Every finding on record at The Hills Post Acute

Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were followed for one of five sampled residents (Resident 4). * LVN 1 failed to perform hand hygiene after the removal of gloves post cleaning of a glucometer (a machine to measure blood sugar level) and a medication tray. This failure posed the risk of spreading infectious organism to the residents in the facility. Findings: Review of the facility's P&P titled Hand Hygiene revised 5/2026 showed hand hygiene is a general term that applied to handwashing, antiseptic hand wash, and alcohol-based hand rub. Hand washing is the vigorous, brief rubbing together of all surfaces of hands with soap and water, followed by rinsing under a stream of water. Alcohol-based hand rub is a 60-95 percent ethanol or isopropyl alcohol-containing preparation base designed for application to the hands to reduce the number of viable microorganisms. Procedure included using an alcohol-based hand rub containing at least 62% alcohol; or alternatively, antimicrobial or non-antimicrobial soap and water after removing gloves. On 6/30/26 at 1226 hours, during the medication administration observation for Resident 4, LVN 1 was observed wearing gloves while cleaning a glucometer and a medication tray. After cleaning the glucometer and medication tray, LVN 1 removed the old gloves and immediately put on new pair of gloves. Hand hygiene was not observed before and after removing the contaminated gloves. LVN 4 proceeded to obtain the blood sugar of Resident 4 by performing the finger prick. On 6/29/26 at 1400 hours, an interview was conducted with LVN 1. When asked about the policy on hand hygiene, LVN 1 stated the nurses should wash hands before and after using gloves. When asked if he performed hand hygiene in between glove use when checking Resident 4's blood sugar, LVN 1 stated he did not. LVN 1 further stated the correct process would be to perform hand hygiene in between every activity including donning on new gloves and removing dirty gloves. On 6/30/26 at 1025 hours, the ADON was informed and acknowledged the above findings. On 6/30/26 at 1330 hours, RN 1 was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nutritional needs were addressed for one of five sampled residents (Resident 2). * Resident 2 was observed with Nepro (specialized, calorie-dense nutritional shake) and Ensure (nutritional supplement) at his bedside table without a physician's order. This failure placed the resident at risk to receive nutritional supplements unnecessarily. Findings: Medical record review for Resident 2 was initiated on 6/30/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was cognitively intact. On 6/30/26 at 1000 hours , during an observation and concurrent interview with Resident 2 in his room, seven cartons of 237 ml vanilla flavored Nepro and one carton of 237 ml vanilla flavored Ensure were found at Resident 2's bedside table. When Resident 2 was asked, who the Nepro and Ensure were for, Resident 2 stated it was his drinks. When asked who provided the Nepro and Ensure, Resident 2 verified it was the facility staff who supplied him the Nepro and Ensure to drink. On 6/30/26 at 1030 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 3. LVN 3 verified the presence of seven cartons of 237 ml vanilla flavored Nepro and one carton of 237 ml vanilla flavored Ensure at Resident 2's bedside table. LVN 3 further verified they were nutritional supplements for Resident 2. On 6/30/26 at 1030 hours, an interview and concurrent review of Resident 2's Order Summary Report dated 6/2026 was conducted with LVN 3. The Order Summary Report failed to show documented evidence the Nepro and Ensure supplements were ordered by the physician. LVN 3 stated the orders for the Nepro and Ensure supplements were discontinued. On 6/30/26 at 1330 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated a physician's order was needed before giving Resident 2 the Nepro and Ensure as supplements. On 6/30/26 at 1430 hours, an interview was conducted with the DON. The DON was informed of the above findings and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of five sampled residents (Resident 5). * The facility failed to administer the potassium chloride (medication used to treat and prevent hypokalemia-low potassium level) medications according to the pharmacy-related directions for Resident 5. This failure had the potential to put the resident at risk for adverse consequences related to the medication use. Findings: Review of the facility's P&P titled Guidelines for Medication Administration (undated) showed if a discrepancy exist or you are unfamiliar with the medication, consult the appropriate resources such as the pharmacist. On 6/29/26 at 1025 hours, a medication administration observation for Resident 5 was conducted with LVN 2. During the medication administration, LVN 2 was observed popping the potassium chloride (mineral supplement primarily used to treat or prevent low blood potassium levels) medication from the bubble pack into a 10 ml cup. LVN 2 then read out loud the potassium chloride bubble pack instructions to dissolve the two tablets in four oz. water and administer by mouth one time a day for supplement, do not crush or chew the tablet. LVN 2 then proceeded with handing the medication and a cup of water to Resident 5. LVN 2 was not observed following the pharmacy related directions shown in Resident 5's potassium chloride extended release 20 mEq bubble pack. On 6/29/26 at 1030 hours, an interview and concurrent review of the pharmacy related directions for potassium chloride extended release 20 mEq bubble pack was conducted with LVN 2. The pharmacy related instructions in Resident 5's potassium chloride extended release 20 mEq bubble pack showed a direction to dissolve two tablets in four oz. of water. However, LVN 2 was not observed dissolving the two tablets of potassium chloride in four oz of water as directed. LVN 2 stated she followed the physician's order and not the pharmacy related directions. Medical record review for Resident 5 was initiated on 6/29/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report for 6/2026 showed a physician's order dated 6/17/26, to administer potassium chloride extended release 20 mEq to give two tablets by mouth one time a day for supplement. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 was cognitively intact. On 6/20/26 at 1430 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure food preparation equipment was in good, cleanable and sanitary condition. * The facility failed to ensure temperature was monitored in the dry storage room. * The facility failed to ensure food items were labeled and discarded by the best by or use by date. These failures had the potential to cause foodborne illnesses in the medically vulnerable residents population who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report revised on 5/4/26, showed 153 residents received food from the kitchen. 1. Review of the facility's P&P titled Sanitation dated 2023 showed correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers, and food storerooms. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the food and supplies will be stored properly and in a safe manner. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and changed frequently. Recommended temperature is 50 to 85 degrees Fahrenheit if dry food storage goes over 85 degrees Fahrenheit take corrective action. On 5/3/26 at 0840 hours, an observation and concurrent interview was conducted with DSS in the kitchen's dry storage room. The DSS verified the facility had no temperature monitoring log or system for the dry storage area. The DSS stated the temperature should be checked to ensure food kept in the storage room was stored at appropriate temperature levels. 2. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 5/3/26 at 0818 hours, an observation and concurrent interview was conducted with the DSS. The following was observed:- One can opener with brown discoloration, silver shavings, and dirt particles.- One mixer with dried food particles.The DSS verified the above findings and stated kitchen equipment should be cleaned and sanitized to prevent contamination of foods prepared in the kitchen. 3. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed food and supplies will be stored properly and in a safe manner. On 5/3/26 at 0808 hours, an observation and concurrent interview was conducted with the DSS inside Walk-In Refrigerator 1. One container of ham showed a use by date of 4/28/26. The ham packaging had no label or date. The DSS verified the findings and stated food items should be labeled to ensure kitchen staff are aware of when food should be served. On 5/6/26 at 1430 hours, an interview was conducted with the Administrator, DON, Clinical Resource Nurse, and Dietary Resource. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for 26 of 153 residents (Resident 94, 18 of 18 residents who received pureed food and seven of seven residents on a renal diet) eating from the kitchen. * The facility failed to ensure the puree recipe for IDDSI Level 4 Pureed Starch (Rice, Pasta, Polenta, Potatoes, etc.) was followed. * The facility failed to follow the renal diet menu. * The facility failed to inform the residents of menu changes. * The facility failed to offer Resident 94 appropriate food substitutions when he refused both breakfast and lunch. These failures had the potential to result in residents on special diets not receiving adequate nutritional and caloric intake as recommended.Findings: Review of the facility's Diet Type Report dated 5/3/26 and revised on 5/4/26, showed 153 residents consumed food prepared in the kitchen, with seven residents on renal diets and 18 residents on pureed diets. 1. Review of the facility's P&P titled IDDSI Level #4: Regular Pureed Diet dated 2025 showed the pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. The P&P further showed all foods are to be prepared in a food processor or blender. Additional liquids, such as broth, gravy, vegetable or fruit juices, or milk, and potentially food thickeners are added to achieve the appropriate final consistency. Review the facility document titled Recipe: Pureed (IDDSI Level #4) Starch (Rice, Pasta, Polenta, Potatoes, etc) dated 2025 showed the directions were to puree the potatoes on low speed to a paste consistency before adding any liquid. Further directions for pureed potatoes showed to gradually add warm milk. On 5/4/26 at 1053 hours, during a puree observation for pureed potatoes, [NAME] 1 was observed adding 25 servings of potatoes in the blender and then added two cups of warm milk into the blender before blending. On 5/4/26 at 1115 hours, an interview and concurrent facility document review was conducted with [NAME] 1. [NAME] 1 verified the above findings and stated the recipe for pureed potatoes was not followed. 2. Review of the facility's P&P titled Menu Planning dated 2023 showed menus and cook's spreadsheets are to be dated and posted in the kitchen and on the consumer bulletin board in the entrance of the facility by the FNS Director two weeks in advance. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook may be kept. The facility Registered Dietitian is to sign and date spreadsheets when changes are made. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. Review of the facility's P&P titled Renal 80-Gram Protein, Low Salt, Low Potassium, In Combination with Controlled Carbohydrate (CCHO) (undated) showed this diet is used for the diabetic resident with renal insufficiency at the 80 grams level of protein, low salt, and low potassium. The diet may be inadequate in certain vitamins and minerals. Review of the facility document titled Spring Menus dated 5/4/26, showed the residents on the renal diets are to receive brown rice with margarine, wheat roll, and pineapple and mandarin orange mix. On 5/4/26 at 1310 hours, during tray line observation and concurrent interview was conducted with RD 1 and the DSS. Reviews of Resident 94 and 175's meal ticket showed both residents were on renal diets. However, during the tray line observation, Residents 94 and 175 did not receive brown rice with margarine, the wheat roll, and pineapple and mandarin orange mix per the facility's menu. RD 1 stated the brown rice was available but was not cooked in time for lunch and macaroni pasta was substituted without informing the residents. The DSS stated the facility did not prepare the fruit mold as per the Spring Menu for renal diets. The DSS stated the fruit mold had bananas while the pineapple and mandarin orange mix did not. RD 1 and the DSS verified the residents were not informed of the change in the menu and none of the residents on renal diet received brown rice with margarine and the pineapple and mandarin orange mix. RD 1 stated the facility should follow the therapeutic diet. 3. Review of the facility's P&P titled Purchasing and Food and Supplies dated 2023 showed food supplies are ordered each week from an appropriate vender. The FNS Director, who selects all suppliers, is responsible for specifying the quantity of food desired. Proper procedures are to be followed in purchasing food and seeing that food is delivered. Frequency of purchasing and delivery is determined by storage space, product type, and frequency of use. Review of the facility document titled Spring Menus dated 5/3/26, showed the residents on renal diets are to receive roast beef SF (salt free) gravy for lunch. Review of the facility document titled Sysco Customer's Invoice dated 4/16/26, showed the facility received six cases of beef roast on 4/16/26. Review of the facility document titled Sysco Customer's Invoice dated 4/22/26, showed the facility received three cases of roast beef on 4/22/26. On 5/3/26 at 1213 hours, during the dining observation, Resident 175's meal ticket for lunch showed the resident was on a renal diet. Resident 175 received a beef patty instead of roast beef with SF gravy. On 5/3/26 at 1248 hours, an observation and concurrent interview was conducted with the DSS in the dining room. The DSS verified Resident 175 and residents with renal diets did not receive roast beef with SF gravy as per the menu. The DSS stated the facility was out of stock for the roast beef and beef patty was substituted. On 5/3/26 at 1315 hours, an interview was conducted with Resident 12. Resident 12 stated he was not informed of the menu change from roast beef to beef patty. When asked if he ate the beef patty, Resident 12 stated he did not and was looking forward to the roast beef. On 5/4/26 at 0830 hours, an interview was conducted with the RD 1 and the DSS. RD 1 verified the Sysco Customer's Invoices for the roast beef and stated the facility had roast beef on hand. When asked why the residents were not served roast beef for lunch on 5/3/26, as per the menu, the DSS stated the facility did not thaw the roast beef in time for lunch. The DSS further stated the recipe should match what was posted on the menu. On 5/6/26 at 1430 hours, an interview was conducted with the Administrator, DON, Clinical Resource Nurse, and Dietary Resource. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Food Substitutions For Residents Who Refuse The Meal reviewed dated 4/10/26, showed nursing personnel will ask any resident who does not eat his meal or food item as to why he is not eating and offer substitution in accordance with the resident's diet order. Medical record review for Resident 94 was initiated on 5/3/26. Resident 94 was admitted to the facility on [DATE]. Review of Resident 94's H&P examination dated 12/26/25, showed Resident 94 had no capacity to make medical decisions. Review of Resident 94's Documentation Survey Report v2 dated 5/3/26, under section Amount Eaten, showed Resident 94 refused breakfast and lunch. On 5/3/26 at 1324 hours, an observation and concurrent interview was conducted with Resident 94. Resident 94's lunch tray was observed far from him on his overbed table. Resident 94 stated he did not like the food and was not offered anything else. On 5/3/26 at 1352 hours, an interview was conducted with CNA 1. CNA 1 verified delivering Resident 94's lunch tray. CNA 1 stated Resident 94 refused to eat his lunch but asked her to keep the tray at bedside. CNA 1 further stated food substitutions were not offered to Resident 94. On 5/5/26 at 0846 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD stated when residents refuse to eat their meals, the CNAs were expected to offer the meals three times and offer food substitutions, using paper communication to request items from the kitchen. The DSD could not provide paper documentation or electronic records showing substitutions were offered for breakfast or lunch on 5/3/26, for Resident 94. On 5/6/26 at 1458 hours, an interview was conducted with the DON, Clinical Resource and Administrator. The DON, Clinical Resource, and Administrator were informed and acknowledged the findings above.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement its Infection Prevention and Control Program in accordance with the facility's P&P. * The facility failed to implement its infection control surveillance program for April 2025 through February 2026. The facility conducted surveillance only for the residents prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infection but not prescribed antimicrobial medications met McGeer's criteria for infection. The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the clean laundry sorting table remained free of staff personal items. A laundry staff member's cell phone was observed on the clean laundry sorting table. * The facility failed to ensure Resident 26's clean gown was not stored on a soiled trash can lid. * The facility failed to ensure the CNA 8 cleaned and disinfected the call light prior to placing it on Resident 12's bed. * The facility to ensure LVN 7 donned proper PPE (gown) during management of Resident 107's GT feeding under enhanced barrier precautions. * The facility failed to ensure Resident 105's case of soda was not stored on the floor. * The facility failed to ensure CNAs performed hand hygiene during the delivery of the residents' meal trays. These failures posed the risk for not identifying resident infections, preventing resident infections, and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the facility's P&P titled Infection Surveillance Outcome and Reporting revised 4/2025 showed it is the policy of the facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreaks. The charge nurse reports any residents displaying signs/symptoms (of infection) and the nature of the symptoms. The charge nurse will be responsible for recording the information of all residents displaying any symptoms of infection on the Infection Surveillance log. The Infection Surveillance Log is maintained by the Infection Preventionist (IP). The IP or designee will trend all validated infections using McGeer's criteria on a monthly basis. Action plans will be written for any identified problems and implemented as soon as possible. On 5/4/26 at 1021 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's infection surveillance program. The IP stated when a resident exhibited signs and/or symptoms of infection and was prescribed an antimicrobial medication, the facility would determine if the resident had met McGeer's criteria. The IP stated this information was documented on the facility's Infection Surveillance V-2 form. The IP then stated on a monthly basis he would determine how many residents in the facility had exhibited signs and/or symptoms of infection and were prescribed an antimicrobial medication. The IP stated he documented this information on the facility's monthly Infection Surveillance log. The IP stated in accordance with the facility's Infection Surveillance Outcome and Reporting P&P, the facility's Infection Surveillance program functioned to identify possible communicable diseases or infections, to ensure that measures were taken to prevent any potential outbreaks. Review of the facility's monthly Infection Surveillance Logs from April 2025 through February 2026 showed the following infection surveillance data for HAIs, CAIs, and residents who did not meet McGeer's criteria (DNMC): - for 4/2025, HAI - 32, CAI – 44, and DNMC – 6; - for 5/2025, HAI - 24, CAI – 53, and DNMC -6; - for 6/2025, HAI - 35, CAI – 37, and DNMC -6; - for 7/2025, HAI – 25, CAI – 52, and DNMC – 13; - for 8/2025, HAI - 23, CAI – 38, and DNMC -10; - for 9/2025, HAI - 40, CAI – 46, and DNMC -11; - for 10/2025, HAI - 38, CAI – 38, and DNMC – 10; - for 11/2025, HAI - 40, CAI –46, and DNMC –11; - for 12/2025, HAI - 29, CAI – 37, and DNMC -7; - for 1/2026, HAI - 20, CAI – 30, and DNMC – 7; and - for 2/2026, HAI - 21, CAI – 37, and DNMC – 6. Further review of the facility's monthly Infection Surveillance Logs from April 2025 through February 2026 showed all the residents included on the Infection Surveillance logs were also prescribed antimicrobial medications. The IP was asked when a resident at the facility exhibited signs and/or symptoms of infection and was not prescribed antimicrobial medications, if the facility initiated the Infection Surveillance V-2 form (McGeer's criteria) for these residents and if these residents were included in the facility's infection surveillance program. The IP stated the facility did not initiate the Infection Surveillance V-2 form for residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications. The IP was asked how many residents in the facility had infections (met McGeer's criteria) and were not prescribed antimicrobial medications (from April 2025 through February 2026). The IP stated he was uncertain as the facility did not initiate the Infection Surveillance V-2 form (McGeer's criteria) for residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications. 2. Review of the facility's P&P titled Infection Prevention Linen Management (undated) showed clean linens are to be kept protected from dust and other contaminants prior to use. On 5/4/26 at 1009 hours, an observation and concurrent interview was conducted with Laundry 1. An observation of the facility's laundry room was conducted with Laundry 1. The counter designated for clean laundry sorting was observed with Laundry 1's cell phone on the countertop, adjacent to clean linens. Laundry 1 verified the findings and stated the cell phone should not be stored on the clean laundry sorting counter adjacent to resident clean linens, for infection control. 3. Medical record review for Resident 26 was initiated on 5/3/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/3/26 at 0900 hours, an observation and concurrent interview was conducted in Resident 26's room. A folded gown was observed stored on the lid of the soiled trash can in Resident 26's room. Resident 26 stated the staff routinely placed gowns, linens, and towels used for her care on the trash can before providing the morning care. Review of Resident 26's H&P examination dated 4/14/26, showed Resident 26 had the capacity to make medical decisions. On 5/3/26 at 0915 hours, an interview and concurrent observation was conducted with CNA 8. CNA 8 stated the linen to be used during the resident's care should be placed on the resident's bedside table or the nightstand table. CNA 8 stated the linen not used during the care should go in the dirty linen hamper. CNA 8 stated Resident 26 just had her breakfast, and the morning care had not been provided yet. CNA 8 verified the above findings. CNA 8 stated the gowns should not be stored on top of the trashcan lid for infection control purposes. CNA 8 was observed removing the gown. 4. Medical record review for Resident 12 was initiated on 5/3/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/3/26 at 0923 hours, during the initial tour of the facility, Resident 12's call light was observed on the ground. On 5/3/26 at 0929 hours, an observation and concurrent interview was conducted with CNA 8. CNA 8 verified the above findings and was observed picking up Resident 12's call light and placing it on Resident 12's bed without disinfecting it. CNA 8 verified she did not disinfect the call light prior to placing it on the resident's bed. CNA 8 stated the call light should be cleaned and disinfected before placing it on the resident's bed for infection control purposes. On 5/6/26 at 0842 hours, an interview was conducted with the IP. The IP stated the linen, gowns, and towels, when not being used should be placed on the bedside drawer or inside the resident's closet. The IP stated the unused linen should go into the dirty linen container and should not be stored on top of the trashcan due to the potential contamination if used on the residents. The IP further stated when the call lights fall on the ground, it should be wiped with an approved disinfectant before placing it on the resident's bed or giving it to the resident to prevent transmission of microorganisms. On 5/6/26 at 1444 hours, an interview was conducted with the Administrator, DON, and Clinical Resource Nurse. The Administrator, DON, and Clinical Resource Nurse were informed and acknowledged the above findings. 5. Review of the facility's P&P titled IPCP Standard and Transmission-Based Precaution revised 3/2024 showed enhanced barrier precaution: use in conjunction with standard precautions and expand the use of personal protective equipment (PPE) through the use of gowns and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents of from resident-to-resident. - Personal Protective Equipment (PPE): the use of gowns and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with indwelling medical devices include, but are not limited to central lines, peripherally inserted central catheter (PICC) lines, urinary catheter, feeding tubes, and tracheostomies. On 5/26/26 at 1213 hours, an observation and concurrent interview for Resident 107 was conducted with LVN 7. Resident 107's GT feeding was heard with an alarming sound. LVN 7 entered to the room, sanitized her hands and donned gloves. LVN 7 was observed turning off the Kangaroo pump (an enteral pump machine to deliver nutrition and hydration directly into a resident's gastrointestinal tract), touching the resident's blanket, disconnecting the GT tube from the resident, and then tucking the resident's blanket. When LVN 7 was asked if she needed to use a gown when she disconnected the GT feeding from resident, LVN 7 stated she did not use the proper PPE when she disconnected the GT but should have used the gown to prevent infection. Medical record review for Resident 107 was initiated on 5/3/26. Resident 107 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 107's MDS assessment dated [DATE], showed Resident 107's BIMS score of 2, indicating severe cognitive impairment. Review of Resident 107's Order Summary Report showed a physician's order dated 3/3/26, for enhanced barrier precautions: personal protective equipment (PPE) required for high contact care activities, indication indwelling medical device (feeding tube). On 5/6/26 at 1024 hours, an interview was conducted with the DON. The DON stated the staff should have used the proper PPE when caring for the residents who were on enhanced barrier precautions to prevent infection. The DON was informed and verified the above findings. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 6. Medical record review for Resident 105 was initiated on 5/3/26. Resident 105 was admitted to the facility on [DATE]. On 5/3/26 at 0950 hours, during an initial tour of the facility, an observation and concurrent interview was conducted with LVN 9 inside Resident 105's room. One case of soda was observed on the floor. LVN 9 verified findings and stated the resident's belongings should not be placed on the floor for infection control. On 5/3/26 at 1041 hours, an interview with the IP was conducted. The IP verified LVN 9 informed him of Resident 105's personal belongings on the floor. The IP stated Resident 105's case of soda should not have been kept on the floor to avoid pests and infection control. On 5/6/26 at 1430 hours, an interview with the Administrator, DON, Clinical Resource Nurse, and Dietary Resource was conducted. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource were informed and acknowledged findings. 7. On 5/3/26 at 1310 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 was observed going into Room A and coming out of Room A without performing hand hygiene. CNA 3 was then observed grabbing meal trays to deliver to the residents. CNA 3 stated she repositioned the resident in Room A and fixed Room A's meal tray. CNA 3 further stated she washed her hands using the sink in Room A and dried her hands with paper towel. When asked to show where CNA 3 threw the paper towel, CNA 3 stated in the resident's trash bin but verified the trash bin was empty without a paper towel. CNA 3 verified she did not perform hand hygiene after providing care and before delivering the meal trays. On 5/3/26 at 1307 hours, an observation was conducted with CNA 4 during the delivery of lunch meal trays. CNA 4 observed delivering the lunch meal tray to multiple rooms but did not perform hand hygiene before and after delivery of the lunch meal trays. On 5/3/26 at 1332 hours, an interview was conducted with CNA 4. CNA 4 verified hand hygiene was not performed before and after delivering lunch meal trays to residents. CNA 4 stated he should have washed his hands before and after delivering the lunch meal trays. On 5/6/26 at 1458 hours, an interview was conducted with the DON, Clinical Resource and Administrator. The DON, Clinical Resource, and Administrator were informed and acknowledged the findings above.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 7) and two nonsampled residents (Residents 31 and 175) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 7 nasal canula tubing was dated and labeled and had an oxygen storage bag as per the facility's P&P. * The facility failed to ensure Resident 31's nasal cannula tubing was dated and labeled as per the facility's P&P. * The facility failed to ensure Resident 175 nasal canula tubing was dated and labeled and had an oxygen storage bag as per the facility's P&P. These failures had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions.Findings: Review of the facility's P&P titled Use of Oxygen revised 5/2021 showed it is the policy of this facility to promote resident safety in administering oxygen. The oxygen cannula or masks, tubings will be changed at least every 7 (seven) days. The tubing should be kept off the floor. Labeled and dated bags should be provided for cannulas and masks to be placed in when not in use. 1. On 5/3/26 at 1235 hours, a dining room observation and concurrent interview for Resident 31 were conducted with LVN 2. LVN 2 verified that Resident 31 was on oxygen at two liters per minute and that the nasal cannula tubing was unlabeled and undated. LVN 2 further stated that oxygen tubing needs to be changed every seven days to prevent infection. Medical record review for Resident 31 was initiated on 5/3/26. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's H&P examination dated 1/21/26, showed Resident 31 had no capacity to make medical decisions. Review of Resident 31's Order Summary Report dated 5/4/26, showed a physician's order dated 4/9/26, to administer oxygen at two liters per minute via nasal continuously. On 5/6/26 at 1024 hours, an interview for Resident 31 was conducted with the DON. The DON verified the above findings. The DON stated the nasal cannula should have been labeled with the date when the tubing was change, for infection control. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. On 5/3/26 at 1235 hours, a dining observation and concurrent interview were conducted with LVN 2 in the dining room for Resident 7. Resident 7 was observed on portable oxygen at two liters per minute, and the nasal cannula tubing was noted to be undated, unlabeled, and without a storage bag. LVN 2 verified that Resident 7's nasal cannula tubing was not labeled or dated and that there was no oxygen storage bag present. LVN 2 stated the nasal cannula should be labeled with the date and changed every seven days. Medical record review for Resident 7 was initiated on 5/4/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 3/4/26, showed Resident 7 had no capacity to make medical decisions due to dementia. Review of Resident 7's Order Summary Report dated 5/4/26, showed a physician's order dated 3/12/26, to administer oxygen at two liters per minute via nasal continuously every shift. 3. On 5/3/26 at 1230 hours, a dining observation and concurrent interview for Resident 175 were conducted with LVN 2 in the dining room. Resident 175 was observed on portable oxygen at two liters per minute, and the nasal cannula tubing was noted to be undated, unlabeled, and without a storage bag. LVN 2 verified that Resident 175's nasal cannula tubing was not labeled or dated and confirmed that there was no oxygen storage bag. LVN 2 stated the nasal cannula should be labeled with the date and changed every seven days. Medical record review for Resident 175 was initiated on 5/4/26. Resident 175 was admitted to the facility on [DATE]. Review of Resident 175's H&P examination dated 2/23/26, showed Resident 175 had the capacity to make medical decisions. Review of Resident 175's Order Summary Report dated 5/5/26, showed a physician's order dated 3/8/26, to administer oxygen at two liters per minute via nasal continuously every shift for shortness of breath. On 5/6/26 at 1430 hours, an interview was conducted with the Administrator and DON for Residents 7 and 175. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for three of three final sampled residents (Residents 2, 12, and 81) reviewed for dialysis care. * The facility failed to ensure the Dialysis Communication Forms for Resident 2 were completed and accurate on multiple dates. * The facility failed to ensure Resident 12's hemodialysis communication records were complete and failed to ensure accurate documentation of the monitoring of Resident 12's fluid restriction as ordered by the physician. * The facility failed to ensure Resident 81's hemodialysis communication records and fluid intake monitoring were completed accurately. These failures had the potential of not identifying negative outcomes for Residents 2, 12, and 81. Findings: Review of the facility's P&P titled Dialysis (Renal), Pre- and Post-Care reviewed 4/2025, showed it is the policy of this facility to: - assist the resident in maintaining hemostasis pre-and post-renal dialysis; - assess and maintain patency of renal dialysis access; - participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Further review of the P&P showed the dialysis access should be assessed upon the resident's return to the facility for patency, any unusual redness, swelling and bleeding. Documentation related to pre- and post-dialysis care will be placed in the clinical record and include: a. Resident assessments, interventions, and any provided education. b. Assessment of renal dialysis access site to include absence and quality of a bruit and thrill for residents with an arteriovenous fistula c. Communication between facility and dialysis staff or medical provider. 1. On 5/3/26 at 0910 hours, an interview was conducted with Resident 2. Resident 2 stated he received hemodialysis treatment three times a week and on fluid restriction but the resident would not specify the dialysis dates or the amount of the fluid restriction. Resident 2 showed he has a Permacath on the right upper chest. Medical Record review for Resident 2 was initiated on 5/4/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report dated 5/4/26, showed the following physician's orders: - dated 1/3/26, to assess the shunt/dialysis site every shift and document: C=Clear, T=Tenderness, R=Redness, B=Bleeding every shift for right upper chest Permacath site. - dated 4/16/26, for Resident 2 to receive the hemodialysis treatments every Tuesday, Thursday and Saturday with Dialysis Center B. Review of Resident 2's Dialysis Center Nursing Communication Records showed inaccurate documentation on the following dates: - dated 2/5/26, Facility Nurse/Post Dialysis section showed bruit and thrill were present. - dated 3/12/26, Facility Nurse/Post Dialysis section showed bruit and thrill were present and failed to show documentation of the assessment of Resident 2's hemodialysis site for sign and symptoms of infection. - dated 4/11/26, Facility Nurse/Pre-Dialysis and Post-Dialysis sections showed bruit and thrill were present. - dated 4/14/26, Facility Nurse/Post Dialysis section showed bruit and thrill were present. - dated 4/16/26, Facility Nurse/Pre-Dialysis section showed bruit and thrill were present. - dated 4/21/26, Facility Nurse/Post Dialysis section showed bruit and thrill were present. - dated 4/28/26, Facility Nurse/Post-Dialysis sections showed bruit and thrill were present. - date 4/30/26, Facility Nurse/Post-Dialysis section showed bruit and thrill were present. - dated 5/2/26, Facility Nurse/Post -Dialysis sections failed to show documentation of the assessment of Resident 2's hemodialysis access site for sign and symptoms of infection, bleeding, dressing in place, vital signs including the blood pressure, pulse rate, respiration rate, temperature, shortness of breath and the present of pain. On 5/4/26 at 1106 hours, an interview and concurrent medical record review for Resident 2 were conducted with the MDS Assistant. The MDS Assistant verified the above findings and stated Resident 2's dialysis access site was a right upper chest (RUC) Permacath. The MDS Assistant stated a bruit and thrill would not be assessed for residents with a Permacath. The MDS Assistant further stated that the documentation should be accurate. On 5/6/26 at 1437 hours, an interview with the DON and Administrator was conducted. The DON and Administrator informed and acknowledge the above findings. 2. On 5/3/26 at 0923 hours, an interview was conducted with Resident 12. Resident 12 stated he was on fluid restrictions and received hemodialysis treatments every Tuesday, Thursday, and Saturday. Resident 12 was able to show his hemodialysis access located in his left arm. Medical record review for Resident 12 was initiated on 5/3/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 4/26/26, showed Resident 12 had the capacity to make medical decisions. a. Review of Resident 12's Order Summary Report dated 5/5/26, showed the following physician's orders: - dated 4/26/26, to assess Resident 12's left Arteriovenous (AV) fistula shunt (a surgically created connection between and artery and vein for hemodialysis treatments) site for bruit (a turbulent whooshing sound heard with a stethoscope over a blood vessel) and thrill (the palpable vibration felt with your fingers in the same location), every shift; and to document + (positive) or – (negative) for the presence of bruit and thrill. To call the physician for absences. - dated 4/26/26, to assess Resident 12's shunt/dialysis site every shift and document the following: C=clear, T= tenderness, R=redness, B=bleeding, every shift. - dated 4/29/26, for Resident 12 to receive the hemodialysis treatments every Tuesday, Thursday, and Saturday with Dialysis Center A. Review of Resident 12's Dialysis Center Nursing Communication Records showed the following missing documentation: - the pre- dialysis treatment section dated 1/17/26, failed to show the documentation of Resident 12's respirations. The post- dialysis treatment section failed to show the documentation of Resident 12's vital signs including the blood pressure, pulse rate, respiration rate, temperature and the presence of pain. - the post- dialysis treatment section dated 1/22/26, failed to show the documentation of the assessment of Resident 12's hemodialysis access site for bleeding and for the presence of bruit and thrill. - the post- dialysis treatment section dated 2/7/26, failed to show the documentation of the assessment of Resident 12's hemodialysis access site for bleeding and for the presence of bruit and thrill. - the dialysis treatment section dated 2/24/26, failed to show the documentation of the assessment of Resident 12's lung sounds. The post- dialysis treatment section failed to show the documentation of the assessment of Resident 12's hemodialysis access site for the presence of bruit and thrill. - the pre- dialysis treatment section dated 4/16/26, failed to show the documentation of the assessment of Resident 12's hemodialysis access site for the presence of bruit and thrill, for any bleeding, and for any signs of infection. The post-dialysis treatment section failed to show the documentation of the assessment of Resident 12's hemodialysis access site for the presence of bruit and thrill, for any bleeding, for any signs of infection at the hemodialysis site, and for the presence of any shortness of breath. - the pre- dialysis treatment section dated 4/23/26, failed to show the documentation of the assessment of Resident 12's hemodialysis access site for the presence of bruit and thrill, for any bleeding, and for any signs of infection. b. Review of Resident 12's Order Summary Report dated 5/5/26, showed the following physician's orders: - dated 4/26/26, to assess Resident 12's left Arteriovenous (AV) fistula shunt (a surgically created connection between and artery and vein for hemodialysis treatments) site for bruit (a turbulent whooshing sound heard with a stethoscope over a blood vessel) and thrill (the palpable vibration felt with your fingers in the same location), every shift; and to document + (positive) or – (negative) for the presence of bruit and thrill. To call the physician for absences. Review of Resident 12's MAR for April and May 2026 showed the licensed nurse documented - on 4/15/26 during the 1500 to 2300 hours shift and on 4/17/26 during the 2300 to 0700 hours shift. Review of Resident 12's medical record failed to show the physician was notified of the absence of bruit/thrill for Resident 12's hemodialysis site access on 4/15 and 4/17/26. c. Review of Resident 12's Order Summary Report dated 5/5/26, showed the following physician's orders: - dated 4/26/26, every evening shift, to calculate Resident 12's total 24-hours fluid restriction. - dated 4/29/26, for Resident 12 to have a total fluid restriction of 1500 ml per day from dietary and nursing. The total nursing fluids of 420 ml per day: for the 0700 to 1500 hours shift = 160 ml, 1500 to 2300 hours shift = 160 ml, and 2300 to 0700 hours shift = 100 ml, every shift. - dated 4/29/26, total fluid restriction of 1500 ml per day. 1080 ml dietary fluid per day. Breakfast = 260 ml, Lunch = 360 ml, and dinner = 360 ml, after meals. Review of Resident 12's MARs for April and May 2026 showed the following documentation for fluid restrictions of 1500 ml per day as follows: nursing to provide 420 ml per day and dietary to provide 1080 ml per day total. - on 4/4/26, the licensed nurses documented Resident 12 received 770 ml for the dietary fluids and 370 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 4/5/26, the licensed nurses documented Resident 12 received 720 ml for the dietary fluids and 420 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 4/6/26, the licensed nurses documented Resident 12 received 770 ml for the dietary fluids and 370 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 4/7/26, the licensed nurses documented Resident 12 received 770 ml for the dietary fluids and 370 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1,500 ml in the 24-hour period. - on 4/13/26, the licensed nurses documented Resident 12 received 720 ml for the dietary fluids and 420 ml for the nursing fluids (a total of 1,140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 4/18 and 4/23/26, the licensed nurse documented Resident 12 received 720 ml for the dietary fluids and 420 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 5/2/26, the licensed nurse documented Resident 12 received 720 ml for the dietary fluids and 420 ml for the nursing fluids (a total of 1140 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. - on 5/4/26, the licensed nurse documented Resident 12 received 1080 ml for the dietary fluids and 370 ml for the nursing fluids (a total of 1450 ml). However, the licensed nurse documented Resident 12 received 1500 ml in the 24-hour period. On 5/5/26 at 1030 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 stated the documented 24-hour fluid intake calculated during the 1500 to 2300 hours shift was not done accurately. Additionally, LVN 6 stated the hemodialysis communication record should be complete. On 5/6/26 at 1049 hours, an interview was conducted with the DON. The DON stated the Dialysis Center Nursing Communication Records was used as a form of communication between the dialysis center and the facility. The DON stated the licensed nurses were responsible for completing the pre- and post- dialysis treatment sections and the dialysis nurse should complete the dialysis section. The DON further stated all the areas on the dialysis communication record should be completed. The DON stated for the residents with a physician's order for fluid restrictions, the licensed nurses were in responsible for the tracking of the fluid intake and documented the total in the MAR. The DON stated the monitoring and tracking should be accurate to account for fluids the resident actually received. On 5/6/26 at 1444 hours, an interview was conducted with the Administrator, DON, and Clinical Resource Nurse. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Medical record review for Resident 81 was initiated on 5/3/26. Resident 81 was admitted to the facility on [DATE], and readmitted back to the facility on 4/28/26. Review of Resident 81's H&P examination dated 4/30/26, showed Resident 81 had the capacity to make medical decisions. Review of Resident 81's Dialysis Center Nursing Communication Record showed inaccurate documentation on the following dates: - dated 4/18/26, Facility Nurse/Pre-Dialysis section showed bruit and thrill were present. - dated 4/16/26, Facility Nurse/Pre-Dialysis section showed bruit thrill were present. - dated 4/9/26, Facility Nurse/Pre-Dialysis and Post-Dialysis sections showed bruit and thrill were present. Review of Resident 81's Order Summary Report for May 2026 showed the following physician's orders: - dated 4/28/26, for total fluid restriction per day 1000 ml. From dietary and nursing, total nursing fluids per day 280 ml; 7-3 PM shift 100 ml, 3-11 PM shift 100 ml, and 11-7 PM shift 80 ml. - dated 4/28/26, for total fluid restriction per day 1000 ml. Total dietary fluid per day is 720 ml, breakfast 240 ml, lunch 240 ml, and dinner 240 ml. - dated 4/28/26, for hemodialysis site to right upper chest (RUC) Permacath. - dated 1/20/25, for hemodialysis days on Tuesday, Thursday, and Saturday schedule time at 0915 hours. - dated 4/29/26, for post dialysis RUC catheter check for bleeding every Tuesday, Thursday, and Saturday Review of Resident 81's Nursing Progress Notes dated 5/5/26 at 2037 hours, showed facility staff spoke with ER Nurse at Hospital A and was informed Resident 81 was admitted to the acute care hospital. Review of Resident 81's MAR for May 2026 showed Resident 81 received 240 ml fluids from the dietary on 5/5/26 at 1800 hours. On 5/6/26 at 0901 hours, an interview and concurrent medical record review for Resident 81 were conducted with LVN 1. LVN 1 verified the above findings and stated Resident 81's dialysis access was a right upper chest (RUC) Permacath. LVN 1 stated a bruit and thrill would not be assessed for the residents with a Permacath. LVN 1 further stated the documentation should be accurate. LVN 1 also verified that Resident 81 was transferred to an acute care hospital from the dialysis center on 5/5/26, and had not returned to the facility. LVN 1 further confirmed the MAR dated 5/5/26 at 1800 hours, showed the resident received 240 mL of fluids from the dietary. LVN 1 stated the resident did not return to the facility on 5/5/26 at 1800 hours, and the documentation was inaccurate. On 5/6/26 at 1430 hours, an interview with the Administrator, DON, Clinical Resource Nurse, and Dietary Resource was conducted. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource acknowledged findings.

Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for two of three medication carts (Medication Carts A and B); and two of 32 final sampled residents (Residents 132 and 164). * The facility failed to ensure safe medication labeling practices was in accordance with the accepted professional standards when the opened inhaler mouthpieces and nasal spray bottles were not properly labeled with sufficient information to clearly identify the specific resident for Resident 192 in Medication Cart A, and Residents 67, 117, and 158 in Medication Cart B. These failures had to potential to cause medication errors and preventable infections from cross-contamination from other residents if accidently mixed up with other residents' similar or same drugs. * The facility failed to ensure the two medication cups of ammonium lactate cream (used to hydrate, soften, and exfoliate dry, rough, and scaly skin conditions) were not left on Resident 164's bedside table unattended. This failure posed the risk for unauthorized individuals to have access to the medications. * The facility failed to ensure the Neosporin (antibiotic) ointment was not left in Resident 132's overbed table at bedside. This failure posed the risk for unauthorized individuals to have access to the medications.Findings: 1. Review of the facility's P&P titled Medication Storage and Labeling reviewed on 4/10/26, showed it is the policy of this facility is all drugs will be labeled and stored in a manner consistent. federal and state regulations, and to enhance accurate and safe medication administration by the facility staff. a. On 5/4/25 at 1532 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 6. When Medication Cart A was inspected, Resident 192 had one opened carton of azelastine nasal solution (over-the-counter antihistamine spray used to treat allergy symptoms like sneezing, itchy or runny nose, and nasal congestion) and one opened carton of ipratropium nasal solution (an anticholinergic medication used to treat a runny nose). Both the azelastine and ipratropium nasal spray bottles were observed unlabeled without resident-specific information. LVN 6 verified the two unlabeled nasal spray bottles was for Resident 192. LVN 6 stated the medication containers were to be labeled in case it falls out of the opened medication cartons. b. On 5/4/25 at 1543 hours, an observation of Medication Cart B and concurrent interview was conducted with RN 2. When Medication Cart B was inspected and showed the following: - Resident 158 had one opened carton of budesonide-formoterol (breathing treatment) inhaler; - Resident 117 had one opened carton of Tudorza Pressair (breathing treatment) inhaler; and - Resident 67 had one opened carton of azelastine (anti-allergy medication) nasal solution. Further review of Medication Cart B showed Resident 158's budesonide-formoterol inhaler mouthpiece, Resident 117's Tudorza Pressair inhaler mouthpiece, and Resident 67's azelastine nasal solution bottle were observed unlabeled without resident-specific information. RN 2 verified the above unlabeled inhaler mouthpieces and the unlabeled nasal spray bottles. RN 2 stated the inhaler mouthpieces and nasal spray bottle were to be labeled with the resident's information to make sure it was administered to the right resident. On 5/6/26 at 1345 hours, an interview was conducted with the DON. The DON acknowledged the concern of medications getting mixed up. The DON stated this could result medication errors. The DON stated for the infection control outcome, obviously, spread disease among the residents. 2. Review of the facility's P&P titled Medication Storage and Labeling(undated) showed the following: - storage of non-legend (over the counter drugs) drugs at bedside shall meet the following conditions: the manner of storage shall prevent access by other residents, the facility shall record in the resident health record the bedside medications used by the resident and the quantity of each drug supplied to the resident for bedside storage shall be recorded in the health record each time the drug is supplied; and - residents who own over the counter medications are kept in original containers and labeled with the resident's name and room number. On 5/4/26 at 0809 hours, an observation was conducted for Resident 164. Resident 164 was observed lying in bed. Two medication cups of white cream was observed inside the open bedside table drawer. On 5/4/25 at 0829 hours, a follow-up observation, interview and concurrent medical record review for Resident 164 was conducted with LVN 3. LVN 3 verified the two medication cups of white cream was ammonium lactate cream and it was used for Resident 164's xerosis. Medical record review for Resident 164 was initiated on 5/3/26. Resident 164 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 164's MDS annual assessment dated [DATE], showed Resident 164's Cognitive Skills for Daily Decision Making was severely impaired. Review of Resident 164's Order Summary Report showed the following physician's order dated 4/29/26, to apply 12% of ammonium lactate cream to general body every day shift for xerosis (abnormally dry, rough and scaly skin caused by lack of moisture in the skin's top layer). Further review of Resident 164's Order Summary Report failed to show a physician's order to self-administer ammonium lactate cream, nor to keep the ammonium lactate cream at the bedside. On 5/4/26 at 0854 hours, an interview and medical record review for Resident 164 was conducted with LVN 2. LVN 2 verified there was no physician's order to self-administer the ammonium lactate cream, nor to keep the ammonium lactate cream at the resident's bedside. LVN 2 stated no medication should be at the resident's bedside table. LVN 2 further stated it would pose a risk for other residents or visitor to take the medication. On 5/6/26 at 1024 hours, an interview was conducted with the DON. The DON stated no medication should be at the resident's bedside due to the risk for other residents to take the medication and self-administer. The DON acknowledged the above findings. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed about the medication found at bedside and acknowledged the findings. 3. Review of the facility's P&P titled Medication Storage and Labeling (undated) showed the following: - storage of non-legend (over the counter drugs) drugs at bedside shall meet the following conditions: the manner of storage shall prevent access by other residents, the facility shall record in the resident health record the bedside medications used by the resident and the quantity of each drug supplied to the resident for bedside storage shall be recorded in the health record each time the drug is supplied; and - residents who own over the counter medications are kept in original containers and labeled with the resident's name and room number. On 5/3/26 at 830 hours, during the initial tour of the facility, Resident 132 was observed with Neosporin ointment on top of the overbed table. Resident 132 stated the nurse gave the medication for Resident 132 to keep. Medical record review for Resident 132 was initiated on 5/4/26. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's H&P dated 4/12/26, showed Resident 132 had the capacity to understand and make decisions. Review of Resident 132s Order Summary Report dated 5/6/26, failed to show a physician's order for Neosporin ointment use. Further review of Resident 132's medical record failed to show the self- administration assessment or care plan for the use of Neosporin ointment. On 5/3/26 at 1050 hours, an observation for Resident 132 and concurrent interview was conducted with CNA 6. Resident 132 was observed with the Neosporin ointment on her hand and Resident 132 stated she did not want the medication to be touched. CNA 6 verified the presence of Neosporin ointment at Resident 132's bedside. CNA 6 stated, I did not realize she had that. On 5/3/26 at 1052 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified the presence of Neosporin ointment at Resident 132's bedside. RN 2 stated no resident should have any medication at the bedside unless they were assessed for self-administration and care planned. On 5/6/26 at 1615 hours, an interview with the Administrator and DON was conducted. The Administrator and the DON were informed regarding Resident 132's Neosporin ointment at bedside. The Administrator and DON acknowledged the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for one nonsampled resident (Resident 77). * The facility failed to ensure Resident 77's call light was answered in a timely manner. This failure had a potential for the resident's need to not be met as the call light was not answered timely and negatively affected the resident's well-being.Findings: Review of the facility's P&P titled Call Light dated 5/2007 showed call light is used to provide the resident a means of communication with nursing staff and to answer the light within a reasonable time, turn off the call light, listen to the resident's request or need. On 5/4/23 at 0914 hours, an observation for Room C was conducted. Room C was observed with a call light on. Multiple staff were observed passing by Room C, walked through the hallway and did not respond to Room C's call light. A minimal sound could be heard from the activated call light in the call light panel at Nurses' Station A with the staff coming in and out of Nurse Station A. On 5/4/26 at 0918 hours, a follow-up observation for Room C was conducted. Housekeeping 1 was observed by the doorway of Room C, donned a gown and went inside Room C. Room C call light remained lit. On 5/4/26 at 0919 hours, a follow-up observation was conducted of Nurses Station A. A facility staff including COTA 1 were observed going to Nurses Station A, then would pass by Room C without responding to the call light in Room C. On 5/4/26 at 0923 hours, AIT 1 went inside Room C and responded to the call light. On 5/4/25 at 0955 hours, an interview was conducted with Housekeeping 1. Housekeeping 1 verified the call light was on in Room C. Housekeeping 1 was asked if she was supposed to answer the call light activated by the residents, Housekeeping 1 responded, no, only to clean. On 5/4/26 at 0957 hours, an interview was conducted with CNA 6. CNA 6 stated she would answer the call light if she passed by and sees it, even if it was not her resident. CNA 6 also stated there was a notification by the nurses' station if a call light was activated. On 5/4/26 at 1157 hours, an interview was conducted with COTA 1. COTA 1 was asked who would respond to the call lights, COTA 1 stated, usually all staff would respond. COTA 1 further stated he remembered going to Nurses Station A and passed by Room C but did not look or see the call light was on. On 5/4/26 at 1550 hours, an interview and concurrent facility record review was conducted with the Administrator. The Administrator showed the electronic gadgets used by the facility to monitor the activated call light and showed as follows:- call light system monitor gadget attached to the medication nurse laptop, on the facility's medication carts;- a monitor screen by the nurse station showing an activated call light, and- the call light station on each nurse's station - lights up the activated call light location with a sound. Review of the call light log from 0900 to 0930 hours was conducted with the Administrator. The log showed Room C's call light was activated at 0914 hours, turned off, immediately reactivated, and then turned off at 0923 hours. The Administrator was made aware the call light log from 0900 hours to 0930 hours for Room C's call light was consistent with the observation. The Administrator was informed no staff were observed entering the room prior to 0918 hours, when Housekeeping 1 entered Room C to begin cleaning and eventually, the call light was turned off at 0923 hours by AIT 1. On 5/6/26 at 1338 hours, an interview was conducted with Resident 77 inside his room. Resident 77 was asked how he feels about the call light use and staff responses. Resident 77 stated it takes the staff a long time to respond and they think that I'm crazy, they come and they turn off the light, then they don't come back. Resident 77 stated he would need assistance in cleaning himself up, sometimes the tv won't turn on the right channel, and sometimes he would walk to the nurse's station to ask for coffee. Resident further stated, it's really not good, I feel bad calling, but I need help. Medical record review for Resident 77 was initiated on 5/6/26. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's MDS assessment dated [DATE], showed a BIMS score of 12 (moderately impaired cognition). Review of Resident 77's Care Plan Report showed the following focused problems: - dated 2/7/26, for ADL Self-care Performance Deficit. The interventions included to encourage Resident 77 to use call light for assistance, and the transfer from chair to bed to chair and toilet required one person assist; and- dated 2/7/26, for risk to falls and injuries. The intervention included to ensure call light is within reach and encourage to use to call for assistance as needed. On 5/6/26 at 1615 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON were informed Resident 77's not being answered in a timely manner. The Administrator and DON acknowledged the findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services was provided for one of four residents (Resident 85) observed for medication pass and the proper accounting procedures of controlled substances was provided for two residents (Residents 90 and 193) reviewed for controlled substances reconciliation. * The facility failed to ensure medication for Resident 85 was administered in accordance with the prescriber's orders. This failure resulted in a medication error and had the potential to negatively affect the resident's health conditions. * The facility failed to ensure the RX Number was documented on the Controlled Substances Log for the bottles of morphine sulfate liquid solutions for Residents 90 and 193 which were stored in Medication Cart B. This failure had the potential for the facility to be unable to trace the movement of the scheduled drugs and identify discrepancies, prevent diversion, and ensure compliance with government regulations. Findings: 1. Review of the facility's P&P titled Guidelines for Medication Administration reviewed on 4/10/26, showed the following guidelines will be observed in the administration of all medications. Under the section for Procedure showed, to observe the five rights of administering the medication.The right dose. Review of Resident 85's Order Summary Report showed a physician's order dated 3/14/26, to give one tablet of calcium carbonate (calcium supplement) 600 mg combined with cholecalciferol (vitamin D3) 10 mcg by mouth two times a day as a supplement. On 5/4/26 at 0830 hours, a medication administration observation for Resident 85 was conducted with LVN 8. LVN 8 prepared and administered to Resident 85 one tablet containing both calcium 600 mg and cholecalciferol (vitamin D3) 5 mcg. On 5/4/26 at 1137 hours, an interview and concurrent record review for Resident 85 was conducted with LVN 8. LVN 8 stated they administered to Resident 85 one tablet containing both calcium 600 mg and cholecalciferol 5 mcg. LVN 8 reviewed Resident 85's medical record and verified Resident 85 had a physician's orders for calcium carbonate 600 mg combined with cholecalciferol 10 mcg. LVN 8 stated Resident 85 was administered with calcium 600 mg with cholecalciferol 5 mcg instead of cholecalciferol 10 mcg as ordered by the physician. On 5/6/26 at 1150 hours, an interview was conducted with the DON. The DON stated the expectation for medication nurse was to verify the medication prior to the medication administration. 2. Review of the facility's P&P titled Q Shift Controlled Drug Reconciliation reviewed on 4/10/26, showed controlled drug quantities will be verified and reconciled at the change of each nursing shift. At the completion of each nursing shift the on-coming and off-going nurses will count and reconcile controlled drugs subject to regulations and/or facility polices for individual counts. Each nurse will sign that such counts on a form. On 5/5/26 at 1450 hours, an observation of Medication Cart B, record review of the Controlled Substances Log and concurrent interview was conducted with LVN 8. When the Medication Cart B was inspected, the blue book containing the Controlled Substances Log was missing the RX Number for the two bottles of liquid morphine sulfate (pain medication) solutions. One bottle was for Resident 90 (on page 217) and another bottle for Resident 193 (on page 197) which were stored in Medication Cart B. On 5/6/26 at 0958 hours, an interview and document review was conducted the DON. The DON verified pages 197 and 217 of the blue book containing the Controlled Substances Log were missing the RX Number on pages 197 and 217 for the liquid morphine sulfate solutions for Residents 90 and 193. The DON stated the incoming and outgoing medication nurses uses the blue book for reconciliation of the controlled substances. The DON stated the purpose of the RX Number was to identify the medication.

Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 107) reviewed for IV therapy, consistent with the professional standards of practice. * The facility failed to ensure Resident 107's IV tubing was correctly labeled. In addition, the facility failed to develop a care plan for the use of an IV antibiotic therapy cefepime (medication used to treat serious bacterial infection including urinary tract infection). These failures posed the risk for the resident to develop complications related to the IV therapy.Findings: 1. Review of the facility's P&P titled Antibiotic Infusion Guideline (undated) showed closely observe and monitor the resident during the first and second doses for any sign of allergic reactions. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 8/2019 showed the baseline care plan will include minimum healthcare information necessary to properly care for a resident. During the initial tour of the facility on 5/3/26 at 0938 hours, Resident 107 was observed in bed awake, with peripheral IV line to right hand area, and was dated 4/26 (meaning 4/26/26). The IV bag has a date of 5/2/26, however, there was no time and initial of the nurse who hung the IV. In addition, the IV tubing had no label, was undated, no time when it was changed, and no initial of the nurse. On 5/3/26 at 0945 hours, an observation and concurrent interview were conducted with the DON. The DON verified the above findings and stated that when a licensed nurse hangs an IV medication, the nurse was required to label the IV bag and tubing with the date, time, and initials to prevent infection. Medical record review for Resident 107 was initiated on 5/3/26. Resident 107 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 107's MDS quarterly assessment dated [DATE], Resident 107's BIMS summary score of 2 (meaning severe cognitive impairment). Review of Resident 107's Order Summary Report showed a physician's order dated 4/27/26, for cefepime one gram, to give intravenously one time a day for urinary tract infection until 5/7/26. Review of Resident 107's care plan failed to show a care plan problem was developed to address the risk associated with the use of cefepime IV antibiotic. Further review of Resident 107's medical record failed to show a documentation of the side effect of the cefepime IV antibiotic was monitored. On 5/4/26 at 1131 hours, an interview and medical record review was conducted with LVN 2. LVN 2 stated a care plan should have been developed when the physician ordered the cefepime medication to monitor the side effect of the medication. LVN 2 verified the above findings. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of three final sampled residents (Resident 164) reviewed for enteral feeding care. * The facility failed to ensure Residents 164 was administered the total amount of the enteral feeding as ordered by the physician. This failure posed the risk of developing complications related to the enteral feeding.Findings: 1. Review of the facility's P&P titled Enteral Feeding Administration revised 5/2020 showed it is the policy of this facility to administer enteral feeding at a constant controlled infusion rate per physician's order. Intermittent delivery schedules are recommended. Medical record review for Resident 164 was initiated on 5/3/26. Resident 164 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident MDS annual assessment dated [DATE], showed Resident 164's Cognitive Skills for Daily Decision Making severely impaired. Review of Resident 164's Order Summary Report showed a physician's order dated 4/29/26, to administer Glucerna 1.2 (an enteral feeding formula) at 60 ml per hour for 20 hours or until volume limit is completed to provide 1200 ml/1440 kcal via GT, restart feeding at 1600 hours. On 5/3/26 at 1010 hours, Resident 164 was observed in bed with a GT feeding hanging and connecting via a feeding pump. The feeding formula was full, with a label showing Glucerna 1.2 (a full bag had a total of 1500 ml) and dated as administered from 5/3/26 at 0630 hours for 60 ml per hour for 20 hours. The feeding bag was still full and running. On 5/3/26 at 1027 hours, an observation for Resident 164 and concurrent interview was conducted with LVN 1. LVN 1 verified the above findings. The bag of Glucerna 1.2 (enteral feeding formula) connected to the GT pump machine was full and the GT pump machine was running. When asked to show the total amount of feeding given to Resident 164, LVN 1 showed the total amount fed was 1850 ml (order was 1200 ml for 20 hours). LVN 1 stated this was incorrect and further stated Resident 164 did not get the total amount of the GT feeding. On 5/6/26 at 1024 hours, an interview was conducted with the DON. The DON verified the above findings. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for one of five final sampled residents (Resident 53) reviewed for nutrition. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions and the physician and resident and/or their representative were notified when Resident 53's had unplanned significant weight loss of 16 lbs. (8.04%) between 4/4 and 5/2/26. In addition, Resident 53's resident-centered care plan was not revised to address Resident 53's severe weight loss of 16 lbs. These failures had the potential for Residents 53 to not receive the necessary intervention to prevent further weight loss.Findings: Review of the facility's P&P titled Nutrition Status Management revised on 4/2025 showed it is the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and other available data, unless the resident's clinical condition demonstrates that this is not possible. The P&P showed the following sections:1. Assessment showed each resident is to be weighed upon admission, then weekly weights for four (4) weeks and monthly weight thereafter. The weight will be entered directly into the electronic health record. (POC/PCC(Point of Care/Point ClickCare), and monthly weights are to be taken starting the first day of the month. Monthly and weekly weights are reviewed by the DNS (Director of Nursing Services)/designee;2. Dietary Evaluation showed if there is a significant change in the resident's condition related to weight or nutrition, the Registered Dietician (RD) will make recommendation to offer additional nutrition to those residents including all high-risk residents. Options include, but are not limited to, fortified cereal, large portions, between meal snacks and commercial nutritional supplements.3. Clinical Evaluation showed any weight that varies from the previous reporting period by more than 5% in 30 days and 10% in 180 days will be evaluated by the Interdisciplinary Team (IDT) to determine the cause of weight loss/gain and intervention required, the nurse will notify the physician, family and/or resident of the weight loss/gain with interventions, and any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly with the weight entered into POC/PCC(Point of Care/Point ClickCare). Weekly weights will be reviewed by the Registered Dietitian (RD)/designee. Medical record review for Resident 53 was initiated on 5/3/26. Resident 53 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Residents 53's MDS assessment dated [DATE], showed Resident 53's BIMS summary score was 9 (moderate cognitive impairment). Review of Resident 53's Weight Summary showed the following dates and weights:- dated 4/4/26, 199 lbs;- dated 4/13/26, 195 lbs; a weight loss of 4 lbs from 4/4/26;- dated 4/18/26, 192 lbs; a weight loss of 7 lbs from 4/4/26;- dated 4/25/26, 188 lbs, a weight loss of 11 lbs or 5.5% from 4/4/26; and- dated 5/2/26, 183 lbs, a weight loss of 16 lbs or 8.04% from 4/4/26. Review of Resident 53's Order Summary report showed a physician's order dated 4/13/26, for a regular soft and bite sized diet, with thin liquid. Review of Resident 53's Nutrition Evaluation note dated 4/10/26, showed Resident 53's goal was to maintain the weight of 189 to 199 lbs. Review of Resident 53's medical record failed to show a change of condition was documented, the physician and resident/or responsible party was informed when the Resident 53 has a weight loss of 16 lbs. or 8.04% in 28 days. Further review of Resident 53's medical record failed to show a care plan was initiated to address Resident 53's weight loss. On 5/3/26 at 0923 hours, an observation and concurrent interview were conducted with Resident 53. Resident 53 was observed in bed with a breakfast tray on the overbed table. Resident 53 stated that she did not want to eat breakfast and only wanted to drink her glass of milk. On 5/4/26 at 0929 hours, an observation and concurrent interview for Resident 53 was conducted with CNA 10. Resident 53 was observed in bed holding her glass of milk and only wanted to eat the bread. CNA 10 stated Resident 53 did not like the food in the facility and only wants to eat the bread with cheese and soup. On 5/5/26 at 1008 hours, an interview for Resident 53 was conducted with RD 2. RD 2 was asked if she was aware of Resident 53's 16 lbs weight loss in 28 days. RD 2 stated she was only made aware of Resident 53's weight loss today. RD 2 further stated that she was still in training and there was an RD who was doing the RD/Nutritional assessment remotely. On 5/5/26 at 1015 hours, an interview and concurrent medical record review for Resident 53 was conducted with LVN 2. LVN 2 verified and stated when a resident had 16 lbs weight loss, an eINTERACT change of condition should have been made and communicated to the resident's physician and responsible party. LVN 2 further stated the Registered Dietitian (RD) should have assessed the resident's weight loss and a care plan should have been implemented. On 5/6/26 at 1024 hours, an interview was conducted with the DON. The DON was asked regarding significant weight loss of a resident, stated a 5 lbs and above weight loss was a significant weight loss. The DON stated a change of condition documentation should have been done, and the resident's physician and responsible party should have been notified. The DON stated the RD should have assessed Resident 53 and a care plan should have been implemented for weight loss. The DON further stated a change of condition for the weight loss should have been done since last week. The DON acknowledged the above findings. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for two of 32 final sampled residents (Residents 53 and 98) was revised to reflect the resident's current care needs and interventions. * Resident 53's care plan was not updated to reflect the resident's care needs and interventions. * Resident 98's plan of care was not revised to reflect resident's care needs and interventions. These failures posed the risk of not providing Residents 53 and 98 with individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 8/2019 show it is the policy of this facility that the Interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.- the resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment. 1. Medical record review for Resident 53 was initiated on 5/3/26. Resident 53 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Residents 53's MDS 5-day PPS (prospective payment system - a Medicare payment method where providers are paid a set amount based on diagnosis, rather than the cost of treatment) assessment dated [DATE], showed Resident 53's BIMS summary score was 9 (moderate cognitive impairment). Review of Resident 53's Care Plan Report failed to show that plan of care for the resident was reviewed and updated. On 5/5/26 at 0954 hours, an interview and concurrent medical record review for Resident 53 was conducted with LVN 2. LVN 2 verified resident's care plan was not revised nor updated on target date of 5/1/26. 2. Medical record review for Resident 98 was initiated on 5/3/26. Resident 98 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Residents 98's MDS annual assessment dated [DATE], showed Resident 98's BIMS summary score was 15 (meaning cognitively intact). Review of Resident 98's Care Plan Report failed to show that plan of care for the resident was reviewed and updated. On 5/4/26 at 1316 hours, an interview and concurrent medical record review for Resident 98 was conducted with RN 1. RN 1 verified the resident's care plan was not revised nor updated on target date of 4/29/26. On 5/6/26 at 1024 hours, an interview was conducted with the DON. The DON was asked regarding updating the care plan. The DON stated the care plan were the guide of the facility in providing care to the residents and need to be updated and revised if the intervention was effective or not. The DON verified that Residents 53 and 98 care plan was not updated nor revised. On 5/6/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive, person-centered care plan was developed and implemented for four of 32 final sampled residents (Residents 1, 12, 13, and 94). * The facility failed to develop a comprehensive, person- focused care plan addressing Resident 1's noncompliance with the prescribed dietary regimen. * The facility failed to develop the comprehensive, person-centered care plan to address Resident 12's hemodialysis treatments, fluid restrictions, hemodialysis access monitoring, and nutrition status. * The facility failed to develop a care plan to address Resident 13's use of a low air loss mattress (LAL). * The failed to develop a care plan to address and support Resident 94's care needs related the resident's diagnosis of dementia. These failures had the potential to result in inconsistent, inappropriate or non-individualized care for Residents 1, 12, 13, and 94.Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan dated April 2025 showed it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 1. On 5/3/26 at 0929 hours, Resident 13 was observed lying in bed on the LAL mattress. Medical record review was initiated on 5/4/26. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 3/16/26, for use of a LAL mattress for skin maintenance, including monitoring proper function and setting every shift. Setting to be based on the resident's weight then comfort. On 5/4/26 at 1015 hours, an interview and concurrent medical record review for Resident 13 was conducted with the MDS Assistant. The MDS Assistant verified there was no care plan addressing the resident's LAL mattress use on or after 3/16/26. On 5/6/26 at 1445 hours, an interview with the DON and Administrator was conducted. The DON and Administrator were informed and acknowledged the above findings. 2. On 5/3/26 at 910 hours, during the facility tour, Resident 1's room was observed with two small unopened bags of chips on the windowsill and an open box containing small packs of chips inside Resident 1's open closet. Further review of label information of Doritos Nacho Cheese tortilla chips one ounce bag contained 170 mg of sodium, 7 % of daily value and Doritos Cool Ranch flavor tortilla chips showed a one-ounce bag contained 160 mg of sodium, 7 % of daily value. Medical record review for Resident 1 was initiated on 5/4/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/6/25, showed Resident 1 could make needs known and medical decisions at this time. Review of Resident 1's nutrition care plan showed the following interventions: - dated 3/14/26, to monitor and honor residents' rights to make personal dietary choices and provide dietary education as needed; and - dated 3/14/26, to monitor and report to MD as needed for any signs and symptoms of decreased appetite. Review of Resident 1's Order Summary Report dated 5/4/26, showed a physician's order dated 4/16/26, for a NAS (No Added Salt) regular diet, level seven texture, thin liquids. On 5/4/26 at 0815 hours, an interview was conducted with CNA 9. CNA 9 stated Resident 1 had many bags of chips and soda brought in by a friend. CNA 9 further stated he fed the resident chips when requested. On 5/4/26 at 9025 hours, an interview and concurrent medical record review was conducted with RD 2. RD 2 reviewed Resident 1's diet orders and acknowledged Resident 1's consistent chip consumption was not addressed in the Nutrition Care Plan and stated, I will follow up. On 5/4/26 at 1207 hours, an interview and concurrent medical record review was conducted with Case Manager 2. Case Manager 2 reviewed Resident 1's medical record and verified Resident 1's frequent eating of chips was not addressed in the resident's care plan, despite the NAS diet. On 5/6/26 at 1615 hours, an interview with the Administrator and DON was conducted. The Administrator and DON were informed and acknowledged the findings. 3. On 5/3/26 at 0923 hours, an interview was conducted with Resident 12. Resident 12 stated he was on fluid restrictions and received hemodialysis treatments every Tuesday, Thursday, and Saturdays. Resident 12 was able to show his hemodialysis access on the left arm. Medical record review for Resident 12 was initiated on 5/3/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 4/26/26, showed Resident 12 had the capacity to make medical decisions. Review of Resident 12's Order Summary Report dated 5/5/26, showed the following physician's orders: - dated 4/26/26, to assess Resident 12's left arteriovenous (AV) fistula shunt (a surgically created connection between and artery and vein for hemodialysis treatments) site for bruit (a turbulent whooshing sound heard with a stethoscope over a blood vessel) and thrill (the palpable vibration felt with your fingers in the same location), every shift; and to document + (positive) or – (negative) for the presence of bruit and thrill. To call the physician for absences. - dated 4/26/26, to assess Resident 12's shunt/dialysis site every shift and document the following: C= clear, T= tenderness, R= redness, B= bleeding, every shift. - dated 4/29/26, for Resident 12 to receive the hemodialysis treatments every Tuesday, Thursday, and Saturdays with Dialysis Center A. - dated 4/29/26, for Resident 12 to have a total fluid restriction of 1500 ml per day from dietary and nursing. The total nursing fluids of 420 ml per day: for the 0700 to 1500 hours shift = 160 ml, 1500 to 2300 hours shift= 160 ml, and 2300 to 0700 hours shift = 100 ml, every shift. - dated 4/29/26, total fluid restriction of 1500 ml per day. 1080 ml dietary fluid per day. Breakfast = 260 ml, Lunch = 360 ml, and Dinner = 360 ml, after meals. - dated 4/29/26, for Resident 12 to receive a regular renal diet- level 7 texture, thin liquids-level 0 consistency. Review of Resident 12's plan of care failed to show a care plan was formulated to address Resident 12's nutrition, fluid restrictions, hemodialysis treatment, and the monitoring of Resident 12's hemodialysis access. On 5/5/26 at 1030 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 6. LVN 6 stated Resident 12 received hemodialysis treatments every Tuesdays, Thursday, and Saturdays. LVN 6 stated Resident 12 was on fluid restrictions of 1500 ml per day. LVN 6 reviewed Resident 12's medical record and verified the above findings. On 5/6/26 at 1049 hours, an interview was conducted with the DON. The DON stated the purpose of the comprehensive care plans was to guide the provisions of the resident's care while the resident was at the facility. The DON stated upon admission to the facility, the admitting nurse would initiate the care plan, and the care plan would be revised quarterly and as needed. The DON stated the care plans should be individualized for each resident The DON further stated for a resident receiving hemodialysis treatments, there should be a care plan problem to address the residents hemodialysis treatments, hemodialysis access site monitoring, nutritional status, and fluid restrictions. On 5/6/26 at 1444 hours, an interview was conducted with the Administrator, DON, and Clinical Resource Nurse. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Dementia Care Policy/ Procedure revised 01/2021 showed develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment and on quarterly and annual basis, the IDT shall review and revise care plans that have not been effective and/or when the resident has a change in condition. Medical record review for Resident 94 was initiated on 5/3/26. Resident 94 was admitted to the facility on [DATE]. Review of Resident 94's H&P examination dated 12/26/25, showed Resident 94 had no capacity to make medical decisions and diagnosis of dementia. Review of Resident 94's Care Plan Report (undated) showed no care plan addressing dementia or dementia-related needs had been developed for the resident. On 5/3/26 at 1056 hours, a telephone interview was conducted with Family 1. Family 1 stated Resident 94 had dementia and expressed concerns about communication breakdown among the facility staff regarding how to care for the resident. On 5/5/26 at 1409 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 94 was forgetful and did not exhibit negative behaviors. CNA 5 further stated she communicated with Resident 94 calmly while providing care and allowed him plenty of time to respond. On 5/5/26 at 1451 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated care planning began upon admission and should be reviewed and revised quarterly and as needed. RN 1 verified Resident 94 did not have a person-centered care plan with measurable goals and interventions addressing dementia care needs since the resident's admission on [DATE]. RN 1 stated Resident 94 was scheduled for a care plan meeting in March 2026 but verified the only care plan meeting held was on 12/20/25. On 5/6/26 at 1458 hours, an interview was conducted with the DON, Clinical Resource, and Administrator. The DON, Clinical Resource, and Administrator were informed and acknowledged the findings above.

Based on interview, medical record review, and document review, the facility failed to ensure the PASRR Level 1 screening was accurate for one of four final sampled residents (Resident 94) reviewed for PASRR. * Resident 94 had diagnosis of psychosis, however, the PASRR Level 1 screening showed Resident 94 had no diagnosis of serious mental illness and had no psychotropic medication. This failure had the potential risk for Resident 94 not to receive the necessary care and services due to inaccurate assessment.Findings: Review of PASRR screening background statement showed the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) and 42 Code of Federal Regulations Sections 483.100 through-483.138 requires that each individual, including, but not limited to, an applicant and resident, regardless of payment source, applying for admission to, or residing in, a Medicaid-certified Nursing Facility (NF) be screened and evaluated for serious mental illness and intellectual disability, developmental disability and related condition(s). Federal law prohibits payment for Nursing Facility services until the PASRR screening has been completed. Medical record review for Resident 94 was initiated on 5/3/26. Resident 94 was admitted to the facility on [DATE]. Review of Resident 94's H&P examination dated 12/26/25, showed Resident 94 had no capacity to make medical decisions. Review of Resident 94's PASRR Level 1 screening dated 12/17/25, showed Resident 94 had no diagnosis of mental illness and no prescribed psychotropic medications. The form further showed the Level 1 screening was negative and a Level 2 evaluation was not required because the resident did not have a serious mental illness. Review of Resident 94's Face Sheet dated 5/5/26, showed under the Diagnosis Information section, the resident had unspecified psychosis not due to a substance or known physiological condition. Review of Resident 94's Order Summary Report dated 5/5/26, showed a physician's order dated 12/24/25, to administer Seroquel (antipsychotic) 25 mg one tablet by mouth two times a day for psychosis as manifested by combative behavior. On 5/4/26 at 1128 hours, an interview and concurrent medical record review for Resident 94 was conducted with the MDS Assistant. The MDS Assistant verified the above findings and stated the Level 1 PASSR screening was inaccurate and a resident review should have been completed because Resident 94 had a serious mental illness diagnosis and was prescribed a psychotropic medication. On 5/6/26 at 1458 hours, an interview was conducted with the DON, Clinical Resource, and Administrator. The DON, Clinical Resource, and Administrator were informed and acknowledged the findings above.

Based on interview, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the Office of the State Long-Term Care Ombudsman for one of the two residents (Resident 7) who were transferred to the acute care hospital. * The facility failed to ensure copy of the transfer discharge notification was sent to the Ombudsman when Resident 7 was transferred to the acute care hospital on 2/24/26. This failure had the potential for the resident to not receive additional protection when the residents was being inappropriately transferred or discharged .Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised April 2025 showed the facility shall send a copy of the notice to the State Long-Term Care Ombudsman. The notice shall be made at least 30 days before the resident transferred or discharged or as soon as practicable before transfer or discharge when:- The safety or health of individuals in the facility would be endangered;- The resident's health improves to allow a more immediate transfer or discharge;- An immediate transfer or discharge is required by the resident's urgent need; or- A resident has not resided in the facility for 30 days. Closed medical record review for Resident 7 was initiated on 4/23/26. Resident 7 was admitted to the facility on [DATE], and transferred to the acute care hospital on 2/24/26. Review of Resident 7's Physician Order Summary showed a physician's order dated 2/24/26, to transfer Resident 7 to the acute care hospital for further evaluation due to altered mental status and facial drooping and bed hold for seven days if admitted . Review of Resident 7's Notice of Proposed Transfer/Discharge form showed Resident 7's name and other information on the form was not filled out. Further review of Resident 7's medical record failed to show documented evidence the Ombudsman was notified of Resident 7's transfer to the acute care hospital. On 5/5/26 at 1042 hours, an interview and concurrent closed medical record review for Resident 7 was conducted with the MRD. The MRD reviewed Resident 7's Notice of Proposed Transfer/Discharge form and verified the form was not completed. The MRD stated when transferring a resident, the charge nurse had to fill out the Notice of Proposed Transfer/Discharge form and fax the form to the Ombudsman. The MRD verified the notice was not sent to Ombudsman. The MRD further stated the facility should have sent the notice so the Ombudsman would have a record of the resident's being sent to the acute care hospital. On 5/6/26 at 1430 hours, an interview was conducted with the DON and Administrator. The DON and the Administrator was informed and acknowledged above findings.

Based on observation, interview, and medical record review, the facility failed to maintain a safe, clean, and homelike environment for two of 32 final sampled residents (Residents 26 and 48) and one nonsampled resident (Resident 117). * Resident 26 resided in Room D. The wall behind Resident 26's bed was observed in disrepair with black streak marks on the wall and chipped paint on the wall and wall trimmings. In addition, Resident 26's ceiling was observed with chipped and peeling paint. * Resident 48 resided in Room E. The wall behind Resident 48's head of bed was observed in disrepair with chipped paint and cracked wall trims. * The walls and bathroom door in Resident 117's room were observed in disrepair. These failures had the potential to negatively impact on the residents' quality of life. Findings: 1. Medical record review for Resident 26 was initiated on 5/3/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/3/26 at 0900 hours, Resident 26 was observed lying in bed in Room D. A white thin panel was observed hanging from the ceiling to the right of Resident 26's bed. A cord was observed between the thin panel and connected to the electrical power strip. The ceiling was observed with chipped and peeled paint. Additionally, the wall behind Resident 26's head of bed was observed with black vertical streak marks and chipped paint on the wall and wall trimming. On 5/5/26 at 1011 hours, an interview and concurrent observation of Room D was conducted with LVN 6. LVN 6 verified the above findings and stated the ceiling needed to be painted and she did not know what the black streak marks were. LVN 6 further stated the residents should have a homelike environment in their rooms. On 5/6/26 at 0930 hours, an interview was conducted with Resident 26. Resident 26 stated after looking at the ceiling her visitor asked her if the facility was falling apart. 2. Medical record review for Resident 48 was initiated on 5/3/26. Resident 48 was admitted to the facility on [DATE]. On 5/5/26 at 1419 hours, an interview and concurrent observation was conducted with Resident 48 in Room E. Resident 48 was observed lying in bed. The wall behind Resident 48's head of bed was observed in disrepair with chipped wall trimmings and chipped/peeling paint on the wall. On 5/6/26 at 1010 hours, an interview and concurrent observation of Room E was conducted with LVN 6. LVN 6 verified the above findings. On 5/6/26 at 1049 hours, an interview was conducted with the DON. The DON stated the facility should promote a homelike environment as much as possible. The DON stated the facility was in process of repairing rooms in need of repairs. On 5/6/26 at 1444 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Medical record review for Resident 117 was initiated on 5/6/26. Resident 117 was admitted to the facility on [DATE]. On 5/6/26 at 1055 hours, an observation and concurrent interview was conducted with Resident 117. Resident 117 was observed in her room (Room B) sitting in a wheelchair. The wall and bathroom door adjacent to Resident 117's bed was observed in disrepair, as evidenced by scratches and chipped paint. When Resident 117 was asked to describe the condition of her room, Resident 117 stated the entire room needed to be painted. On 5/6/26 at 1600 hours, an interview was conducted with the DON. The DON stated the facility was in the process of repairing the residents' rooms in need of repairs.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 32 final sampled residents (Resident 54) and one nonsampled resident (Resident 147). * The facility failed to ensure Resident 54 and 147's call light was within the resident's reach. This failure had the potential to negatively impact the residents' psychosocial well-being and cause delays in receiving the needed care.Findings: Review of the facility's P&P titled Call Light/Bell revised 5/2007 showed to leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. 1. Medical record review for Resident 54 was initiated on 5/3/26. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's MDS assessment dated [DATE], showed Resident 54 had a BIMS score of 2 (severe cognitive impairment). Furthermore, the MDS assessment showed Resident 54 had one side impairment on upper extremity. On 5/3/26 at 0828 hours, an observation was conducted for Resident 54. Resident 54 was observed seated in a wheelchair on the left side of the bed. The resident's call light button was observed on the left side of the bed. However, the call light was positioned on the right side of the resident's wheelchair and not within Resident 54's reach. On 5/3/26 at 0840 hours, an observation for Resident 54 and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 54 had right upper extremity mobility impairment and the call light button was too far for Resident 54 to reach. CNA 1 verified the call light was placed on the bed where Resident 54 could not reach using his left arm. 2. Medical record review for Resident 147 was initiated on 5/3/26. Resident 147 was admitted to the facility on [DATE]. Review of Resident 147's MDS assessment dated [DATE], showed Resident 147 had a BIMS score of 6 (severe cognitive impairment). On 5/3/26 at 0916 hours, an observation and concurrent interview was conducted with Resident 147. Resident 147's call light button was observed hanging on the left side of the headboard behind Resident 147. Resident 147 stated he could not locate his call light button. On 5/3/26 at 0925 hours, CNA 2 was called to Resident 147's room and an observation and concurrent interview was conducted with CNA 2. CNA 2 stated Resident 147 would call for help by pressing his call light button. CNA 2 verified the call light button was hanging on the left side of the headboard and Resident 147 could not reach the call light button. On 5/6/26 at 1458 hours, the DON, Clinical Resource, and Administrator were informed and acknowledged the findings above.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three sampled residents (Residents 1 and 3) were free from abuse. * Resident 1 was found with a bed sheet tightly wrapped around his body to purposely restrict movement of his arms and preventing him from eating breakfast. * Resident 3 was found on two separate occasions with her gown tied in a knot to purposely restrict access to her body. These failures had the potential to cause serious injury and physical and/or psychosocial harm to the residents. On 2/20/2020 at 0[AGE]9 hours, the facility was informed the IJ was identified as evidenced by the following deficient practices: * The facility failed to thoroughly investigate and report the abuse when Residents 1 and 3 were found physically restrained. Resident 1 had a blanket wrapped tightly (like a mummy) around his upper shoulders, arms, and extending down to his thigh. Both Residents 1 and 3 had their hospital gowns tied to purposely restrict the residents' movement and access to their bodies. * The facility failed to protect the residents from further abuse when Resident 3 was observed a second time in bed with her gown tucked tightly underneath her body, restricting access to her body. On [DATE]20 at 1641 hours, the IJ was abated after the facility had implemented the following plan of corrective actions: * Initiated an investigation and suspended the identified staff pending the outcome of the investigation. * Interviewed all alert residents regarding abuse and restraints. * Conducted the head to toe assessments for Residents 1 and 3 and placed them on monitoring for adverse effects. * Conducted facility tour rounds on all shifts to ensure no residents were physically restricted. * In-service all staff on the facility's P&Ps regarding abuse and restraints The facility provided documented evidence which showed the staff, including the nursing, department management, maintenance, and housekeeping staff had been in-serviced on the facility's P&Ps for abuse and restraints. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against dated 11/28/17, showed each resident has the right to be free from abuse. The facility will provide oversight and monitoring to ensure staff deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. 1. Review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form which showed the facility had reported an allegation of physical abuse against Resident 1. Resident 1 was found with the bed sheets tightly wrapped around his body restricting the resident's movement of his arms. On [DATE]20 at 1121 hours, an observation and concurrent interview with Resident 1 was conducted. Resident 1 was observed awake and lying in bed. Resident 1's gown was observed to be loose and could easily move all his extremities freely. Resident 1's upper and lower extremities were observed with no bruises or injuries. Resident 1 was asked if anyone had tied his gown around his legs before. Resident 1 stated he could not remember. Resident 1 was asked if anyone had tucked his bed linens tightly, restricting his movement. Resident 1 did not respond. Medical Record review for Resident 1 was initiated on [DATE]20. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had severely impaired cognition, required extensive one person assist for bed mobility (how resident moves in bed such as turning from side to side) and eating, and had no limitation in ROM functions on both upper and lower extremities. Review of Resident 1's eInteract Change in Condition Evaluation dated 2/15/2020, showed Resident 1 was found with his upper and lower extremities wrapped with a bed sheet. The document showed Resident 1 did not sustain any injuries from the incident. On [DATE]20 at 1504 hours, a telephone interview was conducted with LVN 2. LVN 2 verified he worked on 2/15/2020 during the day shift (0700-1500 hours). LVN 2 stated he was familiar with Resident 1's care. LVN 2 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. LVN 2 stated at around 0910 hours he went into Resident 1's room to administer Resident 1's injectable medication. LVN 2 stated he noticed Resident 1 was lying in bed a blanket was loosely draped over the resident's body. LVN 2 stated he observed the resident's breakfast had been placed on the overbed table; however, the bedside table was not within the resident's reach and his breakfast was untouched. LVN 2 stated he prepared to administer Resident 1's medication by removing the blanket and when he did, he found Resident 1 wrapped like a mummy in another white blanket. LVN 2 stated a white blanket was wrapped around Resident 1's body multiple times. LVN 2 stated Resident 1 was wrapped from his shoulders to just above Resident 1's knees and his arms were wrapped inside the blanket. LVN 2 stated Resident 1 could not move his arms. LVN 2 stated he asked Resident 1 if he could move. LVN 2 stated Resident 1 said he was hungry but could not reach his breakfast tray. LVN 2 said he tried to remove the blanket from Resident 1's left shoulder and but was it was hard to pull. LVN 2 stated he was able to partially free the resident left shoulder but had to ask for assistance from CNA 4. LVN 2 stated CNA 4 assisted him in unwrapping Resident 1 by turning the resident a few times and pulling at the blanket. LVN 2 added the blanket was pretty tight. LVN 2 stated after they had freed the resident from the tightly wrapped blanket, he and CNA 4 then found the end of Resident 1's hospital gown tied and knotted together around the back of the resident's legs, just above his knees. LVN 2 stated he performed a body assessment and found no obvious injuries, bruises or trauma. LVN 2 stated he immediately reported the incident to RN 1. LVN 2 stated RN 1 interviewed Resident 1 and overheard Resident 1 say a lady during the night had wrapped him around in a blanket. LVN 2 stated he notified Resident 1's primary physician and family member of the incident. On [DATE]20 at 1333 hours, an interview was conducted with CNA 4. CNA 4 verified she worked the day shift on 2/15/2020. CNA 4 stated she was familiar with Resident 1's care. CNA 4 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. CNA 4 stated she was called into Resident 1's room by LVN 2. CNA 4 stated she observed Resident 1 with a blanket tightly wrapped around his body. CNA 4 was asked what part of Resident 1's body was wrapped. CNA 4 stated the blanket was wrapped around Resident 1's shoulders, his arms and extended to just above his knees. CNA 4 described Resident 1 looked like he was rolled in the blanket. CNA 4 stated, she and LVN 2 had to roll Resident 1 several times in order to remove the blanket. CNA 4 stated once the blanket was removed, Resident 1 was observed with the ends of the gown tied securely around his legs and knotted in the back behind his lower thigh area. CNA 4 stated Resident 1 could not move at all. CNA 4 said she helped LVN 2 remove the knots from Resident 1's gown. On [DATE]20 at 1441 hours, an interview was conducted with RN 1. RN 1 verified she worked the day shift on 2/15/2020, as the RN Supervisor. RN 1 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. RN 1 stated LVN 2 reported he found Resident 1's arms, legs, and body were rolled into a blanket, which prevented the resident from feeding himself. RN 1 stated she asked Resident 1 a few questions and the resident stated the incident happened during the night by a female CNA. The resident had stated the CNA had wrapped him in a blanket. RN 1 stated Resident 1 did not know the CNA's name. RN 1 stated she called the Administrator and reported the incident. Review of the facility's assignment sheet dated 2/14/2020, showed CNA 1 was assigned to Resident 1 the night shift (2300 to 0700 hours) of 2/14/2020. On 2/20/2020 at 0532 hours, an interview was conducted with CNA 1. CNA 1 verified she worked the night shift on 2/14/2020. CNA 1 was asked about Resident 1's care. CNA 1 stated Resident 1 was incontinent of bowel and he had behaviors of playing with his feces. CNA 1 was asked how often this behavior happened. CNA 1 stated, every day. CNA 1 was asked if the behavior was a new behavior and if the licensed nurses were aware. CNA 1 stated Resident 1's behavior was not new, it had been going on for a long time. CNA 1 said the licensed nurses should know of the behavior; however, CNA 1 could not confirm if the licensed nurses were aware of the resident's behavior. CNA 1 stated in order to keep Resident 1 from reaching into his briefs, she would tie the ends of his hospital gown around his legs. CNA 1 stated Resident 1 was able to remove the knotted gown and therefore, she wrapped Resident 1 like a baby to further prevent him from playing with his diaper. CNA 1 was asked to clarify how she wrapped Resident 1. CNA 1 stated she tightly wrapped a blanket around Resident 1's body from under his arms to right above his knees. When asked, CNA 1 denied wrapping Resident 1's arms inside the blanket. CNA 1 stated she had forgotten to remove the wrapped blanket and untie the knotted gown before the end of her shift. CNA 1 acknowledged she knew it was wrong, but she did it to keep Resident 1 and his environment clean from feces. CNA 1 stated she informed the Administrator she was responsible for Resident 1 being wrapped tightly in a blanket and having the ends of his gown tightly tied around his legs. Review of Resident 1's Allegation of Abuse-Investigation Report dated 2/20/2020, showed the investigation identified staff interviews on 2/15/2020. Documentation showed the staff interviewed included CNA 1. The document showed CNA 1 was asked if she had tucked Resident 1 tightly using a bed sheet; however, CNA 1 had denied having done so. The documentation showed CNA 1 stated she had tucked Resident 1's sheet around his lower extremities but denied tucking the sheet tight or wrapping him in it. On [DATE] at 1125 hours, a telephone interview was conducted with the Administrator. The Administrator stated he was informed of the alleged abuse against Resident 1 the morning of 2/15/2020. The Administrator stated RN 1 had informed him Resident 1 stated a female CNA had wrapped Resident 1 with a blanket. The Administrator stated he conducted the interviews with the staff the same day, however, stated he was unable to determine who the perpetrator was. The Administrator was asked if he changed any of the staff assignments or removed any staff from the care of Resident 1. The Administrator stated no, he had not. 2. Medical record review for Resident 3 was initiated on [DATE]20. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 had moderately impaired cognition, required extensive one person assist for bed mobility, and had limitation in ROM functions on both lower extremities. Review of Resident 3's history and physical examination [REDACTED]. On [DATE]20 at 1314 hours, an interview was conducted with CNA 3. CNA 3 stated she found Resident 3 with the ends of her gown tightly tied together around Resident 3's legs on 2/15/2020 around 0900 hours. CNA 3 stated the gown was tied so tightly it restricted the movement of Resident 3's legs. CNA 3 stated she immediately informed LVN 2 about what she found. CNA 3 stated Resident 3 was normally capable of moving her arms and legs, however she was weak. On [DATE]20 at 1504 hours, a telephone interview was conducted with LVN 2. LVN 2 stated CNA 3 informed him that she found Resident 3 with her gown tightly knotted on the morning of 2/15/2020. LVN 2 stated he observed the hospital gown tied in a double knot around the resident (this type of gown is normally open in the back to allow free movement of the person). LVN 2 stated he reported his findings to the Administrator on the same day (2/15/2020), and the Administrator told him it was not a concern and he did not consider it to be abuse. On 2/20/2020 at 0440 hours, an observation and concurrent interview was conducted with CNA 2 at Resident 3's bedside. Resident 3 was observed awake, lying in bed, and had a blanket covering her from her chest to her legs. CNA 2 was asked to remove Resident 3's cover. When CNA 3 removed the cover, Resident 3 was observed with the bottom of her gown tucked tightly underneath the back of of both of the resident's thighs. The position of the gown was in such a manner that the resident could not have done this herself. CNA 2 was observed to pull Resident 3's gown with force in order to loosen it from underneath the weight of the resident's body. CNA 2 was asked if Resident 3's hospital gown was knotted, and he stated no. CNA 2 stated he did not knot Resident 3's gown, he only tucked it in tightly underneath the resident in order to keep her from reaching into her incontinence brief and playing with her feces. On 2/20/2020 at 0548 hours, an interview was conducted with CNA 1. CNA 1 was asked about Resident 3. CNA 1 stated Resident 3 needed to be changed and cleaned often because she had a behavior of playing in her feces. CNA 1 stated in order to keep Resident 3 from reaching inside her incontinence brief, she would wrap the resident with a blanket from under their arms down to her knees. CNA 1 stated she also tied Resident 3's hospital gown into a knot and placed the knot underneath the resident's legs to keep her from reaching into her incontinence brief. CNA 1 stated she knew it was wrong, but she did not know how else to keep the resident clean. CNA 1 stated she was asked by the Administrator on 2/15/2020, if she had knowledge regarding Resident 3 being tied up. CNA 1 stated she told the Administrator she was responsible for Resident 3's clothing being tied tightly to restrict the resident's access to their feces. On 2/20/2020 at 0[AGE]9 hours, a telephone interview was conducted with the Administrator. The Administrator stated he received a call on 2/15/2020, and was informed of Resident 3 was found with a her gown tied in a knot and secured underneath her legs. The Administrator stated he did not report or investigate the circumstances regarding this because he did not think it constituted abuse or a restraint. The Administrator stated Resident 3's gown was wrinkled and she was able to bend her knees, therefore Resident 3's movement was not restricted. The Administrator stated he interviewed CNA 1 and CNA 1 denied knotting Resident 3's gown. The Administrator verified nobody was suspended or corrective actions taken because there was no investigation. Review of the facility's assignment sheets for 2/15, 2/16, 2/17, and 2/18/2020, showed CNA 1 continued to be assigned to Resident 3 on the night shift (2300 to 0700 hours) for three days after Resident 3 was found with her gown knotted and wrapped tightly to purposely restrict the resident's movement and access to her body.

Based on observation, interview, and medical record review, the facility failed to ensure one of 28 sampled residents (Resident 126) and three nonsampled residents (Residents 1, 7, and 15) were free from significant medication errors. * The facility failed to ensure Resident 7 received her routine medications including the antihypertensive, antianxiety, and narcotic pain medications in a timely manner. As a result, Resident 7 experienced a lot of pain, anxiety, and was not able to participate in the afternoon group activities, which she loved to do in the afternoon. In addition, the licensed nurse who administered Resident 7's medications late, did not inform the oncoming licensed nurse about the delay in the medication administration, resulting in duplicate medication administration with less than a 10 minutes interval. * Resident 126 did not receive his [MEDICATION NAME] (antidiabetic medication) injection on 7/30/19 at 2100 hours. RN 5 was running behind with her medication pass and did not get to Resident 126 until 2300 hours. Resident 126 was asleep, so RN 5 documented Resident 126 refused the [MEDICATION NAME] injection. As a result, Resident 126 had a [MEDICAL CONDITION] episode the following morning, requiring the insulin coverage. In addition, on 7/29/19, RN 5 was running behind with her medication pass and could not take Resident 126's blood pressure, so Resident 126 refused to take the blood pressure medications. * Resident 1 was not administered her medications as ordered by the physician and as scheduled. * Resident 15 was administered her pain medication from another resident's medication supply. Findings: 1. On 7/29/19 at 0913 hours, an interview was conducted with Resident 7. Resident 7 brought up a concern of not getting her medications in a timely manner when nurses from the registry agency were working. Medical record review for Resident 7 was initiated on 8/1/19. Resident 7 was admitted to the facility on [DATE]. Review of the annual MDS dated [DATE], showed Resident 7 had no cognitive impairment. Review of the Medication Administration Record [REDACTED] - duloxetine [MEDICATION NAME] (antidepressant medication) delayed release capsule 40 mg one capsule; - [MEDICATION NAME] (blood pressure medication) 5 mg one tablet; - [MEDICATION NAME] (stool softener) powder 17 grams; and - [MEDICATION NAME] (medication for [MEDICAL CONDITION] or reflux) delayed release tablet 20 mg one tablet. Further review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] (antianxiety medication) 0.25 mg one tablet; - [MEDICATION NAME] sodium (stool softener) 250 mg one capsule; - [MEDICATION NAME] (iron supplement) 325 mg one tablet; - [MEDICATION NAME] sulfate (medication for [MEDICAL CONDITION] arthritis) 200 mg one tablet; - saccharomyces boulardii ([MEDICATION NAME]) 250 mg one capsule; and - vitamin D3 tablet 1000 iu one tablet. Further review of the Medication Administration Record [REDACTED]. On 8/1/19 at 1335 hours, a follow-up interview was conducted with Resident 7. Resident 7 stated she did not receive her 0900 hours routine medications and 1200 hours pain pill until later in the evening on 7/28/19. Resident 7 stated she was in a lot of pain so she asked the licensed nurse multiple times for her pain pill. Resident 7 stated the licensed nurse repeatedly told her .she could not find it in the system. Resident 7 stated she was in a lot of pain due to her broken vertebrae. Resident 7 stated she missed going to the afternoon activities that day because of her pain. Resident 7 stated, .I was so upset that day. I was miserable. Review of the LN - Pain Management Review dated 7/20/19, showed Resident 7 experienced back pain daily or several times a day. The assessment showed Resident 7's pain was worst at mid-morning and the afternoon; and the pain could affect Resident 7's therapy or activities of choice, and her ability to bathe, groom and dress self. The medication that relieved her pain in the past was the [MEDICATION NAME] tablet. Review of the Activity - Annual Evaluation dated 7/15/19, showed Resident 7 enjoyed participating in all kinds of activities in the afternoon. Review of the One-to-One Activity Participation Documentation for (MONTH) 2019 showed Resident 7 refused an activity invite on 7/28/19. Review of the Medication Administration Audit Report (showing the actual administration and documentation times for each medications administered to the resident) for 7/28/19, showed all medications scheduled to be given to Resident 7 at 0900 and 1200 hours were administered at 1829 and 1830 hours. However, further review of the Medication Administration Audit Report for 7/28/19, showed the medications scheduled to be administered at 1700 hours to Resident 7 were all administered at 1838 hours. Resident 7 received duplicate medications, including the [MEDICATION NAME] 0.25 mg tablet and [MEDICATION NAME] 5-325 mg tablet in eight and nine minutes intervals. Review of the Controlled Drug/Receipt/Record/Disposition Form for the [MEDICATION NAME] 0.25 mg tablet showed two tablets were taken on 7/28/19 at 0900 and 1700 hours. Review of the Controlled Drug/Receipt/Record/Disposition Form for the [MEDICATION NAME] 5-325 mg tablet showed four tablets were taken on 7/28/19 at 0000, 0600, 1200, and 1800 hours. Review of the medical record failed to show Resident 7's physician was notified of the delay in the medication administration. On 8/1/19 at 1547 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 reviewed the medical record and verified the above findings. RN 3 stated she could not find any documentation the physician was informed of the delay in the administration of medications to Resident 7. RN 3 also verified Resident 7's blood pressure was not monitored on 7/28/19, when she was not administered her antihypertensive medication in a timely manner. Cross reference to F684, example #2. On 8/5/19 at 1534 hours, a telephone interview was conducted with LVN 2. LVN 2 stated she worked the 1500 to 2300 hours shift on 7/28/19, and administered Resident 7's medications as scheduled. LVN 2 stated she did not receive any report from the outgoing licensed nurse (0700 to 1500 shift) regarding Resident 7's medications being administered late. 2. Medical record review for Resident 126 was initiated on 7/29/19. Resident 126 was admitted to the facility on [DATE]. Review of the history and physical examination [REDACTED]. a. On 7/31/19 at 0945 hours, an interview was conducted with Resident 126. Resident 126 stated he did not receive his bedtime [MEDICATION NAME] injection last night (7/30/19). Resident 126 stated the [MEDICATION NAME] injection at bedtime was important for him because his blood sugar levels were not stable. Review of the Order Summary Report showed a physician's orders [REDACTED]. The [MEDICATION NAME] injection was increased from 20 units to 32 units on 7/16/19, due to high blood sugar levels. Review of the Medication Administration Record [REDACTED]. On 7/30/19, RN 5 documented the medication was not administered because Resident 126 refused the [MEDICATION NAME] injection. Further review showed Resident 126's blood sugar level on 7/30/19 at 1630 hours was 305 mg/dl, and the resident was administered four units of insulin injection per sliding scale (the dose of insulin based on the resident's blood sugar level). Resident 126's blood sugar levels had been unstable ranging from 82-500 mg/dl from 7/1 to 7/31/19. Resident 127's blood sugar level at 0630 hours the past week (7/24 to 7/30/19) had been stable at 88 to 169 mg/dl when he received his [MEDICATION NAME] injection the night before. However, on 7/31/19 at 0630 hours, Resident 126's blood sugar level was 249 mg/dl, when he did not receive his [MEDICATION NAME] injection the night before. On 7/31/19 at 1330 and 1500 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 reviewed the medical record and verified the above findings. RN 5 stated she was running behind with her medication pass and when she got in to Resident 126's room he was already asleep, so she documented Resident 126 refused the [MEDICATION NAME] injection. b. Review of the Order Summary Report showed a physician's orders [REDACTED].>- 6/27/19, for [MEDICATION NAME] (blood pressure medication) 10 mg one tablet by mouth once a day; and - 7/22/19, for losartan potassium tablet 25 mg one tablet by mouth once a day. Review of the Medication Administration Record [REDACTED]. However, on 7/29/19, the documentation showed Resident 126 refused both blood pressure medications. Review of the Blood Pressure Summary showed Resident 126's blood pressure were not monitored from 7/28 to 7/30/19. On 7/31/19 at 0804 hours, Resident 126's blood pressure reading was 162/100 mmHg. On 7/31/19 at 1000 hours, an interview was conducted with Resident 126. Resident 126 stated he refused the blood pressure medications because RN 5 did not take his blood pressure before administering the medications. On 7/31/19 at 1330 hours, an interview was conducted with RN 5. RN 5 stated she worked the 0700 to 1500 shift on 7/29/19. RN 5 verified the above findings and stated she did not take Resident 126's blood pressure and heart rate on 7/29/19, because she was running behind with her medication pass. 3. Review of the facility's P&P titled Medication Administration Guidelines (undated) showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The medications supplied for one resident are never administered to another resident. a. On 7/29/19 at 1437 hours, a Resident Council meeting was conducted with the residents. Resident 1 verbalized she did not receive all her morning medications. Medical record review for Resident 1 was initiated on 7/29/19. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 6/27/19, showed the resident was to receive the following medications: [REDACTED] * [MEDICATION NAME] tablet 100 mg one tablet by mouth at 0900 hours, * aspirin tablet 81 mg one tablet by mouth at 0900 hours, * fludrocortisone acetate tablet 0.1 mg one tablet by by mouth at 1200 hours, * polyethelene [MEDICATION NAME] 3350, 17 gm by mouth at 0900 hours, * [MEDICATION NAME] chloride tablet 5 mg two tablets by mouth at 0900 hours, * saccharomyces boulardii capsule 250 mg two capsules by mouth at 0900 hours, * [MEDICATION NAME] sodium capsule 250 mg one capsule at 0900 and 2100 hours, * [MEDICATION NAME] capsule 500 mg one capsule at 0900 and 1700 hours, * calcium [MEDICATION NAME] tablet chewable 500 mg one tablet at 0630, 1130, and 1630 hours, * [MEDICATION NAME] hcl tablet 10 mg one tablet at 0600, 1400, and 2200 hours, and * [MEDICATION NAME] tablet 10 mg one tablet at 0630, 1130, 1630, and 2000 hours. Review of Resident 1's Medication Admin Audit Report dated 7/31/19, showed the Resident 1's medication administration times for the following medications administered on 7/29/19 were as follows: * calcium [MEDICATION NAME] tablet chewable 500 mg, administered at 1703 and 1731 hours * [MEDICATION NAME] hcl 10 mg, administered at 1703 and 1731 hours * [MEDICATION NAME] capsule 500 mg, administered at 1703 and 1747 hours, and * trauma hcl 50 mg, administered at 1703 and 1749 hours On 7/29/19 at 1639 hours, the DON was informed and acknowledged the above findings. The DON stated RN 4 should have taken Resident 1 ensured Resident 1's medications were administered on time. On 7/29/19 at 1648 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 4. RN 4 stated she did not administer Resident 1's morning medications as scheduled because the resident was in the activity room throughout her shift. She stated she was told she could not administer the residents' medications when they were in the activity room. RN 4 verified Resident 1's morning medications were administered late. 4. On 7/31/19 at 1524 hours, a narcotic count verification for Medication Cart #5 was conducted with LVN 1. Review of Resident 15's [MEDICATION NAME] hcl 15 mg bubble pack identified the count did not match. The number of pills in the bubble pack compared to the resident's Controlled Drug Receipt/Record/Disposition Form showed one tablet was unaccounted for. LVN 1 was asked about discrepancy. LVN 1 stated she used one tablet of Resident 94's [MEDICATION NAME] hcl 15 mg to administer to Resident 15 because Resident 15's [MEDICATION NAME] hcl ER 15 mg supply had ran out. LVN 1 stated she should have told the resident she had to hold the medication because the pharmacy had not delivered it yet. Review of Resident 15's Order Summary Report dated 6/27/19, showed the resident was supposed to get [MEDICATION NAME] hcl ER 15 mg one tablet by mouth once a day, not [MEDICATION NAME] hcl 15 mg. On 7/31/19 at 1555 hours, the DON was informed and acknowledged the above findings. The DON stated LVN 1 should have obtained the [MEDICATION NAME] hcl ER 15 mg from the facility's emergency medication kit instead of getting it from another resident's medication supply. On 7/31/19 at 1628 hours, Resident 15 was observed in bed lying on her back watching a television program. The resident was asked by CNA 11 in their native language how she was feeling and if she was experiencing pain at this time. Resident 15 stated no.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for two [MEDICAL TREATMENT] residents of 30 final sampled residents (Residents 123 and 1) to ensure the residents attained and maintained their highest physical well-being. * The facility failed to place Resident 123 on the fluid restriction as ordered and failed to monitor the I&O. Resident 123 required [MEDICAL TREATMENT] and had a history of [REDACTED]. These orders were not implemented, resulting in Resident 123 being transferred to the acute care hospital on [DATE], and admitted with fluid overload. Following the readmission to the facility on [DATE], the facility continued to fail to implement the orders for fluid restriction and monitor the I&O. In addition, the facility failed to consistently assess Resident 123 post [MEDICAL TREATMENT] treatments. This failure had the potential to cause a delay in necessary care and services to Resident 123. * The facility failed to remove Resident 1's [MEDICAL TREATMENT] dressing after returning from [MEDICAL TREATMENT] as ordered. This failure had the potential to delay facility nursing staff in identifying any issues with the resident's [MEDICAL TREATMENT], including signs of infection and active bleeding. Findings: 1. Medical record review for Resident 123 was initiated on 7/25/18. Resident 123 was admitted to the facility on [DATE], readmitted on [DATE], and readmitted a second time on 7/14/18. a. Review of Resident 123's MDS dated [DATE], showed Resident 123 required supervision and setup help for eating. Review of the history and physical examination [REDACTED]. Review of Resident 123's history and physical examination [REDACTED]. Review of the [DIAGNOSES REDACTED]. Review of Resident 123's Order Audit Report showed an order dated 6/12/18, to administer sodium chloride tablet one table by mouth two times a day for [MEDICAL CONDITION]. However, review of the Order Audit Report showed the sodium chloride was not discontinued until 7/6/18, more than three weeks later. Review of Resident 123's [MEDICAL TREATMENT] Communication Record dated 6/20/18, showed an order from the [MEDICAL TREATMENT] center to discontinue the sodium chloride supplement and place Resident 123 on a fluid restriction of 1200 ml per day. However, there was no documented evidence the resident was placed on a fluid restriction as ordered from the [MEDICAL TREATMENT] center even though the resident had been admitted to the acute care hospital on [DATE], with a [DIAGNOSES REDACTED]. In addition, there was no care plan developed to address the resident's need to be placed on a fluid restriction of 1200 ml per day. Review of Resident 123's Progress Note dated 7/11/18 at 1208 hours, showed Resident 123 complained of chest pain and tightness and had difficulty breathing. The facility called 911 and the paramedics arrived and transported Resident 123 to the acute care hospital. Review of the Consultation Note - Nephrology (medical specialty dealing with the kidneys) from the acute care hospital dated 7/11/18, showed Resident 123 was admitted for acute hypoxic [MEDICAL CONDITION] secondary to fluid overload, [MEDICAL CONDITIONS], hypertensive (high blood pressure) crisis, and [MEDICAL CONDITION] (disease of the brain). Further review of the document showed Resident 123 had a BNP value of 709 pg/ml. According to Lexicomp, normal BNP levels are below 150 pg/ml. A value above 150 pg/ml is indicative of heart failure. Review of Resident 123's plan of care showed a care plan problem dated 7/24/18, addressing weight gain related to [MEDICAL TREATMENT] and [MEDICAL CONDITION] and resident at risk for fluid overload. The care plan interventions included to determine the individual fluid needs and monitor the oral intake. However, there was no documented evidence the facility was monitoring the resident's oral intake as careplanned. On 7/26/18 at 1050 hours, an interview was conducted with LVN 1. LVN 1 was asked about Resident 123's care, specifically fluid restriction and monitoring I&O. LVN 1 stated Resident 123 was not on fluid restriction, and they were not monitoring the resident's I&O. On 7/26/18 at 1126 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about the procedure when Resident 123 went to [MEDICAL TREATMENT]. LVN 1 stated the licensed nurse was responsible for filling out the top portion of the [MEDICAL TREATMENT] Communication Record, and the form was sent in a binder with the resident to [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] Center completed the middle section including any new orders and returned the form in the binder with the resident back to the facility. LVN 1 stated the licensed nurse assigned to the resident was responsible for inputting any new orders and communicating those new orders to Resident 123's PCP. On 7/26/18 at 1432 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked if Resident 123 was on a fluid restriction. The RD verified between 6/19/18, to the present, there were no orders or other documentation in the medical record regarding the resident's fluid restriction. On 7/26/18 at 1442 hours, LVN 1 was asked about the order from the [MEDICAL TREATMENT] center dated 6/20/18, regarding discontinuing the sodium chloride supplement. LVN 1 was unable to find any documentation Resident 123's PCP was notified of the order to discontinue the sodium chloride supplement and place the resident on a fluid restriction, or any documentation the orders were carried out. LVN 1 stated it must have been missed. On 7/30/18 at 1506 hours, a telephone interview and concurrent medical record review was conducted with the [MEDICAL TREATMENT] center's [MEDICAL TREATMENT] RN. The [MEDICAL TREATMENT] RN was asked about Resident 123's [MEDICAL TREATMENT] Communication Record dated 6/20/18. The [MEDICAL TREATMENT] RN stated the [MEDICAL TREATMENT] physician wrote an order for [REDACTED]. The [MEDICAL TREATMENT] RN stated the [MEDICAL TREATMENT] Communication Record section filled out by the [MEDICAL TREATMENT] center's staff was the order from their physician and she expected the facility to follow it when Resident 123 returned to the facility. On 7/30/18 at 1524 hours, an interview was conducted with CNA 9. CNA 9 was asked how she assisted Resident 123 with meals. CNA 9 stated Resident 123 ate and drank without assistance. CNA 9 stated Resident 123 requested lots of fluids and asked for more fluids in addition to what came on her meal trays. CNA 9 stated Resident 123 often requested a big pitcher full of ice upon return from [MEDICAL TREATMENT]. CNA 9 stated Resident 123's I&O was not being monitored. On 8/1/18 at 0953 hours, a telephone interview was conducted with Resident 123's PCP. The PCP stated he never ordered a fluid restriction for Resident 123 as the [MEDICAL TREATMENT] physician would order it if the resident needed it. The PCP further stated it would be the facility's responsibility to follow that order; it would have nothing to do with him. He was never notified of an order to discontinue the sodium chloride supplement or to put the resident on a fluid restriction. On 8/2/18 at 1545 hours, an observation was made of Resident 123. Resident 123 was in bed and had a one liter pitcher filled with 950 ml of water on her bedside table within reach. On 8/2/18 at 1555 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the water pitcher being at Resident 123's bedside. The DON stated Resident 123 should not have the water pitcher and she would inform Resident 123's nurse, the CNA, and dietary department. The DON was asked about the I&O monitoring for [MEDICAL TREATMENT] residents. The DON stated the facility would only monitor the I&O if the resident was on a fluid restriction and verified Resident 123 should have been on a fluid restriction. When asked what was expected of the licensed nurse when they received the resident from the [MEDICAL TREATMENT] center with a new order, the DON stated the licensed nurse should call the resident's PCP, tell them the recommendation, and input the order. On 8/2/18 at 1620 hours, a follow-up interview was conducted with the RD. The RD was asked when she assessed Resident 123. The RD stated the first time Resident 123 was assessed was 6/19/18. The RD stated she recommended to discontinue Resident 123's zinc sulfate and add a renal multivitamin with minerals and a supplement for wound healing. There were no recommendations regarding the resident's fluid needs. When asked how she determined the interventions for Resident 123, the RD stated she looked at Resident 123's diagnoses, history and physical, and hospital notes. The RD stated she did not recall seeing anything about the fluid overload or [MEDICAL CONDITION] in Resident 123's medical record. The RD stated she assessed Resident 123 again on 7/20/18. When asked why Resident 123 was not placed on a fluid restriction or monitoring after her return from the acute care hospital, the RD stated she was not informed Resident 123's latest admission to the acute care hospital was due to a fluid overload. The RD stated she must have missed why Resident 123 was hospitalized . On 8/2/18 at 1640 hours, an interview and concurrent medical record review was conducted with LVN 8 and the DON. LVN 8 stated he was assigned to care for Resident 123 during the 3-11 shift on 6/20/18. LVN 8 stated he received Resident 123 from the [MEDICAL TREATMENT] treatment on 6/20/18, and wrote a Progress Note but did not sign the [MEDICAL TREATMENT] Communication Record. LVN 8 stated it was his responsibility to review the [MEDICAL TREATMENT] Communication Record for any new orders, but he did not recall why he did not input the order from [MEDICAL TREATMENT] or notify Resident 123's PCP. When asked who was supposed to sign the [MEDICAL TREATMENT] Communication Record, the DON stated the receiving nurse. On 8/2/18 at 1648 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked who signed the [MEDICAL TREATMENT] Communication Record dated 6/20/18. The DON stated the form was signed by RN 6. The DON stated RN 6 was no longer employed by the facility. b. Review of the [MEDICAL TREATMENT] Communication Records showed the following: - Resident 123 received [MEDICAL TREATMENT] treatment on 7/6/18; however, the post-[MEDICAL TREATMENT] assessment was not completed by the licensed nurse until 7/8/18. - Resident 123 received [MEDICAL TREATMENT] treatment on 7/16/18; however, the sections to be completed by the [MEDICAL TREATMENT] center and the post-[MEDICAL TREATMENT] assessment were left blank. - Resident 123 received [MEDICAL TREATMENT] treatment on 7/18/18; however, the post-[MEDICAL TREATMENT] assessment was left blank. - Resident 123 received [MEDICAL TREATMENT] treatment on 7/20/18; however, the post-[MEDICAL TREATMENT] assessment was dated 7/23/18. 2. Medical record review for Resident 1 was initiated on 7/24/18. Resident 1 was readmitted to the facility on [DATE], with end stage [MEDICAL CONDITION] and was receiving [MEDICAL TREATMENT]. Review of Resident 1's physician's orders [REDACTED]. * An order dated 7/21/18, for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. * An order dated 7/18/18, to monitor the resident's [MEDICAL TREATMENT] site every shift for signs or symptoms the site. Notify the physician at the [MEDICAL TREATMENT] center immediately with any urgent problems. * An order dated 7/21/18, to remove the dressing from the [MEDICAL TREATMENT] shunt (a connection surgically created to connect a vein and an artery to access for the [MEDICAL TREATMENT] treatments) after four hours, scheduled every Monday, Wednesday, and Friday. On 7/26/18 at 1526 hours, Resident 1 was observed sleeping in bed. A gauze dressing was noted on the resident's right bicep area. On 7/26/18 at 1552 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 1's [MEDICAL TREATMENT] site dressing was still present from the previous day. LVN 2 stated the dressing should have been removed last night, usually six hours after returning from the [MEDICAL TREATMENT] center. When LVN 2 was asked how he assessed Resident 1's [MEDICAL TREATMENT] site, LVN 2 stated he checked for the bruit (the sound of blood passing through the shunt) and thrill (the feel of the blood passing through the shunt) through the dressing and did not visually assess the site. LVN 2 then removed the [MEDICAL TREATMENT] dressing and assessed the site. On 7/26/18 at 1624 hours, a concurrent interview and medical record review was conducted with Medical Records Staff 1. When asked to locate Resident 1's [MEDICAL TREATMENT] site dressing removal order on the Treatment Administration Record, Medical Records Staff 1 stated the order dated 7/21/18, was entered as an ancillary order and would not show in the resident's electronic treatment record as needing to be completed by the nurse. On 7/31/18 at 0918 hours, Resident 1 was observed in bed. A gauze dressing was noted on the resident's right bicep area. On 7/31/18 at 0919 hours, and interview was conducted with RN 1. RN 1 verified the gauze dressing from the previous day's [MEDICAL TREATMENT] treatment was still in place and should have been removed after [MEDICAL TREATMENT]. RN 1 verified Resident 1 last received [MEDICAL TREATMENT] yesterday. RN 1 removed the dressing and assessed the site.

Based on clinical record review, observations and interviews, the facility failed to have a system in place to ensure appropriate treatment and services were provided to residents fed by GT (a soft rubber tube surgically inserted through the abdominal wall to into the stomach to deliver medications and nutrition) for five of 24 sampled residents (Resident 3, 10, 11, 16, 21). *On 5/26/12, Resident 3 pulled out his GT. Resident 3's GT was replaced by nursing staff with different sizes not ordered by the physician. Resident 3 had a physician's orders [REDACTED]. The facility did not ensure the resident was evaluated timely by the physician to determine if treatment was needed. In addition, Resident 3's GT lacked a dressing; his abdominal binder (an elastic band covering the abdomen) was stuck in his GT site and stained with dry brown crusty material. The facility failed to provide assessments, documented evidence they were monitoring Resident 3's GT insertion site, and failed to notify Resident 3's physician timely. These have the potential for delay in treatment. The facility failed to assess the level of pain before providing Resident 3's GT site treatment. *The facility failed to assess and develop plans for possible GT replacements for Resident 10 who had a newly placed GT . Resident 10 had a physician's orders [REDACTED]. Replacing a GT that has not formed a tract can lead to misplacement of the GT into the peritoneal cavity. *The facility failed to have a system in place to ensure nursing staff received training and were required to demonstrate competency in order to safely insert GTs according to accepted standards of practice. These failures have the potential for peritonitis (infection of the abdominal wall),[MEDICAL CONDITION], and death. All these failures have the potential for serious harm that is an Immediate Jeopardy. *The facility failed to accurately monitor Resident 6 for fluid consumption when Resident 6's physician ordered 240 ml of water every four hours for adequate hydration. The order was not implemented. Findings: On 6/13/12 at 1350 hours, the Administrator and DON were made aware of the immediate jeopardy situation identified by the survey team. The concerns identified were not following their P&P related to GT care, having a physician's as needed order to replace clogged/dislodged GTs without identification of tube type and size, failure to ensure the competency of the licensed nurses who reinsert the clogged or dislodged GT, failure to provide ongoing assessment of the GT site, failure to notify the physician when there is a change in the GT site, and failure to assess the resident for pain before holding the resident down when they resist care to provide care to an affected GT site. On 6/13/12 at 1605 hours, the facility's final plan of correction taken to abate the immediate jeopardy was reviewed with the DON and the Administrator. The corrections the facility took were: 1. Resident 3's physician was notified of his GT site redness and drainage; 2. The licensed nurse was inserviced on pain management; 3. The licensed nurse and CNA were inserviced on handling residents resistive to care and never to hold a resident's arms as a method to handling resistive care; 4. Resident 3's care plan was updated and revised; 5. All residents with a GT were reassessed for any changes at the GT insertion site; 6. The standard "as needed" orders to replace a dislodged or clogged GT were discontinued; 7. Licensed nurses and CNAs were inserviced on assessing for pain, notifying the physician for changes in conditions, only RNs to reinsert GTs after competency training completed and proper handling of residents resistive to care. 8. The Governing Body updated and revised the GT replacement policy and procedure. The Immediate Jeopardy was abated on 6/14/12 at 1400 hours, prior to the exit date of survey, when they demonstrated they had completed the above actions. According to American Society for Gastrointestinal Endoscopy (www.asge.org) PEG (Percutaneous Endoscopic Gastrostomy or GT) is a procedure through which a flexible feeding tube is placed through the abdominal wall and into the stomach. It allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. The PEG tract maturation usually occurs within the first 7-10 days. A PEG tube that is accidentally removed during this period should be replaced endoscopically (a procedure done under anesthesia in the hospital), as the tract may be immature and the stomach and anterior abdominal wall can separate from each other, resulting in perforation (Practical [MEDICATION NAME], November 2004 pp 73). 1a. Review of the facility's P&P titled "Gastrostomy Tube Replacement" (undated) shows gastrostomy tube replacement requires a physician's orders [REDACTED]. Clinical record review for Resident 3 was initiated on 6/12/12. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 3 has severe cognitive impairment, requires extensive assistance with all activities of daily living, and has a feeding tube. Review of a physician's orders [REDACTED]. Another physician's orders [REDACTED]. The orders do not include the type and size of catheter or balloon to use when changing the resident's GT. Review of a physician's progress notes dated 4/30/12, showed a physician's documentation Resident 3 stated "no good," the resident is complaining his stomach is hurting, and the GT site is tender. Review of a the SBAR (Situation, Background, Assessment, and Request) Physician/NP/PA Communication and Progress Notes for New symptoms, Signs and Other Changes in Condition form dated 5/25/12 at 2200 hours, showed agitation manifested by pulling out GT during the shift. The physician requested to monitor the vital signs and observation. Review of the Daily and Q Shift Charting form dated 5/26/12 at 0800 hours, showed documentation the RN Supervisor reinserted the gastrostomy feeding tube, 24 French (the size of the tube) with a 7-10 ml balloon. Aseptic technique was used and the resident tolerated well. On 6/13/12 at 0830 hours, LVN 6 was observed passing medications through Resident 3's GT. LVN 6 was asked to lift up Resident 3's abdominal binder in order to check the GT insertion site. The abdominal binder was stuck in the GT site and stained with a brown sticky substance. The GT was a small, urinary catheter that fit loosely in the stoma (the hole in the abdomen where the GT is inserted). There was a device placed around the catheter, used to stop the tube from advancing and migrating into the abdomen. The device was approximately 5 cm out of the insertion site, and was not secured to the resident's abdomen. According to the policy and procedure, the superficial skin disc should be positioned to allow 1 - 2 millimeters between the skin and the ring. Resident 3 was moaning and guarding his abdomen with both arms. LVN 6 stated she was unaware why the resident's GT did not have a dressing as ordered by the physician, or if the physician was notified of the GT reinsertion. On 6/13/12 at 0840 hours, Resident 3 was observed up in a gerichair (a recliner wheelchair) positioned with the leg rest up, with a lap tray table attached to the gerichair's armrests. Resident 3 was unable to stand up, or raise his lower extremities. Resident 3 continued to moan, guarding his abdomen with his arms crossed. LVN 4 entered the resident's room accompanied by CNA 4 (a large male). CNA 4 washed his hands and, without talking to the resident, forcefully placed his hands around Resident 3's upper arms to keep Resident 3 from moving his arms toward his abdomen. CNA 4 held each arm down to the gerichair's armrests, pressing with his body weight. The resident continued to struggle with CNA 4, screaming "stop it! NO! NO! NO!" while LVN 4 continued to cleanse his GT insertion site. During this event, the GT insertion site started bleeding. The resident's gerichair moved towards the surveyor. The surveyor had to intervene and ask them to stop the "procedure" and let the resident go. At this time, LVN 4 was asked if she had previously assessed Resident 3 for pain. The LVN stated "I should, but I didn't." The LVN asked the resident, "are you in pain?" Resident 3 screamed Yes! Yes! Yes!" The LVN asked the resident, "do you want some pain medication now?" Resident 3 stated "Yes!" When LVN 4 was asked if the physician was notified regarding the condition of the resident's GT insertion site, the LVN stated, "I'm not certain." She stated the resident's GT site has been like this for a while. On 6/13/12 at 0900 hours, during a follow up interview with LVN 4, LVN 4 reviewed Resident 3's clinical record and was unable to find documentation, and confirmed the physician was not notified regarding Resident 3's GT site condition of drainage, redness, and pain. On 6/13/12 at 0920 hours, during interview and review of the clinical record, LVN 4 reviewed the Licensed Nurses Weekly Summary from 4/29/12 to 6/10/12, and stated the only documentation related to the GT is the GT is intact and warm to the touch. LVN 4 stated the resident's GT site has yellowish/brownish discharge, pain, and redness, and confirmed no staff member has notified the physician. Review of a physician's orders [REDACTED]. The order included to apply triple antibiotic ointment and cover with a dry dressing daily for 21 days. The order also showed to pre-medicate the resident with Tylenol 650 mg via GT 30 minutes prior to dressing change, and to start Keflex (an antibiotic) 500 mg via GT every 8 hours for 10 days due to GT site drainage. On 6/13/12 at 1000 hours, an interview was conducted with RN 1 from Station 3. RN 1 confirmed she was not notified regarding Resident 3's GT drainage. Review of the care plan showed a care plan problem dated 4/11/12, to address the problem of Feeding Tubes related to gastrostomy, risk of deterioration, risk of ostomy infection site with feeding tube device insertion. The approaches listed to provide enteral feedings as ordered, treatment as ordered, monitor tolerance to feeding, monitor for signs and symptoms of aspiration. However, the IDT did not address how the staff is to monitor the GT site for infection, use of an abdominal binder, prevent the resident from pulling out the GT and, if out of place, how to safely replace it. Review of another care plan problem dated 4/11/12, to address Pain & Pain Symptom showed approaches listed to assess the level of pain using a pain rating scale, implement non-pharmacological interventions, reassuring words and gestures and evaluate the need to provide medications prior to treatment or therapy (30 minutes before therapy and established schedules). b. On 6/14/12 at 1415 hours, an interview was conducted with CNA 4. CNA 4 was asked if he received any training regarding residents refusing treatment in the facility. CNA 4 stated "I don't need any training to hold the resident's arms down. CNA 4 stated Resident 3 is combative, "I anticipated he could swing his hands and hit someone." c. On 6/12/12 at 1530 hours, an interview was conducted with LVN 7. The LVN was asked if she re-inserts a resident's GT. She stated sometimes, if a resident pulls the GT out more than one time, we just re-insert a urinary catheter, because it is safer. LVN 7 stated GTs don't have the risk to go in the lungs. The LVN stated "at nursing school, we always do." On 6/12/12 at 1545 hours, an interview was conducted with LVN 1. The LVN stated, "I'm new here; I never had any training to re-insert GTs, never re-inserted one while here or previous employment." LVN 1 stated he already watched the other LVNs re-insert several times; if it is needed, he would know how to re-insert one, since he already observed the procedure. On 6/13/12 at 1100 hours, an interview was conducted with the DSD regarding staff training and demonstration of competency to insert GTs and administer tube feedings. The DSD stated they send all the residents out to the acute hospital to re-insert all the GTs. On 6/13/12 at 1110 hours, an interview was conducted with LVN 6. The LVN stated LVN 4 re-inserts the GTs when they come out. LVN 6 stated she never had training on GT re-insertion. On 6/13/12 at 1200 hours, an interview was conducted with the DSD regarding GT re-insertion. The DSD stated the facility does not provide nurses with specific training to replace GTs, the nurses are not required to demonstrate competency to perform the procedure. The DSD stated she never "heard" RNs or LVNs were re-inserting GTs at the facility, they wouldn't be able to know if it is safe to do it. On 6/13/12 at 1415 hours, an interview was conducted with the DON. The concern related to GT re-insertion was addressed. The DON stated the RNs and the LVNs are expected to re-insert the residents' GTs at the facility. The DON did not know if the staff was receiving training and demonstrating competency in GT re-insertion. On 6/13/12 at 1430 hours, an interview was conducted with RN 1. RN 1 confirmed the LVNs and RNs in the facility, including her, re-insert the GTs. The RN stated GTs were discussed during general orientation when she began employment five years ago. She stated she was not required to demonstrate competency for GT insertion. On 6/14/12 at 0900 hours, review of nursing staff's personnel and training records for RN 1 the Licensed Nurse Competency Evaluation Worksheet for Enteral Feeding showed no documentation related to replacement/insertion of gastrostomy tubes. 2. On 6/12/12 at 0830 hours, Resident 10 was observed lying in bed, alert, but nonverbal. The GT feeding and tubing was hanging on the pump stand. The tubing was connected to Resident 10's GT. The feeding pump was on, the solution was infusing. On 6/12/12, clinical record review for Resident 10 was initiated. Resident 10 was admitted to the facility on [DATE], with a [MEDICAL CONDITION] tube or NG tube (the insertion of a plastic tube through the nose, past the throat, and down into the stomach, in order to deliver medications and nutrition). Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. KUB stat (immediately) for NG tube placement. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the care plan showed a care plan problem dated 5/18/12, to address feeding tubes, NG tube and GT. The approaches included providing enteral feeding as ordered, treatment as ordered, monitor tolerance to feeding, monitor for signs and symptoms of aspiration; however, the care plan did not address the risk of GT re-insertion related complications due to an immature GT tract. On 6/13/12 at 1500 hours, an interview was conducted with RN 1. RN 1 stated Resident 10 had pulled out her NG tube multiple times; now she has a GT. RN 1 confirmed Resident 10 has a physician's as needed order to re-insert her GT. RN 1 was not aware Resident 10 had a newly inserted GT. 3. Clinical record review for Resident 21 was initiated on 6/13/12. Resident 21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Review of Resident 21's emergency room Report dated 2/15/12, showed the resident dislodged his GT and the nursing staff was unable to replace it. An assessment of Resident 21's abdomen showed there is a GT site, which is closed and there is no well-defined tract. b. Review of Resident 21's Daily and Q Shift Charting record dated 4/3/12 at 2130 hours, showed the resident pulled his GT out and an indwelling urinary catheter size 16 FR (French) with a 30 ml balloon was inserted (GT re-insertion). There was no documentation to show who re-inserted the GT, the size of the GT used or how the resident tolerated the procedure. c. Review of Resident 21's Patient Transfer Record dated 5/3/12, showed three unsuccessful attempts were made to re-insert his GT and he was transferred to the hospital for a GT reinsertion. Review of Resident 21's physician's orders [REDACTED]. The order did not identify the size of the catheter to be used or to notify the physician if the GT becomes dislodged. During an interview with the ADON on 6/14/12 at 1040 hours, the ADON agreed the physician's orders [REDACTED]. 4. Clinical record review for Resident 6 was initiated on 6/11/12. Resident 6 was readmitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the care plan for Resident 6 shows a care plan problem dated 8/29/11, to address dehydration/fluid maintenance. The approaches do not include water 240 ml every four hours while awake, in addition to general hydration. During an interview and review of the physician's orders [REDACTED].[REDACTED]. During an interview with CNA 3 on 6/12/12 at 0800 hours, CNA 3 was asked if Resident 6 is on intake and output monitoring. CNA 3 stated Resident 6 is not on intake and output monitoring. CNA 3 stated she has not been told anything specific about the amount of fluid Resident 6 is to drink. 5. Review of Resident 11's clinical record was initiated on 6/12/12. The resident was admitted to the facility on [DATE], following hospitalization and treatment for [REDACTED]. Review of the physician's orders [REDACTED]. diff ([MEDICAL CONDITION], a spore forming bacteria excreted through the feces). Review of the ADL sheet showed the resident had bowel movements on 6/3, 6/4, 6/6, 6/7 and 6/8/12. Review of the laboratory reports found one result for a stool specimen obtained on 6/9/12, and reported to the facility on [DATE]. The result showed positive for [DIAGNOSES REDACTED]. There were no other reports of stool cultures found in the clinical record. On 6/12/12 at 1110 hours, RN 4 was asked to locate evidence a second stool specimen was obtained as ordered by the physician. She looked through the clinical record, but was unable to find the requested documentation. RN 4 stated she would call the laboratory. At 1125 hours, RN 4 stated there was only one stool specimen obtained. She was unable to explain why only one specimen had been obtained. RN 4 stated she would contact the physician for clarification of the order, since Resident 11 is already being treated with antibiotics for the infection and he no longer has diarrhea. Resident 11 had been placed in isolation for [DIAGNOSES REDACTED] precautions. 6. Review of Resident 16's clinical record was initiated on 6/12/12. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Review of the physician's orders [REDACTED]. The recapped order dated 5/18/12, specifies the dietary department will provide 720 ml of fluids and nursing will provide 780 ml of fluids per 24 hours. Observation of the breakfast meal for Resident 16 on 6/13/12 at 0800 hours, showed the resident was served an 8 ounce glass of juice, an 8 ounce glass of [MEDICATION NAME] and an 8 ounce cup of coffee. This totals 720 ml of fluids for breakfast alone provided from the dietary department. Review of the Intake and Output Record for 6/13/12, showed the fluid intake for the day shift was 400 ml. This is not what was observed the resident took in just for his breakfast meal. On 6/14/12 at 0820 hours, Resident 16 was observed with his breakfast tray. The tray contained an 8 ounce glass of juice and an 8 ounce glass of [MEDICATION NAME]. On 6/14/12 at 0830 hours, LVN 2 was asked about Resident 16's fluid restriction. LVN 2 stated nursing can give the resident 400 ml of fluids on the day shift. When asked about the amount of fluids dietary can provide with each tray of food, LVN 2 acknowledged the dietary department has not broken down the fluid restrictions for Resident 16. At 0840 hours, CNA 8 acknowledged Resident 16 drank all of the fluids provided to him on his breakfast tray. This is a total of 480 ml of the 720 ml dietary is to provide. On 6/14/12 at 0850 hours, an interview was conducted with the DSS. When asked about the fluid restrictions for Resident 16, the DSS looked in his computer and stated he did not receive an order to place Resident 16 on fluid restrictions. Further review of the clinical record and interview with RN 7 on 6/14/12 at 0900 hours, showed the fluid restriction order dated 5/8/12. However, the RD notes do not reflect the fluid restriction. There was no documented evidence the dietary department was sent an order reflecting the fluid restrictions until 6/11/12. b. Review of the physician's orders [REDACTED]. The order does not specify where the shunt is located. Review of the [MEDICAL TREATMENT] Communication Records for Resident 16 showed the [MEDICAL TREATMENT] catheter (shunt) location site was the left forearm on 5/19, 5/23, and 5/25/12, the left upper arm on 5/21 and 5/28/12, and the left arm on 6/4/12. The remainder of the [MEDICAL TREATMENT] Communication Records failed to show the site of the shunt. Review of the care plan showed a care plan problem dated 5/18/12, to address [MEDICAL CONDITION] on [MEDICAL TREATMENT]. The approaches/needs or preferences column showed to observe/monitor for bruit/thrill every shift for the A/V (arterial/venous) shunt. Observe for bleeding at catheter site, and change the dressing as ordered. However, the care plan does not identify where the shunt site is located, or that the dressing will be changed only by the [MEDICAL TREATMENT] center. c. Review of the [MEDICAL TREATMENT] Communication Records dated from 5/10/12 through 6/11/12, showed the licensed nursing staff is not always filling the Pre-[MEDICAL TREATMENT] Assessment portion of the form to keep the [MEDICAL TREATMENT] center informed of the resident's condition. For example, the pre-[MEDICAL TREATMENT] assessment is to include the resident's blood sugar level, the time it was tested and the amount of insulin given; the vital signs, the type of access site and any significant change of condition noted in the past 24-48 hours. These assessments were not documented on the records sent to the [MEDICAL TREATMENT] center on 5/10, 5/14, and 5/19/12. Review of the clinical record showed a laboratory report showing the facility was notified on 5/25/12 at 0657 hours, Resident 16 tested positive for [DIAGNOSES REDACTED]. Review of the [MEDICAL TREATMENT] Communication Record showed the [MEDICAL TREATMENT] center was not made aware of this transmissible infection until 6/1/12.

Based on interview, clinical record review and observation, the facility failed to provide assistance with medically related social services issues for four of 24 sampled residents (Residents 21, 13, 1 and 5). *The facility failed to obtain a dental consult for Resident 21 since his admission on 2/12/12, to assess his dental needs. On 6/14/12, a dental consult was obtained showing Resident 21 has gum pain and a severe periodontal condition. www.medicalnewstoday.com (Web Based Internet site): Periodontitis means "inflammation around the tooth" - it is a serious gum infection that damages the soft tissue and bone that supports the tooth. Untreated periodontitis will eventually result in tooth loss, and may increase the risk of stroke, heart attack and other health problems. The facility failed to obtain an optometry consult for Resident 21's severely impaired vision. On 6/14/12, an optometry consult was obtained showing Resident 21 has cataracts and recommends eye examinations every six months. This caused pain and poses the potential for decreased self-esteem. The facility failed to obtain an appropriate representative to handle Resident 21's medical decisions. The IDT was identified as his main support and to be his surrogate decision maker. No documentation was available to show a diligent effort was done to locate Resident 21's family. This has the potential for a conflict of interest between the resident's welfare and the facility. *The facility failed to have a system in place from threats of Resident 13's family member coming into the facility with a gun and killing Resident 13, visitors and staff. This has the potential for serious bodily harm and possibly death. *The facility failed to aggressively identify the needs and pursue the provision of dental services for Resident 5. This has the potential for negative effects on the physical, mental, and psychosocial well being of the residents. *Resident 1 and his spouse questioned the discharge plans for the resident, but they stated no one is telling them anything. Social service staff have not followed up with the resident and his spouse to obtain information from them and to keep them informed regarding the plans for his treatment and discharge. This leaves the resident and family feeling frustrated. Findings: Review of the facility's Director of Social Service job description shows an essential duty and responsibility is to work with the facility's consultants as necessary for administering social service programs. Review of the "Social Service Assessment" P&P revised date 3/30/07, shows the social service department assesses the needs of all residents. If information about a resident is not available, attempts shall be made to find out as much as possible about that resident from family members, friends, staff, physician, etc. Attempts will be documented in the social service notes. Review of the facility's P&P titled "Referral to Community Resources" revised date 3/30/07, shows, as the quarterly assessment is completed, areas of need will be reviewed. The documentation will include any newly identified needs as well as referrals made since last assessment. Common referral needs include: dental and vision. Review of the facility's P&P titled "Bioethics Council" revised date 3/30/07, shows the purpose of the committee is for guidance in approaching situations that are actual or potential ethical dilemmas. Issues may include a cognitively impaired resident without a surrogate decision maker that needs specific medical treatment. 1a. Clinical record review for Resident 21 was initiated on 6/13/12. Resident 21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 21's physician's orders [REDACTED]. Review of Resident 21's MDSs (an assessment tool) dated 2/28/12 and 5/23/12, shows Resident 21 has short and long term memory impairment and rarely understands and is rarely understood. No dental concerns were identified. Review of Resident 21's Social Service Update dated 5/23/12, showed his concrete needs (Podiatry, Psychiatry, clothing) were addressed. Review of Resident 21's Dental/Oral assessment dated [DATE], showed he has natural teeth, with some missing teeth. It was "unknown" if the resident had been seen by a dentist within the last year. A second Dental/Oral assessment dated [DATE], showed Resident 21 was not seen by a dentist within the last year, (If no, then an examination by a dentist should be performed). Review of Resident 21's care plan dated 3/2/12, to address his dental care, showed he was dependent for oral hygiene. No documentation was available to show Resident 21 was examined by a dentist. Review of Resident 21's Social Work Progress Note dated 6/13/12, showed Resident 21 was to have a dental and optometrist examinations on 6/14/12. Review of Resident 21's Dental Consultant examination dated 6/14/12, showed he has a severe periodontal condition, with gum pain. The [DIAGNOSES REDACTED]. b. Resident 21's MDSs dated 2/28/12 and 5/23/12, showed he has highly impaired vision (object identification in question, but eyes appear to follow objects). Review of Resident 21's CAA dated 2/28/12, shows an ophthalmology consult would be obtained if his vision worsened. Review of Resident 21's care plan dated 3/1/12, to address his impaired visual function showed an approach plan for an Ophthalmology/Optometry consult. During an interview on 6/13/12 at 0930 hours, interpreted by CNA 7, Resident 21 was able to follow simple commands such as raising his arms, opening his mouth and shaking his head yes or no. Review of Resident 21's Eye Consultant Record dated 6/14/12, shows the resident has mild cataracts and a recommendation for a re-examination to monitor his cataracts in six months. c. Review of Resident 21's Face Sheet showed no documentation to identify his marital status, race, religion, birthplace, primary language, or emergency contacts. Review of Resident 21's Social Service Progress Note dated 2/16/12, shows Resident 21's physician requested the SSD try and find emergency contacts for Resident 21. The SSD documented the acute care hospital had no contact information on Resident 21. Review of Resident 21's Social Service assessment dated [DATE], shows he has no family and the facility is his main support system. A Social Service Update dated 5/23/12, shows no family found as yet, facility staff is his main support system. No further documentation was available to show the SSD attempted other avenues to pursue Resident 21's personal information or family/friends. Review of Resident 21's Psychoactive Medication Acknowledgement sheets shows on 6/12/12, the IDT agreed to have Ativan (antianxiety medication) 1 mg every 12 hours given for thrashing in bed and Depakene (an anticonvulsant drug used off label to treat psychiatric conditions) 500 mg three times a day given for behavioral disturbances. On 3/22/12, the IDT agreed to have Zyprexa (antipsychotic medication) 5 mg given twice a day for being resistive to care and on 3/7/12, Ambien (sleeping pill) 5 mg every night for sleeplessness. Review of Resident 21's Informed Consent for Chemical/Physical Restraints, revised date 6/10/12, showed the IDT was notified and approved to have a Wanderguard bracelet applied (a device to alert the staff if the resident wanders out of the facility), a non-release seat belt to alert the staff of attempting to get out of the wheelchair, and bilateral hand mittens for episodes of pulling out his GT. On 6/12/12, the IDT was notified and approved for Resident 21 to have a Tab alarm (alarm to alert the staff when the resident attempts to get up unassisted) and bilateral half siderails up. During an interview on 6/13/12 at 1015 hours, the SSA stated Resident 21 has no contact information on his Facesheet. She was unable to locate documentation to show Resident 21 was discussed at a Bioethics Committee meeting, an attempt for guardianship or any court order for the facility to act as Resident 21's responsible party. During an interview on 6/13/12 at 1020 hours, the Administration stated Resident 21 was not discussed at a Bioethics Committee meeting. During an interview on 6/13/12 at 1020 hours, when the SSD was asked who was involved in determining the facility's IDT would be Resident 21's conservator and decide his plan of care, she was unable to determine how the IDT became his conservator. When she was asked if the Ombudsman was involved in determining Resident 21's plan of care, she stated, "no." On 6/13/12, Resident 21's Social Work Progress Notes shows a letter was faxed to the acute care hospital in an attempt to obtain Resident 21's personal information. In addition, the SSD documented the Medical Director will be contacted to schedule a Bioethics Committee meeting, a Public Guardian was contacted for conservatorship and the Ombudsman was contacted to assist in the care needs of Resident 21. During an interview on 6/13/12 at 1420 hours, the SSD stated Resident 21 was scheduled for a dental and vision examination on 6/14/12, and a Bioethics Committee was being scheduled. 2. Clinical record review for Resident 13 was initiated on 6/11/12. Resident 13 was admitted to the facility on [DATE], with status [REDACTED]. Resident 13's room is in the front hallway of the facility and the resident's bed is next to a window. Review of Resident 13's acute hospital Social Services Progress Notes dated 6/5/12 at 1600 hours, shows a referral was made to the social service department related to a threat of violence to Resident 13, her family members and facility staff. The notes showed Resident 13's family member threatens to kill her, hits her with his cane, threatens to shoot her with his gun and will break her neck. In addition, Resident 13's family member threatens to shoot the staff at the hospital if they try to stop him from visiting her. The hospital security department was notified of the allegations to shoot Resident 13, her family members and staff. Resident 13's identity was changed to "no information" to protect her. The local police was notified and a temporary restraining order was obtained against Resident 13's family member. Review of Resident 13's care plan dated 6/11/12, to address her psychosocial needs related to her family member threatening to kill her, showed no approach plans to address her safety and the safety of the staff and visitors. No documentation was available to show the SSD was aware of the temporary restraining order for Resident 13's family member, or how the facility was going to protect the resident, visitors and staff. During an interview on 6/11/12 at 1515 hours, the SSD stated Resident 13's family member was becoming more aggressive, has a weapon and is threatening to kill her. When the SSD was asked what steps have been put in place for Resident 13's safety, she stated the receptionist is aware to not forward any telephone calls to Resident 13. The SSD stated the facility does not have a photograph of Resident 13's family member who is threatening to kill her, and is unaware if the family member has access to a weapon. The SSD was unaware a temporary restraining order had been filed against Resident 13's family member. On 6/12/12 at 0800 hours, the SSD stated a picture of Resident 13's family member was obtained and posted at the receptionist's desk and the nurses' station. She stated the staff had been instructed to contact the police in the event the family member arrives at the facility. In addition, the SSD stated Resident 13 was offered a room towards the back of the facility, away from the window. 3. During initial tour on 6/11/12 at 0915 hours, Resident 1 and his spouse were in the resident's room. The spouse asked when the resident can go home. Resident 1 stated he is ready to go home. The resident was observed with a GT feeding and with an intravenous catheter site to his right arm. Clinical record review for Resident 1 was initiated on 6/11/12. Resident 1 was admitted to the facility on [DATE], following hospitalization for an intestinal obstruction, septic shock, acute renal failure and electrolyte imbalance. Review of the physician's orders [REDACTED]. Resident 1 is also receiving specialized rehabilitation services. Review of the social services documentation showed the last assessment and entries were dated 5/9/12, the day of admission. The social service staff documented a note which showed social services will follow up with the spouse for discharge planning. On 6/13/12 at 1120 hours, an interview was conducted with Resident 1 and his spouse. Both the resident and his spouse inquired as to when he is going home. Resident 1 stated, "I'm ready to go home." Further review of the clinical record showed a physician's telephone order dated 6/11/12, for physical therapy to be continued for two more weeks. Review of the social service notes showed no additional documentation since the entry dated 5/9/12. On 6/13/12 at 1140 hours, another interview was conducted with Resident 1 and his spouse. They were unaware of the physician's orders [REDACTED]. The spouse stated they have insurance to cover that type of care in their home. On 6/13/12 at 1141 hours, the SSD was made aware of Resident 1 and his spouse's concern about discharge planning and not being kept informed about the resident's care updates. The SSD stated she will send in the SSA assigned to Resident 1 as soon as they returned to the office. 4. Clinical record review for Resident 5 was initiated on 6/11/12 at 1330 hours. The admission MDS dated [DATE] shows no documentation of dental problems. A dietary assessment progress note dated 6/7/12, shows a regular lowfat diet. On 6/11/12 at 1415 hours, an interview was conducted with Resident 5. During the interview, an observation shows the resident has no upper and lower teeth in the front of his mouth. When asked how he is able to chew his food, he stated he chews with his gums. He stated he had a partial when he came into the facility last year, but they broke and he threw them in the trash. On 6/13/12 at 1100 hours, an interview with SSA 2 was conducted. When asked whether Resident 5 had a dentist appointment, SSA 2 stated she wasn't sure, but she will make a phone call to obtain insurance approval and make the dentist appointment. Before making the phone call, she found a letter from the resident's dental insurance plan dated the week of 5/20/12, addressed to the Director of Nursing at the facility's address. She refers to handwritten notes on the bottom of the letter showing Resident 5 was seen on 5/25/12, and authorization was already approved. No attempt had been made to make an appointment for the dentures. On 6/14/12 at 1600 hours, the SSD stated Resident 5's dentist appointment has been made for 6/15/12 at 0800 hours. She informed the resident of the appointment to start extractions for upper and lower dentures.