), anxiety disorder, abnormalities of gait and mobility, and spondylopathy (spinal arthritis). A record review of Resident #39's annual MDS assessment dated [DATE], revealed Resident #39 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses, adequate hearing, impaired vision without corrective lenses, clear speech with the ability to communicate and is usually understood and can understand others. Resident #39 was assessed with a BIMS score of 14 out of a possible 15 which indicated no cognitive impairment. Resident was assessed with a need for Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort with the following: Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Tub/shower transfer: The ability to get in and out of a tub/shower. Resident #39 was assessed as always incontinent with urine. A record review of Resident #39's weight assessment dated [DATE] revealed Resident #39 weighted 360 lbs. A record review of Resident #39's Nursing: Transfer / Lift Status, dated 04/10/2024, revealed RN Q assessed Resident #39 as needing total lift care and the intervention was Transfer: total lift x 1 team member. A record review of Resident #39's Nursing: Transfer / Lift Status dated 10/25/2022 revealed Resident #39 was assessed as requiring 2 staff for a mechanical lift related to Resident #39's inability to stand, pivot, and walk with limited or no physical assistance from staff and Resident #39's inability to bear weight on at least one leg; Total Lift Candidate While lifts are safe for one person transfer, physical limitations, medical conditions, behavioral factors, weight, girth, etc. of individual resident/patient, the number of team members required must be evaluated to perform safe patient transfers. b. Two Team Members. A record review of Resident #39's care plan dated 05/03/2024 revealed Resident #39 had a self-care deficit related to obesity, poor physical functioning, incontinence of bowel and bladder. Further review revealed Resident #39 was provided with interventions which included, TRANSFER: Total Lift x 1 Team Member, Date Initiated: 04/10/2024, Created on: 04/10/2024, Created by: (RN Q), ADNS (Assistant Director of Nursing Services). During an interview on 05/052024 at 01:20 PM Resident #39 stated she was unable to transfer out of bed by herself and needed assistance with a mechanical lift. Resident #39 stated she was accustomed to the staff to assist her with transferring out of bed with 2 staff but recently she had been transferred by 1 staff member. Resident #39 stated she was ok with the change if the staff was careful. During an interview on 05/05/2024 at 11:38 AM CNA R stated he was trained in mechanical lift safety and further stated the process required 2 persons to perform. During an observation on 05/05/2024 at 03:54 PM revealed Resident #39 was attended by CNA R and was transferred from her bed to her wheelchair. CNA R was unassisted by any other staff. CNA R asked Resident #39 to assist him by turning herself from her supine position to her left side and grabbing the left side 1/4 bed rail while he pulled on the transfer sheet from the right side of the bed. CNA R placed a mechanical sling underneath Resident #39's right side and asked Resident #39 to assist him by turning herself from her left side position to her right side and grabbing the right side 1/4 bed rail while he pulled on the transfer sheet from the left side of the bed. CNA R completed placing the mechanical lift sling underneath Resident #39 and proceeded to position the mechanical lift over her and connected the lift to the sling. CNA R proceeded to lift Resident #39 utilizing his right hand with the remote control of the mechanical lift while simultaneously guiding Resident #39 by manipulating the sling with his left hand. CNA R proceeded to manipulate the mechanical lift with his feet, and both hands and occasionally used his hands to stabilize Resident #39 when she began to slightly swing while suspended mid-air in the sling. While CNA R positioned the sling and mechanical lift behind Resident #39's wheelchair CNA R used his right hand to manipulate the mechanical lift and the remote control simultaneously and used his left hand to stabilize Resident #39 from swinging when Resident #39's bilateral toes rubbed against the center mast of the lift to which Resident #39 called out Oww! Watch my toes! CNA R released his right-hand grasp on the lift and stabilized Resident #39 with both hands while continuing to hold the remote control. CNA R continued to position the mechanical lift directly behind Resident #39's wheelchair and lifted Resident #39 higher than the back of the wheelchair and placed Resident up and over the back of the wheelchair to seat resident #39 in the wheelchair. Three attempts were made to lift Resident #39 and reseat her in the wheelchair due to her complaints that she said, I am slipping out .I am not comfortable During the multiple attempts CNA R continued to use his left hand to hold Resident #39's sling and his right hand to manipulate the remote control and the mechanical lift simultaneously. During an interview on 05/05/2024 at 04:30 PM Resident #39 stated she was transferred from her bed to her wheelchair by 1 staff, CNA R, and during the transfer she had discomfort when her toes bumped the mechanical lift, and was not seated well in her wheelchair, and felt anxiety related to fears of falling from the lift. During an interview on 05/05/2024 at 11:39 AM RN Q stated she assessed Resident #39 as a 1 person assist with the mechanical lift. RN Q was asked her rationale on how she came to the 1 person assist she stated she would refer to the DON for the response. 2. Resident #1: A record review of Resident #1's admission record dated 05/05/2024, revealed an admitted [DATE] with diagnoses which included morbid obesity (a severe and complex disease involving having too much body fat, which increases the risk of many other health problems), Vascular dementia (a group of symptoms affecting memory, thinking and social abilities), ankle and foot contractures, muscle wasting and atrophy. A record review of Resident #1's annual MDS assessment dated [DATE], revealed Resident #1 was an [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses, adequate hearing, impaired vision with corrective lenses, unclear speech with the ability to communicate and is sometimes understood and can understand others. Resident #39 was assessed with a BIMS score of 01 out of a possible 15 which indicated severe cognitive impairment. Resident was assessed with a need for Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. with the following: o Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. o Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). o Tub/shower transfer: The ability to get in and out of a tub/shower. Resident #39 was assessed as always incontinent of bowel and bladder. A record review of Resident #1's Nursing: Transfer / Lift Status, dated 04/16/2024, revealed RN Q assessed Resident #1 as needing total lift care and the intervention was Transfer: total lift x 1 team member. A record review of Resident #1's care plan dated 05/05/2024 revealed Resident #1 had a self-care deficit related to cognitive impairment, limited physical functioning related to stiff or limited joint range of motion; poor physical functioning, weakness, and debility; incontinence of bowel and bladder with nursing interventions which included, Transfers: x 2-person assistance with Hoyer Lift Total Lift Sling Size: Large/green (175-300 pounds) Resident #3: A record review of Resident #3's admission record dated 05/05/2024, revealed an admitted [DATE] with diagnoses which included morbid obesity (a severe and complex disease involving having too much body fat, which increases the risk of many other health problems), muscular sclerosis (makes it difficult for the brain to send signals to rest of the body), and Parkinson's disease (symptoms of Parkinson's disease include difficulty walking, difficulty initiating movements, and a slow hand tremor). A record review of Resident #3's annual MDS assessment dated [DATE], revealed Resident #3 was an [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses, adequate hearing, impaired vision with corrective lenses, clear speech with the ability to communicate and is usually understood and can understand others. Resident #39 was assessed with a BIMS score of 08 out of a possible 15 which indicated moderate cognitive impairment. Resident was assessed with a need for Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. with the following: o Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. o Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). o Tub/shower transfer: The ability to get in and out of a tub/shower. Resident #3 was assessed as always incontinent of bowel and bladder. A record review of Resident #3's Nursing: Transfer / Lift Status, dated 04/16/2024, revealed Resident #1 was assessed as needing total lift care and the intervention was Transfer: total lift x 1 team member. A record review of Resident #3's care plan dated 05/05/2024 revealed Resident #3 had a self-care deficit related to cognitive impairment, poor physical functioning, weakness and debility; incontinence of bowel and bladder, and Parkinson's disease with nursing interventions which included, Transfers: x 1-person assistance Resident: #27 A record review of Resident #27's admission record dated 05/05/2024, revealed an admitted [DATE] with diagnoses which included acquired absence of right leg below the knee, dementia (a group of symptoms affecting memory, thinking and social abilities), pressure ulcer of left heel and ankle, and muscle weakness. A record review of Resident #27's annual MDS assessment dated [DATE], revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with medically complex diagnoses, adequate hearing, adequate vision without corrective lenses. Resident #27 was not assessed with a BIMS score because he was not understood. Resident was assessed with a need for Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. with the following: o Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. o Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). o Tub/shower transfer: The ability to get in and out of a tub/shower. Resident #3 was assessed as frequently incontinent of bowel. A record review of Resident #27's Nursing: Transfer / Lift Status, dated 04/16/2024, revealed Resident #1 was assessed as needing total lift care and the intervention was Transfer: total lift x 1 team member. A record review of Resident #27's care plan dated 05/05/2024 revealed Resident #27 had a self-care deficit related to disease process and management, debility and weakness with nursing interventions which included, TRANSFER: x 2-person assistance with Mechanical Lift Date Initiated: 01/25/2024 Created on: 01/25/2024 .TRANSFER: Total Lift Sling Size: Medium/Yellow (125-200 pounds) .TRANSFER: Total Lift x 2 Team Members Resident: #46 A record review of Resident #46's admission record dated 05/05/2024, revealed an admitted [DATE] with diagnoses which included palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure), end stage heart failure, and chronic pain. A record review of Resident #46's quarterly MDS assessment dated [DATE], revealed Resident #46 was an [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses, adequate hearing, adequate vision without corrective lenses, clear speech with the ability to communicate and was usually understood and could understand others. Resident #46 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. Resident #46 was assessed with a need for Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. with the following: o Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). o Tub/shower transfer: The ability to get in and out of a tub/shower. Resident #46 was assessed as frequently incontinent of bowel and bladder. A record review of Resident #46's Nursing: Transfer / Lift Status, dated 04/16/2024, revealed the DON assessed Resident #46 as needing total lift care and the intervention was Transfer: total lift x 1 team member. A record review of Resident #46's care plan dated 05/05/2024 revealed Resident #46 had a self-care deficit related to chronic kidney disease, congestive heart failure, poor physical functioning, and weakness and disability with poor physical endurance with nursing interventions which included, Transfers: Hoyer lift transfer x 2-person assistance During a joint interview on 05/05/2024 at 07:20 PM the Administrator and the DON were asked for their rationale for utilizing 1 person assists with some residents who were assessed with a need for a mechanical lift stated, our company invested in technology (mechanical lifts) to benefit our patients and staff while maintaining safety as the biggest priority in conjunction with manufactures guidelines. A record review of the facility's mechanical lift manufactures website https://www.joerns.com/wp-content/uploads/2023/11/Hoyer_Family_Brochure4-6.pdf ; accessed 05/05/2024, titled Hoyer Family Brochure 4-6 revealed MOBILITY ASSESSMENT & LIFT SELECTION: This assessment is typically performed by a designated health professional or a team of health professionals. In addition, each patient will be assessed with regard to such factors as mental acuity, ability to comprehend instructions and cooperate in lifts and transfers, combativeness, weight, upper extremity strength, ability to bear weight, and specific medical conditions that may affect the selection of an appropriate means for lifting and transferring. Patient Classification: This coding is consistent with activities of daily living (ADL) Self-Performance Codes for a patient's performance over all shifts during the last seven days . DEPENDENT ANOTHER PERSON IS REQUIRED FOR EITHER SUPERVISION OR PHYSICAL ASSISTANCE IN ORDER FOR THE ACTIVITY TO BE PERFORMED - HELP NEEDED . 3 - EXTENSIVE ASSISTANCE (Functional Independence Measure 3) Can perform part of the activity, usually can follow simple directions, may require tactile cueing, can bear some weight, sit up with assistance, has some upper body strength, may be able to pivot transfer. Over the last seven-day period, help provided three or more times for weight-bearing transfers or may have required a total transfer. A record review of the facility's policy titled Safe Resident Handling / Transfers dated January 2023, revealed, Policy: it is the policy of this community to ensure that patients and residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the patient / resident while keeping the team members safe in accordance with current standards and guidelines . team members will perform mechanical lifts / transfers according to the manufacturer's instructions for use of the device 4. Review of Resident #185's face sheet, dated 5/1/24, revealed she was admitted into the facility on [DATE] with diagnoses including Traumatic Suarachnoid Hemorrhage without loss of Consciousness, subsequent encounter and Unspecified Dementia ( is a group of symptoms affecting memory, thinking and social abilities). Review of Resident #185's admission nursing assessment, dated 4/19//24, revealed Resident #185 was severely cognitively impaired; was incontinent of bowel and bladder and she was a high risk for falling; had one or more falls between 3 and 12 months ago. Review of Resident #185's Care Plan initiated on 4/19/24 read have a Self Care deficit r/t weakness. Toileting/Incontinent Care by 1 person assistance and transfer: by 1 person assistance; more assistance at times / as needed only. Review revealed an entry on 4/22/24 which read: am at risk for falls related to Actual Fall on 4/30/24, 4/29/24, 4/27/24, 4/21/24. The approaches included: *Bed at appropriate height when unattended. Date Initiated: 04/22/2024; *Keep commonly used items close to resident for easy access. Date Initiated: 4/30/2024; Refer to therapy for screen and/or eval as indicated. Date Initiated: 04/27/2024; Assist resident to toilet before going to bed at night and/or naps during day. Date Initiated: 04/29/2024; Bed locked and in low position. Date Initiated: 04/30/2024; Bedside mat/mats as indicated. Date Initiated: 05/01/2024; Remind resident regularly to call for assistance in efforts to prevent falls. Initiated on: 04/30/2024; Routine rounds to help with safety checks by all team members. Date Initiated: 04/30/2024. Further review revealed on 4/30/24 Resident #185's Care Plan was updated with a new focused area My skin is fragile and I am at risk for skin injury--new or worsening skin condition. ACTUAL: LEFT ELBOW, TOP OF HEAD. Interventions included Apply treatment as ordered. Keep clean & dry and apply skin barrier cream as indicated. Therapeutic pressure reducing mattress. Review of post-fall review SBAR, dated 4/21/24, revealed Resident #185 had a fall getting out of bed and sustained a laceration to the left side of the scalp. Resident #185 was unable to answer when asked about the fall due to confusion. Review of Resident #185's progress note, dated 4/21/24, revealed she returned from the hospital with sutures to the head. Review of post-fall review SBAR, dated 4/27/24 at 2 PM, revealed Resident #185 had an unwitnessed fall getting out of bed in her room. She sustained a skin tear. She did not complain of pain. Resident #185 was confused and unable to say what happened. Review of post-fall Review SBAR, dated 4/29/24 at 9:30 PM, revealed Resident #185 had an unwitnessed fall getting out of bed in her room. She stated she was going to the bathroom. There were no apparent injuries noted. Review of Resident #185's progress notes for April 2024 revealed on 4/21/24 she had a fall, on 4/22/24 she returned from the hospital with a new order, sutures to be removed in 7-10 days. placed on TAR. On 4/27/24 progress note read Resident had a fall incident at around 1600 noted on this shift. Had an abrasion on Lt/elbow. Vitals WNL On 4/29/24 the progress note read Called to pts room. CNA stated pt was on the floor. Found pt sitting on floor between R side of bed and window. sitting on her buttocks. Pt holding on to side rail. Pt stated, I was trying to go to the bathroom. On 4/30/24 the progress note read Wound Care nurse made SN saw resident was on the floor. resident was parallel to the bed. resident. Resident was noted with blood on her head. Resident was barefoot. Resident was incontinent to bowel. Resident call light was attached to bed. Resident was asked what occurred. Resident stated I don't know. I need to go to the restroom. Further review revealed RP requested for resident to be sent out to hospital. Patient returned from hospital visit at this time. No new orders at this time. Patient is in stable condition. Patient is also continuing to try to get up from bed on her own. Bed remains in lowest position at this time with call light within reach. Review of physician orders for May 2024 revealed the following orders: PT/OT/ST may evaluate and treat as needed, dated 4/19/2024. Sutures to top of Residents head, monitor for signs and symptoms of infection, every day shift for surgical, dated 04/25/2024 and initiated on 04/26/2024. Wound to left elbow, as needed for compromised dressing, dated 05/04/2024, initiated on 05/04/2024. Wound to left elbow, cleanse with wound cleanser or normal saline, pat dry, apply thermoform to wound bed and cover with dry dressing, every day shift every Mon, Wed, Fri for skin tear, dated 5/4/24 and initiated 5/6/24. Observation and interview on 05/01/24 at 11:30 AM revealed Resident #185 lying in bed with 1/2 bed rail up on right side; close to the window and 1/4 side rail up on left side. Resident #185 was asleep. Interview with Resident #185's family member revealed he did not see how Resident #185 fell , but stated she had multiple stitches on the left side of her head. The family member further stated Resident #185 was not oriented and had poor self-awareness. Observation on 5/2/24 at 6:32 PM revealed Resident #185 was trying to get out of bed. There were no staff on the hallway. Further observation revealed the floor mats on both sides of the bed. Interview on 5/2/24 at 6:35 PM at the nurse's station with LVN CC revealed there was a new order on this date for fall mats. Upon entering Resident #185's room, the Resident was lying in bed. LVN CC stated the bed was in the lowest position it would go. LVN CC stated Resident #185 was a high risk for falling because she often tries to get out of bed. He stated staff should making frequent rounds on the Resident. Observation on 5/4/24 at 3:25 PM revealed Resident #185 lying in bed wide awake. She stated she was doing fine and her head did not hurt. She felt of the left side of her head. Further observation revealed a meal tray on top of the bedside table by Resident #185's bed. The fall mat was propped on the wall. Observation and interview on 5/4/24 at 4:05 PM revealed Resident #185's meal tray was still on the bedside table by her bed. Interview with CNA DD revealed lunch was sent out really late today, about 2 PM. CNA DD stated Resident #185's family member asked they leave the lunch tray. She stated she checked in on Resident #185 about 45 minutes to an hour ago and did not notice the mat was not in place. She commented staff probably moved it when they delivered the lunch tray. CNA DD was noted to move the bedside table and placed the mat beside Resident #185's tray. CNA DD stated Resident #185 was a high risk fall and the mats should stay in place at all times as an intervention to try and keep the Resident from sustaining injuries if she fell . Interview on 5/5/24 at 5:47 PM with the DON revealed Resident #185 had a history of falling before her admission. She stated they did not implement fall mats right away because Resident #185 was ambulatory and believed the mats would be a safety hazard. She stated staff was to keep her bed in the lowest position, ensure the bed was locked at all times, take her to the bathroom after meals and therapy was working with her to improve bed mobility. The DON stated and staff was to make frequent rounds on her. The DON stated Resident #185 had fallen multiple times and had sustained a laceration to the left side of her head. She went out to the hospital and sustained multiple sutures as a result of the injury.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 24 residents reviewed for urinary incontinence. (Resident #38) Resident #38 showed symptoms of a Urinary Tract Infection [MEDICAL CONDITION] on 10/15/20 and was not treated for [REDACTED]. This deficient practice could affect residents who were incontinent of bladder and could result in trauma to the bladder or urinary tract infections. Findings include: Record review of Resident #38's PPS 5-Day Scheduled MDS Assessment, dated 10/6/20, revealed Resident #38 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #38 had a BIMS of 4, which indicated severe cognitive impairment, and Resident #38 was always incontinent of bowel and bladder. Record review of Resident #38's Care Plan revealed a focus area that Resident #38 had a self-care deficit related to [MEDICAL CONDITION], cognitive impairment, and poor physical functioning that included an intervention, initiated 10/12/20 of incontinent care x 1-person assistance. Record review of a Nursing Progress Note, dated 10/15/20, revealed Resident #38's RP stated she is concerned Resident #38 has a UTI because she did not know who she was when she came to visit the day before yesterday and informed her we will contact the MD and request an order for [REDACTED].>Record review of a Nursing Progress Note, dated 10/16/20, revealed new orders from the MD for a UA on Resident #38. Record review of a Nursing Progress Note, dated 10/20/20, revealed a UA on Resident #38 was collected. Record review of a Nursing Progress Note, dated 10/28/2020, revealed Resident #38 had a STAT UA C&S collected. Record review of a Change in Condition Evaluation, dated 11/10/20, revealed Resident #38 had foul smelling urine and clear discharge that began on 11/10/20. Record review of a Nursing Progress Note, dated 11/13/2020, revealed staff attempted to reach the MD with UA results for Resident #38 and a voicemail was left. Record review of a Nursing Progress Note, dated 11/16/2020, revealed Resident #38's UA results were sent to the MD, and a new order for [MEDICATION NAME] 500 bid x 7 days was received. During an interview on 11/17/20 at 3:45 PM, Resident #38's RP stated Resident #38's had frequent UTIs and approximately 2-3 weeks ago Resident #38 had a Urinalysis (UA), however, when Resident #38's RP asked a nurse about the result of the UA, the nurse (name unknown) stated, maybe the urine collected never made it to the lab. Resident #38's RP stated the ADON then ordered another UA, but Resident #38's RP did not hear back about the result. Resident #38's RP stated Resident #38 had a cognitive decline in the last 2 weeks due to the UTI. During an interview on 11/20/20 at 12:34 PM, the ADON stated Resident #38 had a UA on 10/29/20 that was not picked up by the lab on time and Resident #38's UA results from 10/28/20, 11/1/20, and 11/13/20 showed they were not a clean catch and the results were inconclusive. The ADON stated Resident #38 was started on an antibiotic on 11/17/20. The ADON did not know why treatment for [REDACTED]. During an interview on 11/20/20 at 4:46 PM, the Corporate Nurse stated she had no idea why it took 4 days to collect a UA on Resident #38 using a bed pan or why Resident #38 did not start treatment for [REDACTED]. The Corporate Nurse stated if there was an unsuccessful urine collection then the MD would give an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident #1) of 8 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. The facility did not provide 2 persons to transfer Resident #1 in accordance with the plan of care. CNA A transferred Resident #1 with assistance of a sitter and without a mechanical lift as care planned. The resident was non-weight bearing and was lifted by her elbows and sustained fractures to her right and left elbow. This failure could place the 7 residents who required the mechanical lift transfers at risk for injury. The findings included: Review of Resident #1's face sheet dated [DATE] revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE]. Review of Resident #1's Nursing Admission Assessment in Point Click Care dated [DATE] at 11:16 a.m. completed by RN B revealed that Resident #1 required two + persons to assist with transfer. Review of Resident #1's comprehensive plan of care (undated) revealed under section Transfer: I require mechanical aide, hoyer for transfers. Interview on [DATE] at 1:00 p.m. with the DON revealed that Resident #1 was supposed to be transferred with a mechanical lift since her admission on [DATE]. Interview on [DATE] at 07:40 a.m. with RN B revealed that Resident #1 was able to tell someone what she wanted. She stated that Resident #1 required a mechanical lift transfer and that was what she was told the resident received while at home. She stated that prior to the incident on [DATE] Resident #1 could drink her coffee and eat with minimal to no assistance. She reported that prior to the incident Resident #1 had no swelling to her shoulders and arms and that she really didn't require pain medication or ask for her Hydrocodone which was ordered PRN for pain. She reported on [DATE]. she stood out in the hallway while in the process of doing treatments and CNA A came out of Resident #1's room and reported that she couldn't find the sling for the mechanical lift, and that she and Resident #1's sitter tried to transfer the resident by themselves and that the resident was complaining of immense pain to her shoulders. She reported that what the family told her about the resident revealed that she was stoic and not one to complain of pain. She stated that Resident #1 was in so much pain there were tears in her eyes. She said that physical therapy helped to get Resident #1 back to bed. RN B stated that Resident #1 had an x-ray done to her shoulders which was negative, and that she received an order for [REDACTED]. She reported that since the incident the resident was not able to use her hands, drink her coffee and had to be fed. RN B stated that two days later Resident #1's elbows and arms up to her shoulders were swollen and bruised. She said that Resident #1 was completely bed bound after that and she hurt too much to even get her up to get her to the beauty shop to get her hair done. She stated that x-rays were done to the residents elbows on [DATE] which revealed fractures to both elbows. She stated that the sitter told her to tell the family they did range of motion exercises with the resident and that is what caused the injuries. She said she told the sitter absolutely not. Review of Resident #1's radiology report dated [DATE] of the right elbow revealed under Impressions: there is a spiral fracture of the distal humerus; apparently patient could not be appropriately positioned owing to severe discomfort .the patient does have a supracondylar fracture of the left elbow. Review of Resident #1's radiology report dated [DATE] of the left elbow revealed under Impressions: acute angulated comminuted supracondylar fracture. Interview on [DATE] at 10:55 a.m. on the telephone with CNA A revealed that she was aware that Resident #1 required a mechanical lift transfer. She stated that she needed to weigh the resident, so she went into Resident #1's room asked the sitter to assist her for Resident #1 to be transferred into the wheel chair. She said that she and the sitter lifted Resident #1 by the arms and the gait belt and tried two times before they were able to get the resident into the wheel chair. She stated that the resident complained of terrible pain in her shoulders after that and she went and told the nurse. She stated that she was not checked off for competency in the mechanical lift, but was shown by the staff what to do. She said that she knew she should have looked on the kiosk or asked the nurse if she did not know how to transfer a resident. Observation on [DATE] at 4:00 p.m. of CNA A demonstrating how she and the sitter transferred Resident #1 to the wheel chair, she linked her elbow into the surveyor's and said she pulled on the gait belt and lifted with Resident #1's arms and the sitter did the same on the other side. Interview on [DATE] at 11:15 a.m. with the Medical Director and physician who examined Resident #1 revealed that he did not believe she came to the facility with the elbow fractures. He stated that the type of fracture she had on her right elbow which was a spiral fracture could only have happened in his professional opinion with her transfer by her right arm hitting a surface and being twisted and her left elbow fracture was from being held or positioned with some force. Indirect trauma from a fall or a twisting action (e.g. arm wrestling) are also encountered and usually result in spiral or oblique fractures. The higher the impact strength, the more likely the fracture is to be comminuted.(https://radiopaedia.org/articles/humeral-shaft-fracture -dated [DATE]). Review of facility policy and procedure on gait belt issue and Return Acknowledgement dated [DATE] revealed that resident transfers should be made with the use of a gait belt to help avoid incidents to the resident and team member. No policy existed for mechanical lift transfer or transfers in general. No competency was available for transfers of residents only an orientation checklist with transfers and a check mark next to it. The facility took action to correct the deficiency on [DATE] with in-services provided to staff on two person transfers, mechanical lift transfers and deviced a competency checklist. CNA A was counseled by the facility administration and increased monitoring and supervision was provided by administration of staff for safe and appropriate transfers of residents. A list provided by the DON on [DATE] revealed 7 residents who required mechanical lift transfers.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 1 of 8 residents reviewed for neglect (resident #1) in that: The facility failed to ensure CNA A was properly trained and monitored for proper transfer of Resident #1 which resulted in two fractured elbows. CNA A and an untrained sitter grabbed Resident #1 by the elbows to transfer her for a 2 person transfer instead of using a mechanical lift as care planned. This deficient practice could place the 7 residents who required the mechanical lift transfers at risk and could result in injury. The findings included: Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's face sheet dated [DATE] revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE]. Review of Resident #1's comprehensive plan of care (undated) revealed under section Transfer: I require mechanical aide, hoyer for transfers. Review of Resident #1's Nursing Admission Assessment in Point Click Care dated [DATE] at 11:16 a.m. completed by RN B revealed that Resident #1 required two + persons to assist with transfer. Review of Resident #1's radiology report dated [DATE] of the right elbow revealed under Impressions: there is a spiral [MEDICAL CONDITION] humerus; apparently patient could not be appropriately positioned owing to severe discomfort .the patient does have a supracondylar [MEDICAL CONDITION] elbow. Review of Resident #1's radiology report dated [DATE] of the left elbow revealed under Impressions: acute angulated comminuted supracondylar fracture. Interview on [DATE] at 1:00 p.m. with the DON revealed that Resident #1 was supposed to be transferred with a mechanical lift since her admission on [DATE]. She reported that nursing staff was trained on transfers. Interview on [DATE] at 07:40 a.m. with RN B revealed that Resident #1 was able to tell someone what she wanted. She stated that Resident #1 required a mechanical lift transfer and that was what she was told the resident received while at home. She stated that a 2 + transfer was the same as mechanical lift. She stated that prior to [DATE] Resident #1 could drink her coffee and eat with minimal to no assistance. She stated that prior to the incident Resident #1 had no swelling to her shoulders and arms and that she really didn't require pain medication or ask for her [MEDICATION NAME] which was ordered PRN for pain. She reported that she was the charge nurse on [DATE], and she stood out in the hallway while in the process of doing treatments and CNA A came out of Resident #1's room and reported that she couldn't find the sling for the mechanical lift, and that she and Resident #1's sitter tried to transfer the resident by themselves and that the resident was complaining of immense pain to her shoulders. She reported that what the family told her about the resident revealed that she was stoic and not one to complain of pain. She stated that Resident #1 was in so much pain there were tears in her eyes. She said that physical therapy helped to get Resident #1 back to bed. RN B stated that Resident #1 had an x-ray done to her shoulders on [DATE] which was negative, and that she received an order for [REDACTED]. RN B stated that two days later on [DATE], Resident #1's elbows and arms up to her shoulders were swollen and bruised. She said that Resident #1 was completely bed bound after that and she hurt too much to even get her up to get her to the beauty shop to get her hair done. She stated that x-rays were done to the residents elbows on [DATE] six days after the incident which revealed fractures to both elbows. She stated that the sitter told her to tell the family they did range of motion exercises with the resident and that is what caused the injuries. She said she told the sitter absolutely not. Telephone interview on [DATE] at 10:55 a.m. with CNA A revealed that she was aware that Resident #1 required a mechanical lift transfer. She stated that she needed to weigh the resident, so she went into Resident #1's room and asked the sitter to assist her to transfer Resident #1 into the wheel chair. She said that she and the sitter lifted Resident #1 by the arms and the gait belt and tried two times before they were able to get the resident into the wheel chair. She stated that the resident complained of terrible pain in her shoulders after that and she went and told the nurse. She stated that she was not checked off for competency on the mechanical lift, but was shown by the staff what to do. She said that she knew she should have looked on the kiosk or asked the nurse if she did not know how to transfer a resident. Observation on [DATE] at 4:00 p.m. of CNA A demonstrating how she and the sitter transferred Resident #1 to the wheel chair, she linked her elbow into the surveyor's and said she pulled on the gait belt and lifted with Resident #1's arms and the sitter did the same on the other side. Interview on [DATE] at 11:15 a.m. with the Medical Director and physician who examined Resident #1 revealed that he did not believe she came to the facility with the elbow fractures. He stated that the type of fracture she had on her right elbow which was a spiral fracture could only have happened in his professional opinion with her transfer by her right arm hitting a surface and being twisted and her left elbow fracture was from being held or positioned with some force. Indirect trauma from a fall or a twisting action (e.g. arm wrestling) are also encountered and usually result in spiral or oblique fractures. The higher the impact strength, the more likely the fracture is to be comminuted.(https://radiopaedia.org/articles/humeral-shaft-fracture - dated [DATE]). The facility took action to correct the deficiency on [DATE] with in-services provided to staff on two person transfers, mechanical lift transfers and deviced a competency checklist. CNA A was counseled by the facility administration and increased monitoring and supervision was provided by administration of staff for safe and appropriate transfers of residents. A list provided by the DON on [DATE] revealed 7 residents who required mechanical lift transfers.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 1 of 8 residents reviewed for neglect (resident #1) in that: The facility failed to ensure CNA A was properly trained and monitored for proper transfer of Resident #1 which resulted in two fractured elbows. CNA A and an untrained sitter grabbed Resident #1 by the elbows to transfer her for a 2 person transfer instead of using a mechanical lift as care planned. This deficient practice could place the 7 residents who required the mechanical lift transfers at risk and could result in injury. The findings included: Review of Resident #1's face sheet dated [DATE] revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE]. Review of Resident #1's comprehensive plan of care (undated) revealed under section Transfer: I require mechanical aide, hoyer for transfers. Review of Resident #1's Nursing Admission Assessment in Point Click Care dated [DATE] at 11:16 a.m. completed by RN B revealed that Resident #1 required two + persons to assist with transfer. Review of Resident #1's radiology report dated [DATE] of the right elbow revealed under Impressions: there is a spiral [MEDICAL CONDITION] humerus; apparently patient could not be appropriately positioned owing to severe discomfort .the patient does have a supracondylar [MEDICAL CONDITION] elbow. Review of Resident #1's radiology report dated [DATE] of the left elbow revealed under Impressions: acute angulated comminuted supracondylar fracture. Interview on [DATE] at 1:00 p.m. with the DON revealed that Resident #1 was supposed to be transferred with a mechanical lift since her admission on [DATE]. She reported that nursing staff was trained on transfers. Interview on [DATE] at 07:40 a.m. with RN B revealed that Resident #1 was able to tell someone what she wanted. She stated that Resident #1 required a mechanical lift transfer and that was what she was told the resident received while at home. She stated that a 2 + transfer was the same as mechanical lift. She stated that prior to [DATE] Resident #1 could drink her coffee and eat with minimal to no assistance. She stated that prior to the incident Resident #1 had no swelling to her shoulders and arms and that she really didn't require pain medication or ask for her [MEDICATION NAME] which was ordered PRN for pain. She reported that she was the charge nurse on [DATE], and she stood out in the hallway while in the process of doing treatments and CNA A came out of Resident #1's room and reported that she couldn't find the sling for the mechanical lift, and that she and Resident #1's sitter tried to transfer the resident by themselves and that the resident was complaining of immense pain to her shoulders. She reported that what the family told her about the resident revealed that she was stoic and not one to complain of pain. She stated that Resident #1 was in so much pain there were tears in her eyes. She said that physical therapy helped to get Resident #1 back to bed. RN B stated that Resident #1 had an x-ray done to her shoulders on [DATE] which was negative, and that she received an order for [REDACTED]. RN B stated that two days later on [DATE], Resident #1's elbows and arms up to her shoulders were swollen and bruised. She said that Resident #1 was completely bed bound after that and she hurt too much to even get her up to get her to the beauty shop to get her hair done. She stated that x-rays were done to the residents elbows on [DATE] six days after the incident which revealed fractures to both elbows. She stated that the sitter told her to tell the family they did range of motion exercises with the resident and that is what caused the injuries. She said she told the sitter absolutely not. Telephone interview on [DATE] at 10:55 a.m. with CNA A revealed that she was aware that Resident #1 required a mechanical lift transfer. She stated that she needed to weigh the resident, so she went into Resident #1's room and asked the sitter to assist her to transfer Resident #1 into the wheel chair. She said that she and the sitter lifted Resident #1 by the arms and the gait belt and tried two times before they were able to get the resident into the wheel chair. She stated that the resident complained of terrible pain in her shoulders after that and she went and told the nurse. She stated that she was not checked off for competency on the mechanical lift, but was shown by the staff what to do. She said that she knew she should have looked on the kiosk or asked the nurse if she did not know how to transfer a resident. Observation on [DATE] at 4:00 p.m. of CNA A demonstrating how she and the sitter transferred Resident #1 to the wheel chair, she linked her elbow into the surveyor's and said she pulled on the gait belt and lifted with Resident #1's arms and the sitter did the same on the other side. Interview on [DATE] at 11:15 a.m. with the Medical Director and physician who examined Resident #1 revealed that he did not believe she came to the facility with the elbow fractures. He stated that the type of fracture she had on her right elbow which was a spiral fracture could only have happened in his professional opinion with her transfer by her right arm hitting a surface and being twisted and her left elbow fracture was from being held or positioned with some force. Indirect trauma from a fall or a twisting action (e.g. arm wrestling) are also encountered and usually result in spiral or oblique fractures. The higher the impact strength, the more likely the fracture is to be comminuted.(https://radiopaedia.org/articles/humeral-shaft-fracture - dated [DATE]). Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility took action to correct the deficiency on [DATE] with in-services provided to staff on two person transfers, mechanical lift transfers and deviced a competency checklist. CNA A was counseled by the facility administration and increased monitoring and supervision was provided by administration of staff for safe and appropriate transfers of residents. A list provided by the DON on [DATE] revealed 7 residents who required mechanical lift transfers.