Every finding on record at The Lodge of Saginaw Health and Wellness

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for clinical records. The facility failed to ensure facility staff documented bruising on Resident #1's Weekly Wound Progress Report during his admission from 04/04/26 - 06/23/26. This failure could place residents at risk for inaccurate assessments and monitoring.Findings include: Record review of Resident #1's face sheet, dated 06/30/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] for rehabilitation after a significant cerebral infarction. Resident #1 had relevant diagnoses which included cerebral infarction (interruption of blood flow to the brain,) acute cystitis (inflammation of bladder,) atherosclerotic heart disease (accumulation of cellular waste in arteries,) and benign prostatic hyperplasia (non-cancerous enlargement of prostate gland.) Record review of Resident #1's MDS, dated [DATE], revealed he was severely impaired with cognitive skills for daily decision making, with short- and long-term memory problems. He required a wheelchair for mobility; and was totally dependent upon staff for toileting, bathing, and other personal hygiene tasks. Record review of Resident #1's Comprehensive Care Plan, on 06/30/26, revealed the resident was on anticoagulant therapy related to CVA (interruption of blood flow to brain.) Record review of Resident #1's Provider Orders on 06/30/26 included: Aspirin 81 mg oral via g-tube one time a day for atherosclerotic heart disease dated 04/07/26. Clopidogrel Bisulfate 75 mg oral via g-tube in the morning for atherosclerotic heart disease dated 04/08/26. Enoxaparin Sodium 40 mg/0.4 ml inject subcutaneously at bedtime to prevent DVT (blood clot) and help with circulation dated 04/04/26. Monitor for signs and symptoms of [bleeding] adverse reaction. abdominal pain. headache, lethargy, dizziness, hematuria (blood in urine,) anemia (decrease in healthy red blood cells, decreasing the ability for the body to carry oxygen efficiently to tissues). hemorrhage (bleeding) . for anticoagulant monitoring dated 04/07/26. Peripheral IV - monitor for s/s of infection every shift . for fluids dated 05/18/26. Sodium Chloride Solution. 75 ml/hr. for volume depletion. 1 liter. dated 05/18/26. Record review of the facility Braden Scale Assessment, dated 05/02/26, revealed Resident #1 was at moderate risk for skin breakdown. Record review of facility provided documentation commonly known as shower sheets for Resident#1 dated 06/13/26 at 2:00 PM revealed bruising with the resident's arms circled bilaterally. Record review of facility provided documentation commonly known as shower sheets for Resident #1 dated 06/16/26 at PM revealed bruising with the resident's arms circled bilaterally. Record review of facility provided documentation commonly known as shower sheets for Resident #1 dated 06/18/26 at 6:00 PM revealed bruising with resident's forearms circled on the left side. Record review of Weekly Wound Progress Report, dated 06/16/26 at 3:09 PM revealed no evidence of documentation related to Resident #1's arms. Record review of Weekly Wound Progress Report, dated 06/22/26 at 11:40 AM revealed no evidence of documentation related to the bruising on the Resident #1's arms. Record review of [Provider] Surgical Note from Wound Care, dated 06/15/26, revealed no documentation related to the bruising to Resident #1's arms. Record review of [Provider] Surgical Note from Wound Care, dated 06/22/26, revealed no documentation related to the bruising to Resident #1's arms. Attempts to interview Wound Care Provider on 06/30/26 at 5:47 PM and 07/01/26 at 10:00 AM were unsuccessful. Attempts to interview Resident #1 on 06/30/26 at 10:00 AM were not successful due to his cognitive limitations. In interview with facility's Treatment Nurse on 06/30/26 at 1:59 PM, she stated she was aware of Resident #1's arms and it was typical of any AC therapy in addition to his age and skin fragility. She stated it was very common and would not necessarily be required to document on the weekly skin assessment. In interview with the DON on 06/30/26 at 5:18 PM, she stated she reviewed the shower sheets daily in the morning meeting. She stated she was aware of the bilateral discoloration due to his age, medical conditions, blood lab draws, IV fluid, and regimen of blood thinners; but she did not feel it required further assessment at that time. She stated she was confident it was not trauma related and only related to his medical condition. She further stated it was her responsibility to review the skin sheets and determine if further assessment and documentation was warranted. She stated Resident #1's bruising was not required to be further documented. Review of facility policy System Pathway #1 Guide - Skin and Wound Management, rev. 06/26 revealed 14. Residents with newly identified or known pressure injuries, ulcers, wounds, etc. should be reviewed by the IDT upon notification and weekly thereafter, and a care plan should be developed, implemented, evaluated, and re-evaluated to treat actual the site(s) and reduce further pressure injuries, ulcers, wounds, etc This will include but not be limited to review of lab results, risk factors, positioning, etc.

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #1and #2) of six residents reviewed for infection control. 1. The facility failed to ensure Wound Nurse J performed hand hygiene and changed her gloves during Resident #1 and #2's wound care on 06/18/26. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/18/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1. Record review of Resident #1's face sheet dated 06/18/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region, stage 4. Record review of Resident #1's MDS dated [DATE] revealed no BIMS evaluation score. It revealed that the Resident has pressure ulcer care and is at risk to develop pressure ulcers. Record Review of Resident #1's Physician Order dated 04/13/26 revealed: Cleanse Sacrum with NS, pat dry, apply calcium alginate and cover with dry dressing daily. Review of Resident #1's care plan dated 04/06/26 revealed the Resident is at risk for significant infections and/or recurrent infections r/t compromised medical condition r/t Acute Cystitis (bladder infection or a common urinary tract infection). 2. Record review of Resident #2's face sheet dated 06/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Acquired Absence of Left Leg Below Knee, Acquired Absence Of Right Leg Below Knee. Record review of Resident #2's MDS dated [DATE] revealed that the resident had a BIMS score of 15 (indicates no cognitive impairment). It revealed that the Resident has surgical wounds. Record Review of Resident #2's Physician Order dated 06/18/26 revealed Left leg/AKA stump: Cleanse area with NS, pat dry,apply Betadine and leave open to air daily. one time a day for wound care. Review of Resident #2's care plan dated 06/05/26 revealed the resident has an alteration in musculoskeletal status bilateral lower leg r/t Right BKA and S/P left AKA with the goal of the resident's wound will heal and progress without complications through the review date. During an Observation and interview on 06/18/26 at 10:16 a.m. to 10:25 a.m. it revealed that Wound Nurse J performed hand hygiene, put on clean gloves, she failed to remove soiled gloves after removing Resident #1's soiled dressing and proceeded to clean the wound with the same soiled gloves. She failed to sanitize hands before putting on clean gloves after she cleaned Resident 2's sacral area and proceeded to cleanse the Left AKA stump surgical wound. During an interview with the wound nurse She stated I should put gloves on, cleanse, change gloves, sanitize hands before putting on new gloves. She stated it is important to change gloves when doing wound care from dirty to clean procedure to prevent wound from getting worse and infected. She stated that not following procedure can affect the resident's health and skin and make them worse. During an observation and interview on 06/18/26 at 10:45 a.m. to 10:55 a.m. with CNA D, she performed incontinent care on Resident #1 and did not change her gloves throughout the observation. During ad interview with CNA D She stated that she should wash hands and change gloves and keep hands clean and not touch the resident with dirty gloves and change gloves throughout the care. She stated that it is important to change gloves to keep the residents safe and free from germs as much as possible. She stated that the resident could develop an infection if gloves are not changed throughout the care. She stated she has received training on incontinent care and that she should have followed the training instructions. During an interview on 06/18/26 at 11:40 a.m. with LVN A She stated that everyone who is incontinent is changed every 2 hours or be helped to go to the toilet. She stated that the CNA should report any changes in skin condition to the charge nurse.She stated that gloves should be changed during the care to prevent infections. She stated that the CNA's are trained periodically on incontinent care. She stated that if gloves are not changed during care it will result in increased chances for infection.She stated that the biggest danger is that they could become septic on top of the infection. During an interview on 06/18/26 at 4:00 p.m. with the DON She stated that gloves should be changed and hand sanitized when going from dirty to clean area or task during wound care and incontinent care. She stated that it is the expectation that the staff follow the training. She stated that the risk to the resident will be potential for infection, prolonged wound healing. Record review of the facility's policy Hand - Washing Skill Checklist revealed: Purpose:To remove germs from hands and prevent the spread of infection. Guidelines and Precautions:1. Hand-washing is the single most important method in the prevention and control of infection.2. Hand-washing should be done at the following times:a) When coming on and going off duty.b) Before and after caring for each residentc) Before applying gloves and after removing gloves.d) Before and after eating, drinking, smoking, using lip balm, touching contact lenses, wiping nose, using toilet.e) After contact with blood, body fluids and contaminated items (Procedural Guideline #9).f) Whenever hands are obviously soiled.3. Precautions:a) Always keep your fingertips pointed down while washing your hands.b) Avoid leaning against sink or splashing uniform during Hand-washing.c) Do not touch the inside of sink or faucet handles with clean hands.4. Handwashing with soap and water or Alcohol Based Gel is approved for cleansing of hands (see number 5)

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of six residents reviewed for wound care. The facility failed to follow the facility's wound cleaning protocol for Resident #2's left above the knee amputation stump dressing change on 06/18/26. This failure put Resident #2 at risk of not receiving necessary treatment and a worsening of their wound.Findings included: Record review of Resident #2's face sheet dated 06/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Acquired Absence of Left Leg Below Knee, Acquired Absence Of Right Leg Below Knee. Record review of Resident #2's MDS dated [DATE] revealed that the resident had a BIMS score of 15 (indicates no cognitive impairment). It revealed that the Resident has surgical wounds. Record Review of Resident #2's Physician Order dated 06/08/26 revealed Left leg/AKA stump: Cleanse area with NS, pat dry,apply Betadine and leave open to air daily. one time a day for wound care. Review of Resident #2's care plan dated 06/05/26 revealed the resident has an alteration in musculoskeletal status bilateral lower leg r/t Right BKA and S/P left AKA with the goal of the resident's wound will heal and progress without complications through the review date. Observation and Interview with Wound Nurse J on 06/18/2026 from 10:25 a.m. to 10:50 a.m. The Wound Nurse cleansed the left AKA stump with wound cleanser, applied betadine solution and covered with 4-inch x 4-inch bordered gauze. When asked about the danger of giving treatment without a physician's order, she stated it is important to follow the wound order by the wound doctor to make sure the wound heals. She stated per Resident #3's request she covered the wound with a bordered gauze which was not part of her wound care orders. She stated she should check with the doctor first to make sure the resident request is applicable for her wound care and then she writes an order before implementing the order. She stated that the resident should be educated per the request and call the doctor to make sure the request is ok before carrying out resident request. During an interview with the DON, she stated that the procedure is to notify the physician of the resident request to get a one time /prn order for the request. She stated that the Resident's should be called in to the physician, obtain an order before the treatment request is carried out by the wound nurse. She stated that everything that is done for the residents is physician driven so an order is needed for any treatment provided. She stated treatment without an order could result in potential for the wound not to heal. A Record review of the facility's Medication and Treatment Orders revealed : Medications and other treatments should be administered only upon the written, verbal or electronic order of a person duly licensed and authorized to prescribe such medications in this state.2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.3. Drug, biological orders and intervention orders are recorded on the physician's order sheet in the resident's chart or in the physician order tab of a residents' electronic medical record. Such orders are by Nursing and reviewed by the consultant pharmacist on a monthly basis.4. All drug, biological orders and intervention orders are written, dated, and signed (electronic signature allowed in PCC) by the person lawfully authorized to give such an order.5. The signing of orders are to be by signature or a personal computer key. Signature stamps may not be used.6. The staff and practitioners should use only approved abbreviations and symbols when ordering and/or charting medications.7. Verbal orders are to be recorded immediately in the resident's chart by the person receiving the order and includes prescriber's last name, credentials, the date and the time of the order.8. Verbal orders are to be signed (written or e-signed) by the prescriber at his or her next visit or electronically.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3's rooms were in a position that was accessible to the resident on 06/18/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record Review of Resident #3's Face Sheet, dated 06/18/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait and mobility. Record Review of Resident #3's Comprehensive Care Plan, dated 04/23/26, revealed the resident has an ADL self-care performance deficit r/t decreased mobility, other lack of coordination with intervention to Encourage the resident to use bell to call for assistance. It revealed the resident is at risk for falls r/t History of falls at home, muscle weakness, other lack of coordination, with intervention to Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and Follow facility fall protocol. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the Resident had a BIMS score of 7 (severe cognitive impairment). The Quarterly MDS Assessment indicated that the residents required substantial assistance for toileting, hygiene, dressing, bed mobility, and transfer. During an observation and interview on 06/18/26 at 10:55 a.m. revealed Resident #3 was in his bed, awake. It was observed that the resident's call light was on the floor. When asked about his call light, the resident pointed to it hanging on off the wall, he did not give any verbal response. During an interview and observation with CNA D on 06/18/26 at 10:57 a.m. She stated that the policy is that all call bells should always be reachable by residents. She stated that for Resident #3, she should check him every hour to make sure the call bell is in place, she stated that all staff are responsible for making sure the call bell is in place. She stated that the call light should be in place for residents who are dependent on staff to call help. She stated that if the call light is not reachable the resident could fall and injure themselves trying to reach it. During an interview with Housekeeper M on 06/18/26 at 11:30 a.m. She stated that the call bell should always be within reach of the resident. She stated that the call bell should be in place just in case the resident need help with something or if they fall. She stated everyone is responsible to make sure that the call bell is in place. She stated that if the call bell is not within reach it could be a fall risk and the resident could be hurt and not have a way to call for help. During an interview with LVN A on 06/18/26 at 11:40 a.m. she stated that Resident #3 throws his call bell away from himself.She stated that the resident is educated on the need to have call bell within reach so he can reach it to call for help, but he keeps throwing it away. She stated that no other intervention has been implemented to make sure the call bell is in place. She stated that the policy is that the call bell has to always be within reach. She stated that the call bell should be withing reach for safety and the resident can call for help when needed. She stated that the resident can fall and injure themselves if the call bell is not withing reach for the resident to call for help. During an interview with the DON on 06/18/26 at 4:00 p.m. She stated that the call bell should always be within reach of the resident. She stated that it should be within reach for residents to call for assistance She stated that the call bell not within reach will be potential for the resident needs not being met. She stated that all facility staff are responsible for making sure the call bell is within reach Record review of the facility's policy Answering the Call Lights revealed: Purpose:The purpose of this procedure is to ensure timely responses to the resident's requests and needs.General guidelinesUpon admission and periodically as needed, explain use of the call light to the resident.Ask the resident to return demonstrationExplain to the resident that a call system is also located in the bathroom.Be sure that the call light is plugged in and functioning at all times.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Some residents may not be able to use the their call light. Be sure you check on these residents fre.Report all defective call lights to the nurse supervisor promptly.

Tag: F689 /4027S/S= D Surveyor Name(s): [NAME] NnadiImmediate Supervisor: Verlair AsheBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 6 residents (Resident #3 and #6) reviewed for accident prevention. The facility failed to ensure Resident #3's fall mat was placed alongside his bed while she was lying in the bed on 06/18/26. 2. The facility failed to ensure Resident #6's bed was in a low position for fall prevention per the care plan while he was lying in bed on 06/18/26. This failure could prevent the residents from having an environment that was free from hazards.Findings include: Record Review of Resident #3's Face Sheet, dated 06/18/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait and mobility. Record Review of Resident #3's Comprehensive Care Plan, dated 04/23/26, revealed the resident has an ADL self-care performance deficit r/t decreased mobility, other lack of coordination with intervention to Encourage the resident to use bell to call for assistance. It revealed the resident is at risk for falls r/t History of falls at home, muscle weakness, other lack of coordination, with intervention to Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and Follow facility fall protocol. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the Resident had a BIMS score of 7 (severe cognitive impairment). The Quarterly MDS Assessment indicated that the residents required substantial assistance for toileting, hygiene, dressing, bed mobility, and transfer. During an observation on 06/18/26 at 10:55 a.m., Resident #3 was in his bed with his fall mat leaning against the wall. During an interview on 06/18/26 at 11:15 a.m., with CNA D she stated that the fall mat should be by the bedside, she stated that the housekeeper moved it while cleaning the floor. She stated that everyone is responsible for making sure the fall mat is in place and that she should have put it back next to the resident when she noticed it leaning on the floor. She stated the resident throws things off his side, and they must go put things back in place. She stated the fall mat should be in place for Resident #3's safety and avoid serious injury when he falls. During an interview on 06/18/26 at 11:30 a.m. with Housekeeper M, she stated the fall mat should be in place to protect the residents if they fall. She stated everyone is responsible to make sure they are in place including myself. She stated she should have put the fall mat back in place when she noticed it was on the wall and not next to the residents' bed. She stated the resident could break a bone or hit his head on the floor if he fall mat is not in place. During an interview on 06/18/26 at 11:40 a.m. with LVN A, she stated that the resident has a history of weakness and has fallen since he has been here and he has been educated to use his call light when he needs to transfer. She stated that the fall mat should be to both sides of bed and bed in lowest position when the resident is in bed. She stated that not having the fall mat could cause the resident to hit his head on the floor and will need to be sent to the hospital. She stated that the nurse is responsible for making sure that the fall mat is in place. 2. Record Review of Resident #6's Face Sheet, dated 06/18/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with Parkinson's disease, fracture of left Femur (long bone of the thigh), multiple fractures of ribs. Record Review of Resident #6's Comprehensive Care Plan, dated 05/15/26, revealed 1) the resident has an ADL self-careperformance deficit r/t Parkinson's disease, Dementia, fall with left Femur and right sided multiple ribs fracture, S/P ORIF leftFemur, muscle weakness, 2) The resident is at risk for falls r/t history of multiple falls, recent fall at home with fracture, muscle weakness, Other lack of coordination, Muscle weakness, Orthostatic Hypotension (abnormal drop in blood pressure when standing), 3) with intervention to Follow facility fall protocol. 3) The resident has had an actual fall on: 06/06/2026, 06/13/2026 with intervention of Bed changed for safety and fall precautions. Record Review of Resident #6's Quarterly MDS assessment dated [DATE], did not reveal a BIMS assessment score. The Quarterly MDS Assessment indicated triggered care area of falls with fall-related fracture in the last 6 months. During an interview and observation on 06/18/26 at 1:52 p.m. with CNA M, the bed position was called to the attention of CNA M and he proceeded to put the bed in the lowest position. He stated that the policy is that the bed should be in the lowest position and fall mat in place. He states that if the bed is not at the lowest position, it could cause serious injury to the residents. He stated that the CNA /Nurse are responsible for making sure the bed is in the lowest position for fall risk residents. He stated that if the care plan is not followed it could lead to serious injuries and the resident could be hospitalized During an interview on 06/18/26 at 1:57 p.m. with LVN S, she stated the bed should be in the lowest position and floor mats in place with call light within reach. She stated that following the care plan is to prevent injury. She stated that it can affect the residents' mobility, independence and emotionally if they fall and injure themselves. She stated that anyone that comes in contact with the resident is responsible for making sure that the bed is in the lowest position. During an interview on 06/18/26 at 4:00 p.m. with the DON, she stated that the fall protocol should be always followedShe stated that the bed should be in the lowest position and fall mat in place. She stated that if the care plan is not followed it could be a risk for injury for the residents. She stated that all facility staff going into the room are responsible for making sure the care plan is followed. A record review of the facilities Fall -Clinical Protocol revealed: Treatment/Management1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls.b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #4 and Resident #5) of six residents reviewed for respiratory care. 1. The facility failed to ensure Resident #4 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 06/18/26. 2. The facility failed to ensure Resident #5 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and BiPAP mask was stored properly when not in use on 06/18/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: 1. Record review of Resident #4's Face Sheet, dated 06/18/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease COPD (a chronic inflammatory disease that causes obstructed airflow from the lungs), Chronic Respiratory failure with Hypoxia (long-term low oxygen in the blood) Record review of Resident #4's Quarterly MDS Assessment, dated 05/16/26, reflected that the resident had a a BIMS score of 08 indicating moderate cognitive impairment. The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #4's Comprehensive Care Plan, dated 05/16/26, reflected the resident had oxygen therapy and one of the interventions was provide oxygen therapy as ordered. The Comprehensive Care Plan did not indicate that the resident was the one taking off her nasal canula. Record review of Resident #4's Physician's Order, dated 05/16/26, revealed the following orders; O2@ 3 Liters via Nasal Canula Continuous every shift related to Acute Respiratory Failure with Hypoxia and Change O2 tubing/water. every night shift every Satlabel/date bag. 2. Record review of Resident #5's face sheet, dated 06/182026, reflected an [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included COPD. Record review of Resident #5's Quarterly MDS Assessment, dated 05/14/26, reflected that the resident had a a BIMS score of 11 indicating moderate cognitive impairment. The Quarterly MDS Assessment indicated the resident is coded for Debility, Cardiorespiratory Conditions, Acute Respiratory failure with Hypoxia. Record review of Resident #5's Comprehensive Care Plan, dated 03/05/26, reflected the resident had BIPAP Therapy. Care plan dated 03/04/24 revealed the resident has the potential for shortness of breath with oxygen therapy Per MD's orders as one of the interventions. Record review of Resident #5's Active Physician's Order on 06/18/26, revealed the following orders: Oxygen PRN @ 2 L/NC for ease of breathing, SOB or saturations less than 92% every 8 hours as needed for SOB, easy of breathing or low SaO2 less than92%. Noninvasive ventilation via BiPAP, Change Nasal Cannula and Humidifier Every Week on Sundays. Date Tubing AndHumidifier When changing. Clean O2 Filter and Concentrator every night shift every Sat, Sun for O2 therapy, During an observation and interview on 06/18/26 at 1:00 p.m. it was revealed Resident 4 was lying in her bed. The oxygen tubbing connected to the Oxygen tank on the wheelchair was draped across the wheelchair. It was not stored in a bag. Resident #4 stated she does not know how the Oxygen tube should be stored. During an observation and interview on 06/18/26 at 1:17 p.m. Resident #5 was sitting in his wheelchair, it was observed that his oxygen tubbing connected to his oxygen machine was laying on his nightstand and not stored in a bag. The BiPAP machine and breathing mask were on the nightstand. The breathing mask was not bagged. He stated he uses oxygen every time he lays in bed.He stated that the staff makes his bed for him. He stated no one had told him the oxygen tube and the BiPAP mask should be in a bag. During an interview on 06/18/26 at 1:25 p.m. with CNA A, she stated that she changed Resident #4 and left her in bed per Resident request and did not notice the nasal canula connected to the oxygen tank on the wheelchair was exposed. She stated that the facility policy is that the nasal canula and any breathing Masks should be bagged when not in use. She stated that the nurses and CNAs are responsible for making sure it is bagged. She stated that bagging the canula is to prevent contamination. She stated that if not bag it could cause infection and make the resident sick. She stated she had the training at school and at the facility. During an interview on 06/18/26 at 1:44 p.m. with LVN S, she stated that the facility policy is that the Oxygen tubes and BIPAP mask should be bagged. She stated that it should be bagged for infection control. She stated that the nurse and the CNA's are responsible for making sure it is bagged. She stated that if the canula is not bagged it could cause the residents to have respiratory infection. She stated that they have educated Resident #5 to put his oxygen tube in a bag, but not sure if it was documented. During an interview on 06/18/26 at 4:00 p.m. with the DON, she stated that anytime the oxygen tube and the BiPAP mask is not in use it should be placed in a bag to prevent bacterial contamination. She stated that all facility staff doing round are responsible for making sure that the cannulas are bagged when not in use. She stated that the risk of not having the cannula bagged could be potential for infection for the residents. Record review of the facility's policy Oxygen Concentrator & Other Respiratory Equipment. Revealed: Oxygen Concentrator & Other Respiratory Equipment - continued1. Change the oxygen cannula and tubing every seven (7) days and date or as needed. NOTE: Night shift may crossover from one day into the next day.2. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use or cover tubing with [NAME] poly tubing cover.

Based on observation, interview, and record review the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in 1 of 1 kitchen. The facility failed to ensure various foods stored in the kitchen freezer inside the walk-through fridge were sealed, dated and labeled and remove items opened past 7-day time frame. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview of the walk-through fridge on 12/15/25 at 9:00 AM with the Dietary Manger revealed a container of red sauce, corn, gravy, and green beans were not labeled identifying the contents and did not have a disposal date. The fridge also had open, exposed diced ham, and sliced turkey in their original packaging that was not sealed and open to air nor did it have a disposal date. The fridge also had link sausage in its original packaging that was open to air and did not have a disposal date. Observation of the freezer inside the walk-through fridge two clear bags of unknown/unlabeled white balls and the bags were not sealed and opened to air. According to the Dietary Manager she had been out of work for a week and returned 12/15/25 and had not completed her daily walk through the kitchen. The Dietary Manager stated the red sauce was enchilada sauce, Mexican Corn, gravy and the green beans were leftovers that could be used throughout the week and would be disposed after the 7th day. The Dietary manager stated the cooks, and all kitchen staff were responsible for properly labeling, dating and removing items for the past 7 days. The Dietary Manager further stated food items should be properly labeled, dated and sealed so that everyone knew what it was, and to prevent items from spoiling or having salmonella. Interview on 12/17/25 at 4:07 PM with the Administrator revealed he was not aware food was found to be opened and not sealed, had missing labels such as contents and open or disposal dates. The Administrator stated the Dietary Manager was responsible for ensuring food was kept in a safe manner to prevent foodborne illnesses. The Administrator stated that not properly sealing, labelling, and dating food items could cause staff to use outdated food items potentially causing an allergy or negative reactions in residents. Review of the facility's Food Storage policy, revised June 1, 2019, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, should always maintain clean food storage areas. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training and care of the cognitively impaired for 2 (CNA G and CNA H) of 5 CNAs reviewed for annual training. The facility failed to provide CNA G and CNA H with 12 hours per year of annual training. This failure could place residents at risk of being cared for by untrained staff.Findings included:Review of CNA G's personnel record revealed a hired date of 10/24/23. The annual training in-service provided by the facility did not include evidence of 12 hours of annual training. Review of CNA H's personnel record revealed a hired date of 02/28/23. The annual training in-service provided by the facility did not include evidence of 12 hours of annual training. Interview on 12/17/25 at 4:27 PM with ADON G who stated inservices with the CNA's were provided by ADON's and DON collectively. ADON G said she was aware all CNA's had to have 12 hours annually, but she was not aware CNA G and CNA H had been short training hours. ADON G said she was unsure who kept up with the number of inservices hours to ensure they were complete, and she said it was important for CNAs to have the proper number of inservices hours, so they were up to date on their care education. Interview on 12/17/25 at 4:33 PM with the DON revealed she and the ADONs provided in person monthly CNA inservices and the company also had a computerized program that sent emails to the aides with certain inservices to complete. The DON said she was not aware CNA G and CNA H did not have their 12 hours of annual inservices and she said it was important for the CNAs to be up to date with their training so they could provide adequate training. Interview on 12/17/25 at 4:44 PM with the Regional Corporate RN revealed the company used a computerized program to keep track of CNA inservices and it appeared the system was corrupted because they could not find the complete 12 hours for CNA G and CNA H. Review of the facility's policy titled In-Service Training Program, Nurse Aide revised 05/2019 reflected the following: All nurse aide personnel participate in regularly scheduled in-service training classes.3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. 4. Annual in-services:.are no less than 12 hours per employment year.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 32 residents (Residents #13 and #98) reviewed for pharmacy services. The facility failed to administer the morning medications on time resulting in Residents #13's hydrocodone scheduled for 2:00 PM not being administered and Resident #98's hydralazine not being administered at 2:00 PM on 12/15/25. This failure could cause residents to develop changes in their medical conditions. Findings included:Record review of Resident #13's quarterly MDS, dated [DATE], reflected Resident #13 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic pain, rotator cuff pain, and Alzheimer's Disease. Her BIMS score was 11, indicating she had moderate cognitive impairment. Her Functional Ability assessment revealed she used a walker and a wheelchair for mobility, and she required moderate assistance with her ADLs. Her Pain Management assessment indicated she received both scheduled pain medications, as well as pain medications when needed or requested. Record review of Resident #13's care plan, dated 11/03/25, reflected she had an ADL self-care deficit related to her Alzheimer's, and she was on pain medications for chronic pain. Record review of Resident #13's physician orders revealed orders, dated 11/07/25, for Hydrocodone-Acetaminophen 10-325 mg, one table three times a day, and Hydrocodone 10-325 mg one tablet every 24 hours as needed. Record review of Resident #13's medication administration record for December 2025 revealed on 12/15/25 the resident did not receive her hydrocodone scheduled for 2:00 PM as evidenced by no documentation of the medication being administered. Record review of Resident #98's quarterly MDS, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included high blood pressure, surgical repair of fractures of the left leg and right pelvis, and dementia. His BIMS score was 10, indicating he had moderate cognitive impairment. His Functional Abilities assessment revealed he used a walker and a wheelchair for mobility, and he required substantial assistance with his ADLs. Record review of Resident #98's care plan, dated 11/05/25, reflected he had an ADL self-care deficit related to mobility issues related to his fractures, and high blood pressure with the potential for abnormal blood pressures, impaired vision, headaches and stroke. Record review of Resident #98's physician orders revealed an order, dated 01/31/25 for Hydralazine 50 mg, one tablet three times a day. Record review of Resident #98's December 2025 MAR reflected on 12/15/25 he was not administered his 2:00 PM dose of Hydralazine as evidenced by no documentation of the medication being administered. Record review of Resident #98's vital signs revealed on 12/15/25 his blood pressure was within normal limits with a blood pressure of 122/61. Interview on 12/15/25 at 12:00 PM, LVN-E stated she was still administering the morning medications for the 400 Hall. She stated an Agency Medication Aide had not shown up that morning. The medication aide was supposed to cover [NAME] 200 and 400. She stated an agency nurse, who was working, was pulled off her assignment of the 200 Hall, to administer medications for 200 and 400 Halls. Around 11:30 AM, she stated she realized the morning medications had not been given on the 400 Hall, so she began to administer them. Interview on 12/15/25 at 12:10 PM, ADON-D stated she had been notified around 7:00 AM of the Agency Medication Aide not showing up for work. She stated she spoke with an agency nurse already working on the 200 Hall, pulling her off patient care to pass medications instead for the 200 and 400 Halls. ADON-D stated around 11:30 AM she realized the agency nurse had not made it to the 400 Hall, so she asked the nurse for the 400 Hall to pass the medications instead. ADON-D stated she contacted the physicians about the issue of the morning medications being given late, the physicians stated to not give any medications due in the afternoon, just the morning and evening doses were to be given. ADON-D stated there were other nurses, including herself, who were in the building and could have assisted with medication administration to get the medications administered in a timelier manner. Observation on 12/15/25 at 1:10 PM revealed the last morning medication for the 400 Hall was administered. Interview on 12/16/25 at 10:59 AM, Resident #98 stated he was not aware he did not receive his blood pressure medicine at 2:00 PM on 12/15/25. He denied any headache. Interview on 12/16/25 at 11:04 AM Resident #13 stated she had not received her mid-day pain medication on 12/15/25. She stated she did not know why it was skipped. She stated she had chronic pain and really did not notice any difference in her pain by missing the dose. She rated her pain a 4 out of 10. Interview on 12/16/25 at 11:10 AM the DON stated she was made aware of the situation around 11:45 AM on 12/15/25. She stated ADON-D had coordinated with the staff to cover the morning medication pass. The DON stated there appeared to have been miscommunication with the agency nurse about the expectation she would cover the 200 and 400 Halls, not just the 200 Hall. The DON stated there were other nurses in the building that could have started helping with medications, but she was not made aware of the situation until 11:45 AM. She stated the risk of the residents not receiving their morning medications on time, and not getting their midday medications could be a worsening of medical problems the medications were prescribed for. Record review of the facility's Medication and Treatment Orders policy, dated July 2016, reflected it did not address medications being administered by the frequency ordered, or the timeliness of medication administration.

Based on observations, interviews and record reviews, the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 Residents (Resident #63 and Resident #5) of 23 residents reviewed for bowel and bladder incontinence.1. The facility failed to ensure Resident #63 was not left in soiled briefs, or being double briefed.2. The facility failed to ensure Resident #5 had physician's order for an indwelling catheter (device used to drain urine from bladder). This failure could place residents at risk of skin breakdown, infections and improper treatment. Findings included: 1. Record review of Resident #63's quarterly MDS, dated [DATE], reflected Resident #63 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure, dementia, and cognitive communication deficit. The resident had severe cognitive impairment with a BIMS score of 2. The MDS reflected that the resident required moderate assistance with toileting, and she had frequent bladder and bowel incontinence. The resident was not on a toileting program. Record review of Resident #63's care plan, dated 10/09/25, reflected that she had the potential for skin impairment, and she had an ADL self-care deficit related to dementia. She also had impaired cognitive function. Observation and interview on 12/15/25 at 11:00 AM revealed Resident #63 was in bed with a brown ring around her on her fitted sheet and an odor of urine about her. The resident was not responsive to questions. Interviews of other residents of the hall revealed no issues with their briefs being doubled. Observation on 12/15/25 at 11:45 AM revealed Resident #63 remained with the brown ring on her sheet. Observation on 12/15/25 at 12:04 PM revealed RN A was bedside with Resident #63 to take the resident's vital signs. She noted the brown ring on the sheet, and RN A called for assistance for changing the resident. Observation on 12/15/25 at 12:10 PM revealed RN A and CNA B were at Resident #63's bedside to change the resident. When the bedding was removed, it revealed the fitted sheet, the top sheet, and the bottom of the resident's shirt were all wet with urine. The resident was also noted to have two briefs on (double briefing) with the inner brief soaked with urine. No skin breakdown noted. Interview on 12/15/25 at 12:36 PM, CNA B stated double briefing the residents was not allowed, she stated it could cause skin breakdown. She stated she was not the CNA for Resident #63 and did not know the last time the resident had been changed. Interview on 12/15/25 at 1:20 PM, CNA-C she stated she had checked Resident #63 around 8:00 AM and the indicator strip on the outside of the brief had not changed colors, indicating she was not wet. She stated she did not see a brown ring around the resident at that time. She was also unaware the resident had two briefs on; she stated that must have been done on the night shift. Interview on 12/15/25 at 1:26 PM, ADON D stated double briefing a resident was not allowed. She stated it could cause skin breakdown and wounds. She stated residents who were incontinent were to be checked every two hours. She stated just observing the indicator strip was not enough to determine if the resident was wet or dirty. Interview on 12/16/25 at 11:06 PM, the DON stated it was not acceptable to double brief residents with the intent to not have to change the resident as often. She stated in rare cases the resident might be care planned for double briefing if they request to do so, but it was not appropriate for residents with cognitive impairment. 2. Record review of Resident #5's re-entry MDS assessment dated [DATE] reflected Resident #5 was [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had a blank BIMS score of 00 indicating Resident #5 could not complete the assessment. Resident #5's MDS further revealed he had short term memory problems and moderately impaired cognitive skills for daily decision making. Resident #5's diagnoses included hypertension (high blood pressure), Hypo-Osmolality and Hyponatremia (low sodium levels in the blood). The MDS reflected Resident #5 was dependent on staff for personal hygiene and toileting assistance with use of an indwelling catheter. Record review of Resident #5's undated care plan revealed Resident #5 had activities of daily living performance deficit related muscle weakness and other abnormalities. Goal: Resident #5 will maintain/improve current level of function. Interventions included assistance of 1 staff with personal hygiene and toilet use. Resident #5 is on enhanced barrier precautions related to Foley Catheter use. Goal: Enhanced barrier precautions to be utilized during activities of daily including but not limited to: Dressing, bathing, transferring, providing hygiene, changing linens/briefs or when toileting, care of indwelling medical device. Record review of Resident #5's undated care plan revealed Resident #5 had Indwelling Catheter: related to Urinary Retention. Goal: The resident will be/remain free from catheter-related trauma. Interventions included Catheter: Position catheter bag and tubing below the level of the bladder and away from entrance room door. refer to physician orders for size and changing the schedule. Check tubing for kinks each shift. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to physician for signs and symptoms Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Privacy bag for drainage bag at all times while in bed, while walking or in wheelchair every shift. Check for privacy bag every shift. Record review of Resident #5's undated care plan revealed Resident #5 had over reactive bladder. Goal: Resident #5 will remain free from skin breakdown. Interventions included to monitor and document intake and output as per facility policy. Monitor/document for signs and symptoms Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #5's December 2025 Treatment Administration Record reflected there was no treatment order regarding his catheter or catheter care. Record review of Resident #5's physician's orders reflected there was not an order for catheter use, what French gauge required, or any care or treatments. Record review of Resident #5's progress note written by LVN J reflected: [AGE] year-old male admitted /readmitted from Hospital under physician care. Diagnosis: Low blood sodium, High blood pressure, High Cholesterol. Resident is alert and oriented by 1-2 with intermittent confusion; requires 2 person assist with transfer and Activities of Daily Living, incontinent of bowel and bladder, has foley catheter, 16 French [catheter size with a diameter of approximately 5.3 mm], inserted on 12/02/2025. Resident is on fluid restriction 1200 milliliter/day. Resident needs follow up appointment with urology and nephrology with in 1-2 weeks. Vital Signs; Blood Pressure 119/76, Pulse 69, Respiratory 18, Temperature 97.0, oxygen saturation 93 percent. Resident is stable, no respiratory distress noted, denies pain. Resident is oriented to call light, room and bed is in low position, no distress noted. Physician/Nurse Practitioner notified of admission and order received to continue current med orders. Interview on 12/15/25 at 12:00 PM with Resident #5 revealed he did have a catheter, had no issues or concerns with it. Resident #5 stated staff was very helpful with it. Resident #5 was not able to express his need for the catheter. Interview on 12/16/25 at 3:45 PM, CNA I revealed she was aware that Resident #5 required use of a catheter. According to CNA I she was responsible for checking Resident #5's catheter at least every two hours for draining needs, cleanliness and to ensure there were no signs of infection. CNA I stated if she saw anything of concern like unusual urine color, no draining, or signs of infection she would report her findings to the nurse. CNA I stated not following those responsibilities would place Resident #5 at risk of urinary tract infections and perhaps pain. Attempted phone interview on 12/17/25 at 9:55 AM with LVN J was unsuccessful. Interview on 12/17/25 at 10:04 AM, LVN K revealed she could not locate an order for use of the catheter, which should have included the proper gauge to use for replacement. LVN K stated she checked him earlier and she did not have any concerns with his catheter. LVN A stated the admitting nurse was responsible for ensuring the catheter order was entered upon admission. LVN K stated the ADON, and the DON would be responsible for verifying that all orders were entered. LVN K said not having an order for use of the catheter placed Resident #5 at risk of staff using the wrong supplies, and not able to monitor his input and output. Interview on 12/17/25 at 12:20 PM, ADON G revealed she expected nurses to enter all orders upon admission of each resident. ADON G stated she was responsible for checking orders the following business day after admissions, she ensured an order would be entered for catheter use and it included the gauge to use. ADON G stated she had been having issues with entered orders saving due to internet issues; however, she was not sure if that was the reason the orders weren't showing. ADON G stated not having catheter orders placed Resident #5 at risk of not having the right plan of care and the treatment he needed. Interview on 12/17/25 at 1:14 PM with the DON revealed there should be an order for catheter use and care and it should include the gauge. The DON stated the admitting nurse should have entered the order upon his admission and the ADON should have reviewed the orders within 24 hours to ensure the orders for his care were entered. The DON added upon review the orders were in the queue; however, they had not been approved and needed to be activated. The DON stated the omission placed Resident #5 at risk of inadequate care to the foley (medical device that helps drain urine from the bladder), monitoring, and infections. Record review of the facility's Briefs/Under Pads policy, dated September 2010, reflected: .11. Apply one new appropriate size of brief and/or one under pad. Record review of the facility's Medication and Treatment Orders policy, dated July 2016, reflected: Orders for medications and treatments should be consistent with principles of safe and effective order writing. 1. Medications and other treatments should be administered only upon the written, verbal or electronic order of a person duly licensed and authorized to prescribe such medications in this state .

Based on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #54) whose drug regimens were reviewed. The facility failed to clarify Resident #54's orders for KCL (potassium chloride, which is used to treat and prevent low blood potassium levels) and Clonidine (a medication used to treat hypertension) when the facility's Pharmacy Consultant made the recommendation for the change on 09/29/25 when the order was to give the medications by mouth. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Record review of Resident #54's Quarterly MDS Assessment, dated 11/05/25, reflected he was a [AGE] year-old male who was readmitted to the facility on [DATE]. He had a BIMS score of 10 which indicated moderate cognitive impairment. His active diagnoses included hypertension (high blood pressure), stroke (a brain injury that occurred because the brain supply was interrupted), and anxiety disorder (a group of mental health conditions characterized by excessive fear, dread, or apprehension). Resident #54 also used a feeding tube while being a resident at the facility, receiving 51% or more of his total calories through tube feeding. Record review of Resident #54's Order Summary Report, dated 12/17/25, reflected the following:- Nothing By Mouth (NPO) Diet with a start date of 06/09/25- Clonidine HCI Oral Tablet 0.1 MG (Clonidine HCI), Give 0.1 mg by mouth every 8 hours as needed for HBP with a start date of 09/25/25- Potassium Chloride Liquid 20 MEQ/15ML (10%) Give 20 mEq by mouth one time a day for Low Potassium with a start date of 09/05/25 Record review of Resident #54's December 2025 Medication Administration Record reflected he received potassium chloride each day but did not receive any clonidine . Record review of Resident #54's undated Care Plan reflected the following: Focus: The resident requires tube feeding r/t Dysphagia, [sic] esophageal varices/ Record review of Resident #54's Quality Assurance- Nursing Recommendations from the pharmacy, dated 09/29/25, reflected the following: .resident receives medication via PEG tube, order for KCL and Clonidine PRN reads to give by mouth, please clarify. There was a check mark in the next column labeled Follow-through. Observation and interview on 12/15/25 at 10:55 AM with Resident #54 revealed he was lying in bed and his tube feeding machine was off and not connected to him. Resident #54 said he was not feeling well and did not want to talk to the surveyor. Interview on 12/17/25 at 10:55 AM with LVN F revealed she was an agency nurse and this was her first shift at the facility and was not familiar with Resident #54, except that he used a g-tube. LVN D said she could not answer any questions about his medications because she just did not know anything. Interview on 12/17/25 at 11:21 AM with ADON G who said that all pharmacy recommendations were reviewed monthly. ADON G said Resident #54 used a g-tube and could not have anything by mouth, including medications. ADON G said she and the other ADON were responsible for reviewing the pharmacy recommendations and making the necessary changes. ADON G said the purpose of following pharmacy recommendations was to ensure that all orders were correct and if changes needed to be made those were addressed with the doctors. ADON G said she had been trained to review the pharmacy recommendations and make whatever changes needed to be. ADON G said if the pharmacy recommendations were not completed the resident could either miss something, get the wrong medication, or get the wrong dose. Interview on 12/17/25 at 1:11 PM with the DON who said Resident #54 used a g-tube and could not have anything by mouth, including medications. The DON said the ADON's were responsible for following-up on an pharmacy recommendations. The DON said she sometimes spot checks the pharmacy recommendations but not often because she trusted the ADON's to complete them accurately. The DON said the purpose of the pharmacy recommendations was for the accuracy of medications and contraindication for treating disease management. The DON said if pharmacy recommendations were not acted upon it could be detrimental to the resident, in this case with Resident #54 it could have led to him receiving something by mouth which could lead to aspiration or pneumonia. The DON said both the ADON's have been trained to review and follow-up on any pharmacy recommendations. Record review of the facility's policy, revised April 2007, titled Medication Therapy reflected: 6. The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. [BH3]

Based on observation, interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including: The right to be fully informed in language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition. for 2 of 12 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to ensure the staff was adequately able to communicate with Residents #1 and #2 in their primary language, Spanish, for their care and service needs. This failure place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.Findings included: A)Record review of Resident #1's admission assessment dated [DATE] revealed a [AGE] year old Mexican American female with a preferred language of Spanish who admitted [DATE]. She had a BIMS score of 11 (Moderate impairment) and for daily preferences it was very important to make decision about choosing clothes to wear and taking care of personal belongings. She had lower extremity functioning impairment on one side and no upper impairment and used a walker and wheelchair. She needed substantial/maximal assistance with most ADLS's for self-care and mobility. She was always incontinent with bowel and bladder and had medically complex conditions. She was diagnosed with hypertension, renal insufficiency, urinary tract infection, hyperlipidemia, arthritis, enterocolitis, Osteoarthritis, obesity, pain in right knee, muscle weakness, lack of coordination, cognitive communication deficit, Right artificial knee joint. She was at risk of developing pressure ulcer/injuries and took antibiotics in the past 7 days. Record review of Resident #1's Care Plan dated 10/06/25 revealed ADL Self-care performance deficit related to muscle weakness, other lack of coordination, potential for pain related to chronic kidney disease, cystitis, right knee and osteoarthritis and at risk for falls related to history of fall, muscle weakness. She had potential for skin impairment related to decreased mobility, incontinence, potential for pain related to chronic kidney disease, acute cystitis, right knee pain and potential for nutritional problem related to clostridium difficile, hyperlipidemia, chronic kidney disease. And dated 10/07/25 revealed a potential for pressure ulcer development related to decreased mobility, renal insufficiency related to chronic kidney disease, altered cardiovascular status related to hyperlipidemia, hypertension. (There was no Spanish language care plan) Interview and observation on 10/16/25 at 5:35 pm Resident #1 was sitting up in bed but did not speak English and was not able to answer questions. There was not any communication boards, binders or devices anywhere on the bedside table or nightstand to communicate with. B) Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed, an [AGE] year old Mexican female who had a primary language of Spanish. She admitted [DATE] with a BIMS score of 10 (Moderate cognitive impairment). She had upper and lower functioning impairment of both side and used a wheelchair, and partial/moderate assist for self-care and mobility assistance. She was occasionally incontinent with bladder and occasionally incontinent with bowel, none Alzheimer's dementia, hemiparesis, depression, schizophrenia, asthma, third lumbar wedge compression fracture, right foot drop. Record review of Resident #2's Care Plan dated 02/19/25 revealed, The resident has an altercation in musculoskeletal status required use of Knee ankle foot orthoses. On 03/19/25 Resident was on anticonvulsant medication related to nerve pain. On 05/15/25 The resident has arthritis. (There was no Spanish language care plan). Interview and observation on 10/16/25 at 5:40 pm Resident #2 spoke Spanish and was not able to answer any questions. There was not any communication boards, binders or devices anywhere on the bedside table or nightstand to communicate with. Interview on 10/16/25 at 3:50 pm, ADON F stated for their Spanish speaking residents they had Spanish speaking staff to translate for them. She stated they had communication boards at the nurses station and therapy room, but not in the resident's rooms. She stated if the staff spoke English to the Hispanic residents, it could result in them not understanding their care and needs. She stated she had used a translator on her phone to communicate with the Hispanic residents. Interview on 10/16/25 at 4:19 pm, MDS RN G stated for the Spanish speaking residents she would get a Spanish speaking CNA to help translate for her. Interview on 10/16/25 at 5:20 pm, SW H stated she had no complaints from anyone about the staff not knowing how to communicate in Spanish. She stated she did not know if the Hispanics had communication boards so they could visualize the picture to choose what their needs were. She stated it depended on the situation on how it could affect the residents. She stated the harm could be minimum or serious, such as needing to be changed more often. She stated the Hispanic residents needs would not be met if they were not able to figure out what the residents' needs were. Interview on 10/16/25 at 5:48 pm, the DON stated she started updating the care plans of the Spanish speaking residents today 10/16/25 because the HHSC Surveyor started asking the staff questions about them. She stated the staff needed to have a phone app to translate with the Hispanic residents to make sure their needs were met. She stated some of the staff used a phone app and ADON F would get a Hispanic therapist from the therapy department to translate to the residents at times. She stated today 10/16/25 RN B asked what would be the right way to communicate with the Hispanic residents. She stated yesterday afternoon on 10/15/25, CNA D asked her how should she communicate with the Spanish speaking residents. She stated telling RN B and CNA D they could use their phone apps just as long as they did not discuss HIPPA sensitive information on them. She stated they had about 90 nursing staff and was not sure if they were using the phone apps on their phones or not. She stated the staff used communication boards in the Hispanic resident's rooms. She stated she had not done any staff trainings on language communication with non-English speaking residents. She stated she had to look to see if Residents #1 and #2 had communication language preference Care plans for being Spanish speaking. She stated she did not see any so she added those care plans today 10/26/25 to their care plans. She stated not properly training the staff to communication with non-English speaking residents could cause mixed communication resulting in the resident not be able to express their needs effectively. She stated the residents could have unmet needs like not getting water or clothes changed when they would like. She stated today 10/16/25, she started trainings with the staff on communication with the communication boards and google app to translate with. Interview on 10/16/25 at 6:21 pm, the Administrator stated he was unaware of any communication barrier issues between the staff and residents. He stated they had Spanish speaking staff translate with the Hispanics and communication boards were used. He stated their IDT composed of SW H, both ADONs, himself, therapy, MDS Coordinators and the DON. He stated the DON was responsible for updating the residents care plans and ensuring the staff effectively communicated with the residents. He stated the IDT was supposed to go over everything about the resident's needs. He stated the plan to prevent this issue from reoccurring was to get with therapy department and speech therapist to Inservice the staff. He stated the staff would be in serviced to make sure the staff and residents understood one another for better communication. He stated the staff needed to be made aware of the communication boards, get them laminated and use them. He stated the communication boards needed to be put in the residents rooms so the residents and staff could communicate better. Interview on 10/17/25 at 11:39 am, LVN I stated she did not speak Spanish and if she did not understand what the Hispanic residents said she would get MA J. She stated if MA J were not working she would get a nurse, Maintenance K or a Therapist to help translate for her. She stated they did not have communication boards in the resident's room. She stated they had laminated communication boards but did she not know what happened to them. Interview on 10/17/25 at 12:19 pm, the FM stated Resident #1 stated the staff did not speak English and every time they visited. They stated They would appreciate if the staff spoke Spanish. They stated Resident #1 told them they wished somebody at the facility spoke more Spanish to her. They stated talking to Resident #1 in Spanish was a better way for her to communicate her needs. They stated having a concern about if everything was being done taken care of Resident #1. They stated seeing how hard it was for the staff to understand Resident #1 and had seen one male staff using a phone but no one else. They stated Resident #1 liked when a Spanish speaking male staff worked because she could communicate herself better. They stated Resident #1 was concerned when she had a virus in her stomach when she would call for the staff to change her and they would not. They stated whenever they were at the facility they would translate in Spanish for Resident #1 communicate with the staff. They stated not being sure how the staff communicated with Resident #1 and said it would be nice if more of the staff spoke Spanish. Interview on 10/17/25 at 12:45 pm, FM N stated Resident #2 had been at this facility for a year and a half. They stated since Resident #2 admitted they told SW H there needed to be better way to communicate with Resident #2. They stated they had just had a care plan meeting last week with SW H and they requested a Spanish speaking Doctor because the one she currently had was not bilingual. They stated the other facility doctor was not in Resident #2's insurance network. They stated they requested SW H to get Spanish speaking nurses and CNA's. They stated they put a camera in Resident #2's room because Resident #2 said the staff did not understand her even though she tried her best to get them to understand. They stated Resident #2 finally had a Spanish speaking therapist three times a week, who was good about getting her out of bed and putting the brace on her Right leg. They stated when reviewing Resident #2's room camera they did not see the staff assisting Resident #2 in the morning with dressing and getting out of bed to her wheelchair. They stated Resident #2 needed staff assistance because her hand and foot was weak and she had a right-sided weakness because of a stroke. They stated the facility had to retrain the staff because they had a high turnover rate which causes more issues. They stated last Wednesday ADON F and SW H was in Resident #2's Care plan meeting and they told them about how Resident #2 wanted to be able to express her pain to the staff. They stated they had never seen staff using any phone apps but when Resident #2 was in the hospital the staff usually used an interpreter screen to communicate on. They stated it seemed that the staff did what they needed to do caring for Resident #2 and kept going without talking to Resident #2. They stated one time Resident #2's Doctor wanted to look under her dress and she asked what was he doing because she did not understand him. They stated Resident #2 felt offended even though it was her Doctor. They stated sometimes they had to drive to the facility to make sure everything was communicated correctly for any issues. They stated they would like more staff to speak Spanish because Resident #2 had a hard time communicating when she was in pain. They stated was it so expensive for the facility to get a translating service and stated she had never seen the staff get Spanish speaking staff to translate. They stated MA J was good with communicating with Resident #2 which was good. They stated Resident #2 loved to communicate with MA J but it was limited because she was not there all the time. They stated Resident #2 said when their doctor asked her questions she just nodded her head even though she was in pain because she did not understand English. Record review of the Facility's Statement of Resident rights policy undated, revealed Pursuant to 40 TAC 19.401(b) a copy of the attached statement of Resident Rights must be given to each resident, next of kin or guardian, and Community staff member. The Community must maintain a copy of the statement signed by the resident or the resident's next of kin or guardian, in Community records. The statement must also be posted pursuant to 40 TAC 19.1921. You, the resident, do not give up any rights when you enter a nursing Community. The Community must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing Community employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. You have a right to: (1) all care necessary for you to have the highest possible level of health. Record review of the Facility's Resident rights poster undated revealed, Participation in your care your have the right to: Communicate in your native language to acquire or receive treatment, care and services.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 12 residents (Residents #1 and #2) reviewed for care plans.The facility failed to ensure their IDT created a communication care plans for their Spanish speaking Residents #1 and #2.This failure could place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.Findings included: A)Record review of Resident #1's admission assessment dated [DATE] revealed a [AGE] year old Mexican American female with a preferred language of Spanish who admitted [DATE]. She had a BIMS score of 11 (Moderate impairment) and for daily preferences it was very important to make decision about choosing clothes to wear and taking care of personal belongings. She had lower extremity functional impairment on one side and no upper impairment and used a walker and wheelchair. She needed substantial/maximal assistance with most ADLS's for self-care and mobility. She was always incontinent with bowel and bladder and had medically complex conditions. She was diagnosed with hypertension, renal insufficiency, urinary tract infection, hyperlipidemia, arthritis, enterocolitis, Osteoarthritis, obesity, pain in right knee, muscle weakness, lack of coordination, cognitive communication deficit, Right artificial knee joint. She was at risk of developing pressure ulcer/injuries and took antibiotics in the past 7 days. Record review of Resident #1's Care Plan dated 10/06/25 revealed ADL Self-care performance deficit related to muscle weakness, other lack of coordination, potential for pain related to chronic kidney disease, cystitis, right knee and osteoarthritis and at risk for falls related to history of fall, muscle weakness. She had potential for skin impairment related to decreased mobility, incontinence, potential for pain related to chronic kidney disease, acute cystitis, right knee pain and potential for nutritional problem related to clostridium difficile, hyperlipidemia, chronic kidney disease. And dated 10/07/25 revealed a potential for pressure ulcer development related to decreased mobility, renal insufficiency related to chronic kidney disease, altered cardiovascular status related to hyperlipidemia, hypertension. (There was no Spanish language care plan) Interview and observation on 10/16/25 at 5:35 pm Resident #1 was sitting up in bed but did not speak English and was not able to answer questions. There was not any communication boards, binders or devices anywhere on the bedside table or nightstand to communicate with. B) Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed, an [AGE] year old Mexican female who had a primary language of Spanish. She admitted [DATE] with a BIMS score of 10 (Moderate cognitive impairment). She had upper and lower functioning impairment of both side and used a wheelchair, and partial/moderate assist for self-care and mobility assistance. She was occasionally incontinent with bladder and occasionally incontinent with bowel, none Alzheimer's dementia, hemiparesis, depression, schizophrenia, asthma, third lumbar wedge compression fracture, right foot drop. Record review of Resident #2's Care Plan dated 02/19/25 revealed, The resident has an altercation in musculoskeletal status required use of Knee ankle foot orthoses. On 03/19/25 Resident was on anticonvulsant medication related to nerve pain. On 05/15/25 The resident has arthritis. (There was no Spanish language care plan). Interview and observation on 10/16/25 at 5:40 pm Resident #2 spoke Spanish and was not able to answer any questions. There was not any communication boards, binders or devices anywhere on the bedside table or nightstand to communicate with. Interview on 10/15/25 at 3:35 pm, CNA A stated he did not know Spanish but used a phone translator for communicating with the Hispanic residents. Interview on 10/15/25 at 4:52 pm, RN B stated he could not speak Spanish to the Hispanic residents. He stated two of the Hispanics spoke a little English but the others did not understand English. He stated he was effective with speaking to the resident in Spanish with a translator assist on his phone. Interview on 10/16/25 at 9:54 am, CNA C stated she did not speak Spanish but used a translator on her phone if there did not have other staff to help translate. Interview on 10/16/25 at 10:30 am, CNA D stated Resident #1 needed a translator because she only spoke Spanish. Interview on 10/16/25 at 3:24 pm, CNA E stated there was no communication binder in the resident's rooms who spoke other languages. Interview on 10/16/25 at 3:50 pm, ADON F stated for their Spanish speaking residents they had Spanish speaking staff to translate for them. She stated they had communication boards at the nurses station and therapy room, but not in the resident's rooms. She stated if the staff spoke English to the Hispanic residents, it could result in them not understanding their care and needs. She stated she had used a translator on her phone to communicate with the Hispanic residents. Interview on 10/16/25 at 4:19 pm, MDS RN G stated for the Spanish speaking residents she would get a Spanish speaking CNA to help translate. She stated they should have Spanish care plans for the residents whose primary language was not English. She stated once the MDS Assessment was completed the Care plan should have been created. She stated she did not see Care plans for Residents #1 and #2 was would have to check. She stated after she checked again that Residents #1 and #2 had Spanish communication care plans that was just created. She stated she was not sure why they were just created today by the DON. Interview on 10/16/25 at 5:20 pm, SW H stated she had no complaints from anyone about the staff not knowing how to communicate in Spanish. She stated she did not know if the Hispanics had communication boards so they could visualize the picture to choose what their needs were. She stated it depended on the situation on how it could affect the residents. She stated the harm could be minimum or serious, such as needing to be changed more often. She stated the Hispanic residents needs would not be met if they were not able to figure out what the residents' needs were. Interview on 10/16/25 at 5:48 pm, the DON stated she started updating the care plans of the Spanish speaking residents today 10/16/25 because the HHSC Surveyor started asking the staff questions about them. She stated the staff needed to have a phone app to translate with the Hispanic residents to make sure their needs were met. She stated some of the staff used a phone app and ADON F would get a Hispanic therapist from the therapy department to translate to the residents at times. She stated today 10/16/25 RN B asked what would be the right way to communicate with the Hispanic residents. She stated yesterday afternoon on 10/15/25, CNA D asked her how should she communicate with the Spanish speaking residents. She stated telling RN B and CNA D they could use their phone apps just as long as they did not discuss HIPPA sensitive information on them. She stated they had about 90 nursing staff and was not sure if they were using the phone apps on their phones or not. She stated the staff used communication boards in the Hispanic resident's rooms. She stated she had not done any staff trainings on language communication with non-English speaking residents. She stated she had to look to see if Residents #1 and #2 had communication language preference Care plans for being Spanish speaking. She stated she did not see any so she added those care plans today 10/26/25 to Residents #1 and #2's care plans. She stated she was responsible for updating the resident's care plans and that all of the department heads spoke daily in their morning meetings to determine which care plans needed to be updated. She stated not properly training the staff to communication with non-English speaking residents could cause mixed communication resulting in the resident not able to express their needs effectively. She stated the residents could have unmet needs like not getting water or clothes changed when they would like. She stated the IDT was responsible for updating the residents' care plan. She stated today 10/16/25, she had started trainings with the staff on communication with the communication boards and google app to translate with. She stated their plan to prevent was for the IDT was going to go over their plan in their morning meeting by making sure they had communication boards in the residents rooms. Interview on 10/16/25 at 6:21 pm, the Administrator stated he was unaware of any communication barrier issues between the staff and residents. He stated they had Spanish speaking staff translate with the Hispanics and communication boards were used. He stated their IDT composed of SW H, both ADONs, himself, therapy, MDS Coordinators and the DON. He stated the DON was responsible for updating the residents care plans and ensuring the staff effectively communicated with the residents. He stated the IDT was supposed to go over everything about the resident's needs. He stated the plan to prevent this issue from reoccurring was to get with therapy department and speech therapist to Inservice the staff. He stated the staff would be in serviced to make sure the staff and residents understood one another for better communication. He stated the staff needed to be made aware of the communication boards, get them laminated and use them. He stated the communication boards needed to be put in the residents rooms so the residents and staff could communicate better. Interview on 10/17/25 at 11:39 am, LVN I stated she did not speak Spanish and if she did not understand what the Hispanic residents said she would get MA J. She stated if MA I were not working she would get a nurse, Maintenance K or a Therapist to help translate for her. She stated they did not have communication boards in the resident's room. She stated they had laminated communication boards but did she not know what happened to them. Record review of the Facility's Care plan policy undated revealed, PURPOSE: The facility IDT team utilizes the CMS requirements of RAI as policy for reviewing and revising care plans. Responsible Disciplines IDT members, resident, Resident Representative STEPS - Care Plan Completion: Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non- comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by S483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT evaluates the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs (additional information is described in detail in Chapter 4 of the CMS RAI manual). The care plan completion date (item V0200C2) must be either later than or the same date as the CAA completion date (item V0200B2), but no later than 7 calendar days after the CAA completion date. The MDS completion date (item Z0500B) must be earlier than or the same date as the care plan completion date. In no event should either date be later than the established time frames as described in Section 2.6 in the CM RAI Manual. For Annual assessments, SCSAs, and SCPAs, the process is basically the same as that described with an admission assessment. NOTE, In these cases, however, the care plan will already be in place. Review of the CAA(s) when the MDS is complete for these assessment types should raise questions about the need to modify or continue services and result in either the continuance or revision of the existing care plan. A new care plan does not need to be developed after each Annual assessment, SCSA, or SCPA type of assessment. Residents' preferences and goals may change throughout their stay, therefore the IDT should have ongoing discussions with the resident and resident representative, and staff member, so that changes can be reflected in the comprehensive care plan. Reference: CMS RAI Manual.

Based on record review and interviews, the facility failed to ensure the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and protect and promote the rights of each resident for 1 of 9 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 did not remain covered in a substance, which appeared to be dried vomit and other detritus, for an extended period. This failure could place residents at risk of psychosocial harm. Findings included:Record review of Resident #3's admission sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included malignant neoplasm of unspecified part of unspecified bronchus or lung (a type of cancer that originates in the lungs, but the exact location within the lungs is unknown); methicillin susceptible staphylococcus aureus infection (a common bacterial infection caused by Staphylococcus aureus bacteria); secondary malignant neoplasm of right lung (a cancerous tumor that has spread to the right lung from another part of the body); moderate protein-calorie malnutrition (a nutritional deficiency state characterized by an inadequate intake of both protein and calories, resulting in muscle wasting, weight loss, and other health problems); benign prostatic hyperplasia without lower urinary tract symptoms (refers to a condition where the prostate gland is enlarged but the individual does not experience any urinary difficulties.); dysphagia (medical term for difficulty swallowing food or liquids.); and cognitive communication deficit (a communication challenge resulting from impaired thinking skills, such as memory, attention, and problem-solving, rather than a language disorder.). Record review of Resident #3's hospital medical records, dated 09/26/25, reflected Prognosis is guarded. D/w [Family Member]. Palliative care team consulted. Record review of a document titled After Visit Summary for Resident #3, dated 10/07/25, reflected Overall prognosis poor, patient has done advanced care planning.patient will continue with palliative chemotherapy for now.Advise consideration of hospice once patient and family are ready. Record review of Resident #3's MDS, dated [DATE], reflected Resident #3 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with self-care, to include upper body dressing, shower/bathe self, roll left and right, sit to lying, and lying to sitting on the side of bed. Record review of Resident #3 progress note, authored by RN B, dated 10/11/25 at 12:14 PM, reflected Resident noted vomiting this morning, coffee ground emesis (emesis-the action or process of vomiting; definition added), dark brown in color, VS sound is stable, no fever. NP contacted and new order to start Zofran 4mg Q4 hours PRN for 5 days: to do CBC. RP [Family Member] notified. Record review of Resident #3 CIC (Change in Condition) notification, authored by RN B, dated 10/11/25 at 1:25 PM, reflected Resident #3 was observed to be nauseous and vomiting which started in the morning on 10/11/25. Record review of Resident #3 progress note, authored by RN B, dated 10/11/25 at 3:15 PM, reflected .No repeat episode of emesis noted after PRN Zofran is administered. Record review of Resident #3 progress note, authored by LVN I, dated 10/12/25 at 9:40 AM, reflected Emesis was brown in color that was observed on bed and second emesis had a yellow mucus in mouth. Record review of Resident #3's second progress note, authored by LVN I, dated 10/12/25 at 9:40 AM, reflected Resident has emesis X2, gave Zofran and tolerated well. Record review of photo provided by complainant titled 20251012_134427, with metadata (the data that describes a photograph, providing details about the image itself, the equipment used to capture it, and its content. This information can include camera settings like aperture and shutter speed, keywords, captions, copyright, GPS location, date and time) indicated the date and time the photo was taken was on 10/12/25 at 1:44 PM. The photo was of Resident #3 from his mid thighs up, lying in bed shirtless, with just his head raised. Along the left side of Resident #3 was a blue vomit bag with a significant amount of a brown substance contained inside the bag. The bag was lying next to Resident #3 on the bed and the substance contained inside appeared to be close to leaking out onto the resident. Resident #3's left thumb, left index finger, left middle finger were seen stained by a dried brown substance. Record review of a photo provided by the complainant titled 20251012_134528, the metadata indicated the date and time the photo was taken was on 10/12/25 at 1:45 PM, reflected Resident #3 lying in bed. The photo was of Resident #3 from the waist up, shirtless. A dried brown substance could be seen on the center of Resident #3's chest. A dried brown substance could also be seen on the center of his stomach. A dried brown substance could be seen underneath his chin and along his left clavicle (commonly referred to as the collarbone), left shoulder, left arm pit, and inner upper left arm. Dark colored detritus (waste or debris of any kind) could be seen on Resident #3's chin and throughout his facial hair. Significant large globules of a brown substance could be seen on his upper right chest area. Record review of the facility's ADL log, dated 10/18/25 at 3:53 PM, reflected personal hygiene with Resident #3 was only conducted at 8:23 AM, by CNA E, and 4:55 PM, by CNA N, on 10/12/25. The ADL log further defined personal hygiene as How resident maintains hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes bath and showers). Interview on 10/17/25 at 2:51 PM with the complainant. The complaint advised they visited Resident #3 on 10/12/25 and found him lying in his bed covered in what she identified as dried vomit. The Complainant stated when she found Resident #3 covered in what she believed to be dried vomit, she informed staff and they cleaned him up. The complainant was able to take photos of the condition Resident #3 was in and provided the photos. Resident #3 deteriorated quickly throughout the day on 10/12/25 and later expired at the hospital in the evening due to existing complex health conditions. An interview was conducted with MA L on 10/18/25 at 1:40 PM. MA L advised they were not working on 10/12/25. MA L stated if they were to observe a resident covered in a substance which appeared to be dried vomit, they would immediately attend to the resident and assist in cleaning them up. MA L said they are routinely in serviced on ANE and was able to define ANE, as well as provide examples of ANE, and identify the ANE coordinator for the facility. An interview was conducted with the DON on 10/18/25 at 2:00 PM. The DON stated they were aware of Resident #3's change of condition regarding their vomiting. The DON stated there is no way to determine how long Resident #3 was left lying in bed covered in the dried brown substance. The DON stated she believed it would take 1-2 hours for vomit to dry. The DON said she was aware Resident #3 had trouble swallowing and often would be unable to swallow their food and spit it out. The DON stated they would expect facility staff to clean a resident if they were observed to be dirty or had a dried brown substance on them. An interview was conducted with CNA M on 10/18/25 at 2:25 PM. CNA M stated if they observed a resident covered in a substance which appeared to be dried vomit, they would immediately attend to the resident and assist in cleaning them up. CNA M further stated they worked on 10/12/25 in Resident #3's hallway, but she was assigned to a group of rooms which did not include Resident #3's room. CNA M said CNA E was responsible for Resident #3's care on 10/12/25. CNA M said they were routinely in-serviced on ANE and was able to define ANE, as well as provide examples of ANE, and identify the ANE coordinator for the facility. An interview was conducted with RN B on 10/18/15 at 3:05 PM. RN B stated they worked on 10/11/25 and observed Resident #3 was vomiting. RN B continued to say they completed a CIC and notified the medical provider. RN B said they received updated orders for lab work and to start Resident #3 on Zofran PRN from the medical provider. RN B stated their usual method of operation was to try to check on each resident once every two hours, however residents with acute conditions, they try to check on resident's every 10-15 minutes. RN B stated they considered vomiting to be an acute condition and checked on Resident #3 several times throughout their shift. RN B stated they were not working on 10/12/25 and could not speak to if Resident #3 was routinely checked on throughout the day. An interview was conducted with LVN I on 10/18/25 at 3:26 PM. LVN I stated she worked on 10/12/25 and was aware of Resident #3's change in condition. LVN I stated when they started their shift at 6:00 AM in the morning, they performed initial rounds, to include checking on Resident #3. LVN I stated when they initially observed Resident #3, he was clean and was not vomiting. LVN I continued to say they returned to Resident #3's room approximately an hour and half later and observed Resident #3 had vomited. LVN I stated they told CNA E of Resident #3's condition and to help clean him up. LVN I said they believed CNA E was in Resident #3's room several times throughout the day and CNA E would have charted each time she performed ADL's with Resident #3. LVN I said they were routinely in serviced on ANE and was able to define ANE, as well as provide examples of ANE, and identify the ANE coordinator for the facility. An interview was conducted with CNA E on 10/18/25 at 4:15 PM. CNA E stated she worked on 10/12/25 and was aware of Resident #3's change in condition. CNA E stated she was in Resident #3's room more than five times throughout their shift to clean vomit. CNA E said they did not chart each time they performed ADL hygiene in the room because they did not have a place to chart. CNA E stated they could not recall if they observed Resident #3 with dried vomit on them. CNA E could not recall if they changed Resident #3's bed linen throughout the day due to being stained with a brown substance. CNA E denied being trained on ANE, could not define ANE, could not provide examples of ANE and did not know who the facility ANE coordinator was. An interview was conducted with the Administrator on 10/18/25 at 4:45 PM. The Administrator stated the facility protocol was to try to check on residents once every two hours. The Administrator stated there was the possibility of psychosocial harm for residents who were left to lay in their drying vomit. The Administrator could not provide an acceptable amount of time a resident could be allowed to lay in vomit or other detritus before they were helped and cleaned. The Administrator stated staff charting is completed by exception. The Administrator stated charting by exception is defined by staff only charting when they perform a service or care action. When asked if providing ADL hygiene assistance would be charted every time it was performed, the Administrator said it should be. Resident Rights policy was requested in the entrance email to the Administrator, during the entrance conference, and during the interview with the Administrator, but was not provided by time of exit. Record review of the facility's policy document titled Dressing and Undressing, Assisting the resident with, dated revised February 2018, reflected: The purposes of this procedure are to assist the resident as necessary with dressing and undressing and to promote cleanliness and may be part of the bath process. Dressing and Undressing, Assisting the resident with further reflected: DocumentationThe following information should be recorded in the resident's medical record:1. The date and time that the care/procedure was performed.2. The name and title of the individual(s) who performed the care/procedure.3. If and how the resident participated in the procedure.4. How the resident tolerated the care delivered/procedure or any changes in the resident's ability to participate in the procedure. 5. Any problems, areas of concern or complaints made by the resident or noted during the care procedure.6. If the resident refused the procedure, the reason(s) why and the intervention taken.7. The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #1 and Resident #2) reviewed for accidents. 1. On 12/31/24, CNA F and CNA G failed to safely transfer Resident #1 during the use of the mechanical lift, which resulted in the resident sustaining a scalp hematoma and T12 compression fracture. 2. On 12/18/24 the Van Driver failed to properly restrain Resident #2's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis. The noncompliance was identified as PNC. The IJ began on 12/18/24 and ended on 01/20/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for severe injury or harm, decline in health, and decreased quality of life and death. Findings included: 1. Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a BIMS of 00 which indicate her cognition was severely impaired and was not able to respond or complete the Brief Interview for Mental Status. The MDS further reflected Resident #1 was dependent on staff for all functional abilities which included eating, and all transfers. The resident's diagnoses included unsteadiness on feet, muscle wasting atrophy, lack of coordination, bilateral primary osteoarthritis of the knees (degenerative joint condition where the cartilage in both knees breaks down gradually). Record review of Resident #1's undated care plan reflected she had the following care areas: - activities of daily living self-care performance deficit related to dementia and impaired balance. The care plan reflected: Goal Resident #1 will remain at current level of function. Interventions included resident required mechanical lift with two staff assistance for transfers; - limited physical mobility related to sarcopenia. The care plan reflected: Goal: Resident will demonstrate the appropriate use of Mechanical lift with staff assistance x2 to increase transfers. Intervention: Resident #1 is dependent on two staff for transfers using Mechanical Lift due to inability to bear weight at this time due to generalized weakness. - an actual fall on 12/31/24. The care plan reflected: Goal: Resident will resume usual activities without further incidents. Interventions: Monitor/document/report as needed for 72 hours to physician signs and symptoms of pain, bruises, change in mental status, New Onset, confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks per facility protocol. Provide care staff Inservice training related to Mechanical Lift/Mechanical lift sling utilization. Send to emergency room for evaluation post fall; and - an alteration in musculoskeletal status related to a fracture of the thoracic spine T12 due to a fall from a mechancial life. The care plan reflected: Goal: Resident will remain free from pain or level of discomfort acceptable to resident (specify using pain scale). Interventions included: anticipate and meet needs. Be sure call light within reach and respond promptly to all request for assistance. Give analgesics as ordered by physician. Monitor and document side effects for side effects and effectiveness. Monitor document for risk of falls. Educate resident/family/caregivers on safety measures that need to be taken to reduce the risk of falls. Record review of Resident #1's progress notes entered by LVN L on 12/31/24 at 6:40 PM reflected: Around 5:40 pm when this nurse doing documentation in nursing station shift CNA called to resident room noted resident on the floor with right side lateral position according to shift CNA during Mechanical lift sling are broke from right side of loop that time resident around 4 feet high she fall by right side of head this nurse did head to toe assessment noted resident have right side of upper back bruise with bump and forehead also bump noted resident vitals Blood pressure =109/57, pulse=88, oxygen=98% resident holding her head face scale [NAME] pain level was 5 usually resident are non verbal and confused status called Nurse Practitioner got new order sent emergency room called resident daughter she came facility before transfer to emergency room and notified DON called 911 they too her local hospital. Record review of Resident #1's progress notes entered by LVN L on 12/31/24 6:47 PM reflected: SBAR Summary for Providers. Situation: The Change in Condition reported on this CIC Evaluation are/were: other change in condition. With vitals at the time of evaluation were: Blood Pressure 107/57. Position lying left/arm. Pulse 70. Pulse Type Regular, Respiratory Rate 18 Record review of Resident #1's progress notes entered by LVN Z on 12/31/24 11:45 PM reflected: Resident returned to unit after emergency room visit due to fall. Resident did not have dinner or evening meds. Hospital paperwork indicates she has a Hematoma of the scalp and a compression fracture of T12 vertebra. Zofran and Morphine were give at 9:00 at the hospital. Resident fell asleep shortly after being put to bed Record review of Resident #1's hospital discharge reflected on 12/31/24 at 6:21 PM Resident #1 presented with: fall from Mechanical lift approx. 4ft onto tile flooring; +head strike, -thinner, -LOC, baseline GCS 14; strike to right posterior and side of head; patient is nonverbal due to late-stage dementia; patient grimacing on right hip with moving to stretcher. The hospital discharge record further reflected: History of Present Illness 6:21 PM Resident #1 is a [AGE] year old female, with history of dementia, COPD, hypertension, and hypercholesteremia, presenting to the emergency department via Emergency Medical Services with fall onset this afternoon. She was brought in from nursing home facility. She was in a mechanical lift in the air when the strap broke and she fell four feet onto tile flooring, landing on her right posterior hip and right side of her head head first. She did not lose consciousness. Her daughter provided a video of the incident. Patient is largely nonverbal, but uttered ow after the event. She is able to say words, but does not answer questions, GCS 14, This is her baseline per family, but she states the patient seems like she is in pain. Emergency Medical Services notes that she grimaced when her right hip was handled. She is not anticoagulated. No further complaints raised at this time. Record review of the radiology report for Resident #1 reflected: Suspected acute compression fracture of the T12 vertebral body with approximately 10% vertebral body height loss. No bony retropulsion. Record review of the facility's Provider Investigation Report dated 01/07/25 reflected: Head to toe skin assessment, pain assessment and pain monitoring. Assessment included bruising to the upper back and forehead hematoma. Both CNAs that were involved with the transfer were suspended pending an investigation. The resident was immediately sent to the hospital for further evaluation and treatment. The resident's family and physician were notified of the incident. On 12/31/24 CNA F, and CNA G went to [Resident #1's] room to transfer her from her bed to her wheelchair so she could sit up and assisted while eating dinner. Both aides helped position Resident in the sling and hooked the sling loops to the mechanical lift arm, one aide on each side of the bed. CNA F was on [Resident #1's] right side and secured the right side sling straps inside the hooks of the mechanical lift arm, while CNA G was on [Resident #1's] left side and secured the left-side sling straps inside the hooks of the mehancial lift arm. CNA G then proceeded to operate the mechanical lift, raising resident in the air off the bed from the left side of the A bed into the space between the A and B beds. While this occurred, CNA F had moved from the right side of the bed to move [Resident #1's] wheelchair around to the left side of the bed (this side the lift was being operated from) and she was standing behind the wheelchair waiting fo the lift to lower resident into the wheelchair. Before CNA G could lower the resident in the lift, the right side sling strap loop broke, causing [Resident #1] to fall backwards toward her right shoulder and then to the ground on her right side. CNA F being towards the foot of the bed and closest to the door, immediately left the room to get the nurse who was right outside the resident's room by the nurse substation. The nurse came into the room, assessed [Resident #1] and called 911 for her to be sent out. [Resident #1] was transferred out by Emergency Medical Services around 7pm and taken to the hospital. She was diagnosed with a scalp hematoma with no intercranial hemorrhage and a T12 compression fracture. She returned to the nursing home facility around 11:45 PM the same evening with no new orders. [Resident #1] is being monitored continually for and adverse effects of the fall. Upon further investigation CNA F stated there were multiple loops on each of the 4 straps and at least 1 broken loop on one of the straps. However, the other loop(s) were intact and looked okay. She stated during interview, she didn't want to try and find another sling because she was in a hurry to get Resident #1 up for dinner. Since the green loops were not ripped or torn, CNA F felt they would be safe to use and told CNA G during the setup for the transfer to use the green loops. Staff have been in-serviced/re-educated on sling safety, ensuring the slings are not ripped or torn, and how to properly secure the loops on the mehanical lift, and the process of taking slings out of service. Nursing staff have also completed observation checkoffs on proper mechanical lift transfers with a one-on-one return demonstration. All slings in the building were inspected and any that were frayed, torn , or deemed unsafe have been discarded. Supply of replacement slings were ordered, and additional slings were ordered as backups. CNA G has received one-on-one training with return demonstration as well, and has returned to work after suspension. The facility has terminated CNA F, because she noticed the slings did not meet safe standards. And decided to continue to use the sling at resulted in an injury to [Resident #1]. Interview on 01/23/25 at 9:44 AM with Resident #1 was attempted; however, due to the resident's severe cognitive deficits the resident did not respond. Observations on 01/23/25 between 9:50 AM and 10:44 AM of two additional transfers with ADON and Treatment Nurse observing CNA A, CNA B, CNA C and CNA D revealed each CNA inspecting the mechanical lift battery, sling connectors, ability to lift and lower, lock, legs to open and close. Each CNA held the mechanical lift sling in their hands looking down the seams and material for any worn, torn or thin spots in the material. Each CNA was observed checking and tugging the loops looking for cuts, open seams, or loose threads. CNAs were observed talking through their inspection of both the machine and the inspection of the mechanical lift slings. Observation revealed they worked together as a team to ensure throughout the transfer the resident felt secure and safe. Staff was heard stating what color loops they were using and double checked to ensure the hooks were secure with the loops. Communicated when to lift, lower, and when to reposition. Observation of the ADON and Treatment Nurse to step in with moving furniture if needed. Interview on 01/23/25 at 10:36 AM with ADON and Treatment Nurse revealed all nursing management were trained, then management trained nursing staff to include nurses and certified nursing assistants. The Treatment Nurse stated staff was inserviced and trained on mechanical lift maintenance, sling maintenance, safe transfers, and completed a check off list step by step on transferring residents. The ADON stated monitoring was still ongoing, spot checks were completed by management staff daily. The ADON and the Treatment Nurse stated during their observations of transfers there has not been any resident concerns when a mechanical Lift was used. Record review of CNA F statement dated 12/31/24 reflected: We were using the mechanical lift on [Resident #1]to get her up for dinner. I was on the side of the bed closest to the wall and CNA G was on the other side controlling the mechanical lift remote. We put the sling under her and fastened the loops on the green loop at her shoulders. Both of us used the green loop. The mechanical sling had a loop that were already ripped, I think it was the blue loop, and that is why we used the green loop. I knew the sling had a broken loop, but I did not go try to find another mechanical lift sling because I was in a hurry to get [Resident #1] to dinner. I stood by the side of the bed and assisted the lift into the air until CNA G moved the resident over to the middle of the beds. I came around to the middle of the room to push the wheelchair underneath the resident and the right shoulder loop snapped causing the sling to release from the clamp and the resident fell out of the sling onto the floor. She landed on the leg of the mechanical lift's closest to the window. I went and got the nurse at that time. The statement was signed by CNA F. Interview on 01/23/25 at 1:04 PM with CNA F revealed she worked with Resident #1 on 12/31/24 as her aide on 2:00-10:00 PM shift when she was told by LVN L to get Resident #1 up and in the dining room for lunch. CNA F stated LVN L refused to assist with the transfer, and she had to find someone to assist her with the mechanical lift transfer. CNA F stated it had taken her 15 minutes to locate help and they nurse was yelling to get Resident #1 to the dining room. CNA F stated Resident #1 had a sling in her room that had been used that morning, CNA F stated she informed LVN L that they sling was damaged but she acted as if she did not care, Obviously the prior shift used the mechanical lift sling for breakfast, and they knew the loops were broken and they still used it. CNA F stated she proceeded with preparing Resident #1 for the transfer with the mechanical sling that was damaged at the loops. CNA F stated I hooked Resident #1 to the mechanical lift on the right side and CNA G hooked the left side. CNA F stated, after connecting Resident #1 to the mechanical lift CNA G lifted her and was pulling her out, I got the wheelchair, about to roll it under Resident #1 and the sling broke, it took me by surprise there was no pop or anything. CNA F stated, CNA G had control of the mechanical lift and I was guiding Resident #1, when I stepped away to grab the wheelchair, she came down headfirst towards me,. CNA F stated the transfer was staged in the middle of both beds A and B, the wheelchair was parked at the end of Bed B. CNA F stated by the time I had my hand on the wheelchair rolling it in front of her the loops broke on the right side, at her right shoulder, Resident #1 came down head first hitting the floor CNA F stated she then alerted LVN L. CNA F stated she observed swelling to Resident #1's forehead from the impact of the fall. CNA F stated she completed interview with the DON, re-enacted the incident, trained on mechanical lift transfers and was suspended, was later terminated. CNA F stated we used the same sling as the morning shift; we knew going into it that there were broken loops and there were no other slings available and the nurse was yelling at us to get her up CNA F stated she was responsible for inspecting and using properly working equipment, and that she was expected to report any broken equipment or when they did not have adequate supplies. CNA F stated not doing so placed Resident #1 at risk for accident and injury to happen. Record review of CNA G statement dated 12/31/24 I was in the room with CNA F, and we were trying to get Resident #1 into the wheelchair for dinner. The sling was under her, and I was controlling the control to the mechanical lift. I attached the green loop on my side of the patient after asking CNA F which color of loop to use. I was in the middle of the two beds when I started to move the patient toward the center of the room with the mechanical lift controller. I opened the mechanical lift's legs out wide, as the mechanical lift came out from underneath the bed and pushed the patient in the mechanical lift toward CNA F and the wheelchair. The mechanical lift's loop snapped that was on her right shoulder and she fell out of the sling and onto the ground. CNA F went to get the nurse to help get the patient looked at. Signed CNA G Interview on 01/23/25 at 1:34 PM CNA G revealed she was working the front hall while CNA F worked the back, she stated CNA F asked her to assist with mechanical lift transfer for Resident #1. CNA G stated, when I entered the room the mechanical lift sling was already under her, and we just needed to hook her to the machine. CNA G stated because I was new, I was asking her questions about the process, I was asking her what color loops we were using. CNA G stated they used green for the upper body and purple for the lower body. CNA G stated she checked her side to ensure the mechanical lift sling was hooked properly to the mechanical lift. CNA G stated she pulled the mechanical to align with the bed, lifted Resident #1 and opened the mechanical lift's legs. CNA G stated CNA F went for the wheelchair and as soon as she was about to put the wheelchair in front of Resident #1 I heard a snap and a bump, I was shocked Resident #1 was on the floor, I could see a bump forming on her forehead resulting from her falling head first. CNA F went to get the nurse. The sling was good, it was in good condition, I did not see anything wrong with the sling or straps. I looked at the colors to ensure I was using the right ones. CNA G stated she was inserviced by the DON and she reenacted the incident to show how the mechanical lift was used. CNA G stated she was suspended and upon return continued training to include mechanical lift transfers, inspecting machine and the sling yourself prior to use. CNA G stated it was her responsibility to look at the straps to ensure they were in good condition, and if not do not use the sling and to report it to the nurse or the DON. CNA G stated not doing so placed residents at risk of injury. Interview on 01/23/25 at 2:30 PM with LVN L revealed she was the nurse on duty during Resident #1's incident on 12/31/24. LVN L stated Resident #1 was a two person assist with use of a mechanical lift for transfers, she stated she was not in the room during the fall, however, was notified by CNA F that Resident #1 had fallen from the mechanical lift. LVN L stated she walked into the room and found Resident #1 on the floor laying on top of the mechanical lift machine legs, LVN L stated she could see that Resident #1 had an injury to the forehead, contacted DON, completed assessment, and called emergency services. LVN L stated she had not yelled or rushed aides to complete a transfer for Resident #1, she was not informed there was issues with the mechanical lift machine or the sling. LVN L stated she expected staff to alert her if there was any issues or concerns with resident transfers, she would not expect staff to use slings that were not in good condition. LVN L stated she was inserviced on mechanical lift transfers, inspecting mechanical lift slings, and demonstrated competency, LVN L further stated there should be two persons at all times to ensure the safety of resident during transfers especially with mechanical lift use. LVN L stated it was the responsibility of the aides or anyone doing a transfer to inspect the mechanical lift machine, mechanical lift slings to ensure its not damaged and if so, the sling should be reported to DON to have it replaced. LVN L stated if aides thought there was a problem she should be notified immediately, not doing so placed residents at risk of a fall or injury. Interview on 01/23/25 at 1:40 PM Laundry Aide H revealed the mechanical lift slings were gathered with laundry off the halls in a barrel, sorted, washed and air dried in the dryer machine. Laundry Aide H stated after they air dry, she folded and delivered the slings to the linen closets on each hall. According to the Laundry Aide H it was the responsibility of the aides to check the sling prior to use, she stated before the incident she would just wash, and air dry in the machine, and delivered them to the floor. Laundry Aide did not address surveyor questions on having any responsibility to inspect, remove or report to management . Laundry Aide H stated she had been inserviced on mechanical lift sling inspection, the facility purchased new slings and created a numbering system to include all mechanical lift slings, the wash and dry system is the same however now the Laundry Aides were responsible for inspecting slings when they come through laundry. Laundry Aides were now responsible for inspecting and documenting the condition of each numbered sling, if one is damaged, frayed or not in good working condition the aide was to report it to the supervisor and the DON taking the damaged sling out of commission and replace it with a new sling. Record review of a form titled Transfer Safety dated 12/06/24 reflected: It is a requirement of your job to ensure we are always putting resident safety first. This is to include during transfers with a mechanical lift or gait belt. Ensure that all limbs (upper and lower) are in a safe place to prevent bruising, skin tears or general discomfort. If you are unsure of where placement should be, speak with the nurse or ADON's before proceeding with the transfer. If you have any further questions, please see the DON or ADON's. Signed by both CNA F and CNA G. Record review of facility policy dated 2024 titled Transfer Equipment/Devices - Includes Use of Slings Guidance reflected: Purpose: To promote safe resident transfers from one surface to another with proper functioning equipment/devices and attachments. Responsible Disciplines: Administrator, Director of Nursing, Maintenance Department staff, laundry staff, Therapy Department staff, Department head and Director Care (Licensed & Non-licensed) staff. Guidance: Slings should be entered into TELS [maintenance management application] system by Director of Maintenance, Administrator or designee when put into use. Slings should be tagged in some way/format with a number. Slings should then be entered into TELS or onto excel spreadsheet in the same process. When a sling is put into use: It should be tagged numerically and dated when it went into service, and this should be noted. Slings should be checked monthly by the maintenance staff. Slings should be checked for wear, tear, rips, broken straps, loose stitching, and the condition of where the sling is hooked to by the transfer lift. If any is worn, damage, it should be taken out of commission and new sling put into use. When a sling is noted with tears, rips, loose threads, broken straps it is to be taken out of commission and immediately reported/brought to Administrator, DON, Maintenance. 2. Record review of Resident #2's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a BIMS of 10 which indicate his cognition was moderately impaired. The MDS further reflected Resident #2 had functional limitation in range of motion on one side for both upper and lower extremities. Resident #2 had use of a wheelchair. Resident #2 required partial/moderate assistance with chair/bed-to-chair transfer. Diagnoses include dependence on Renal Dialysis (treatment used for kidney failure, helps remove extra fluid and waste from the blood when kidney is not able to function properly), and Type 1 Diabetes Mellitus. Record review of Resident #2's undated care plan reflected he had activities of daily living self-care performance deficit related to activity intolerance, Dementia, Impaired balance, Shortness of breath, weakness, Unsteadiness, Goal: Resident #2 will remain at current level of function. Interventions included resident uses wheelchair for mobility, able to use walker for short distances. Resident sometimes require two person assist due to fatigue or weakness. Resident requires one staff assist to move between surfaces. Resident #2 has Diabetes Mellitus, Type1 with the potential for abnormal blood sugar levels, poor wound healing and pain. Goal: The resident will have no complications related to diabetes. Interventions included Check all of body for breaks in skin and treat promptly as ordered by doctor. Diabetes medication/ insulin as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Record review of Resident #2's progress note dated 12/18/24 at 1:38 PM reflected: Fall Details : Date / Time of Fall: 12/18/2024 1:15 PM Fall was not witnessed. Fall occurred elsewhere. Other fall location: facility transportation van Activity at the time of fall: riding in the van The reason for the fall was not evident. Did an injury occur as a result of the fall:No. Did fall result in an ER visit/hospitalization : No. Provider Time notified: 12/18/2024 Notified of: Resident fall Fall Details Note:This nurse was notified of the resident's fall . The van driver states that the resident's wheelchair tipped over while he was driving , he and the resident states that the wheelchair was locked down and do not know how it fell over. Other furniture involved: No. Wheelchair was involved in fall. Wheelchair was not unlocked at time of fall. Were the wheelchair footrest(s) in the way: N/A. Resident was wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Record review of Resident #2's progress note dated 12/18/24 at 1:42 PM reflected: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Falls At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 118/44 - 12/18/2024 13:38 Position: Lying r/arm - Pulse: P 70 - 12/18/2024 13:38 Pulse Type: Regular - RR: R 18.0 - 12/18/2024 13:38 - Temp: T 98.6 - 12/18/2024 13:38 Route: Forehead (non-contact) - Weight: W 281.0 lb - 12/17/2024 03:20 Scale: Mechanical Lift - Pulse Oximetry: O2 97.0 % - 12/18/2024 06:36 Method: Oxygen via Nasal Cannula - Blood Glucose: BS 119.0 - 12/18/2024 11:27 Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: Fall Nursing observations, evaluation, and recommendations are: monitor resident's neuro checks. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: monitor resident Emergency Medical Services were not interviewed during the investigation. Observation and interview on 01/23/25 at 9:20 AM with with the Maintenance Director revealed the van was big enough for two passengers and demonstrated his expectations of the van driver when transporting residents. The Maintenance Director went to the back of the van and opened the two back doors and locked them in place to secure the doors would remain open while operating the ramp. He then lowered the ramp to the ground and locked it in place, then he pulled a strap from the right side of the ramp to the left side of the ramp. He stated, This strap was to keep residents from rolling off the ramp while the ramp is lifted. The Maintenance Director then walked around the van to the passenger section of the van, stating once in the van, you will roll resident inside the passenger section and hook them to the tie downs on the floor board. The Maintenance Director then pick up a tie down and hooked it into the floor board and turning the spindle and pulling it to show it is locked into place. The Maintenance Director then explained that once the tie downs were secure in the floor the straps were hooked to the wheelchair. According to the Maintenance Director, 4 tie downs per wheelchair, he then pulled and demonstrated the seat belt will then hook to the tie down and pull across the resident keeping them secure during the transport. The Maintenance Director stated after the incident with Resident #2 the Van Driver was inserviced and retrained on safely and transporting residents on 01/02/25. The Maintenance Director stated the facility purchased eight new straps, he inspected the van, regional staff came to inspect the van and after review there were no findings as to what happened to cause Resident #2 to tilt during the turn. The Maintenance Director stated the van was checked monthly by himself, the driver and the shop if needed. This document was requested however not provided prior to exit. Interview on 01/23/25 at 9:34 AM with Resident #2 revealed he was headed to dialysis on 12/18/25 when he tilted out of the wheelchair and ended on the floor of the transportation van. Resident #2 stated he could not recall anything specific that would have caused him to tilt out of his wheelchair. Resident #2 stated after the fall he did not have any injuries or pain, he was checked by emergency medical providers on the side of the road, the facility and eventually went to the hospital for an evaluation. Resident #2 stated the Van Driver was a safe driver, and he had gone on the van since the incident and felt safe to do so. Observation on 01/23/25 at 10:00 AM of the Van Driver prepared to transport Resident #3 to an appointment revealed he followed the expectation of the Maintenance Director by ensuring Resident #3 was secure in the wheelchair, when rolled onto the ramp the straps were secure in keeping her from rolling off the ramp. The Van Driver then rolled Resident #3 to the front of the van, ensured she was in secure spot to administer four straps from the tie-down locks in the floorboard. The Van Driver then administered the seat belt across Resident #3 and then attempted to rock the wheelchair and pull-on straps to ensure safety for the resident. Interview on 01/23/25 at 1:48 PM with the Van Driver revealed he had been driving for at least an hour heading to his stop taking Resident #2 to his dialysis appointment. The Van Driver stated he heard a loud popping noise, and when he looked back he saw Resident #2 and his chair moving. The Van Driver stated he attempted to grab Resident #2 to prevent him from falling over but could not grab him and maintain the vehicle so he pulled over to the side of the road. The Van Driver stated he saw Resident #2 fall over on the floor of the van with his wheelchair on top of his feet. The Van Driver stated The seat belt had came off; however the straps were still locked and in place, connected to the wheelchair, they had him pinned under the wheelchair. The Van Driver stated I could only assume something went wrong with the straps. The Van Driver stated he asked if Resident #2 was ok and called 911. The Van Driver stated Resident #2 replied he was ok. Emergency Medical Services and the police came to the van while parked on the side of the road and evaluated Resident #2, at this time Resident #2 refused to transport to the hospital, therefore was transported back to the facility. The Van Driver stated I always checked the spindle, the strap and always shake the wheelchair to ensure it can not move. The Van Driver stated he was inserviced on checking the tie downs and straps prior to transporting residents. The Van Driver stated it was his responsibility to ensure residents are transported safely and that meant to make sure all equipment worked properly, not doing so placed residents at risk of accidents. Interview on 01/23/25 at 2:40 PM with the DON revealed she was notified by nursing staff Resident #1 had fallen from the mechanical lift and was injured. The DON stated she responded by sending Resident #1 out to the hospital. The DON stated investig [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but were not limited to receiving treatment and supports for daily living for one (Resident #1) of six residents reviewed for environment. The facility failed to ensure Resident #1's personal photographs and decor were moved with her into the room she had to temporarily move into on 09/26/24, due to a Covid-19 (a severe acute respiratory syndrome) outbreak. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: Review of Resident #1's Face Sheet, dated 10/06/24, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including cerebral infarction (also known as an ischemic stroke; occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis following cerebral infarction (conditions that cause weakness or paralysis on one side of the body), cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage (refers to a range of impairments in thinking, social interaction, and emotional regulation that can occur after a brain bleed in the space surrounding the brain), and anxiety disorder (a mental illness that causes excessive and uncontrollable feelings of fear and anxiety that can significantly impair a person's daily life). Review of Resident #1's MDS Assessment, dated 08/17/24, reflected she had a BIMS of 10 (indicating she was moderately cognitively impaired). Review of Resident #1's Nurse's Notes, dated 09/27/24, reflected, .Resident moved on 09/26/24 to [a different room] with another negative Covid [a severe acute respiratory syndrome] resident. Resident was in agreement with move until this am [morning]. Spoke with daughter [name] and she is speaking with resident and will reiterate that this is a temporary move. Resident did agree to stay on [the new room number] for the time being . Observation of Resident #1 on 10/05/24 at 12:05PM reflected she was sitting in her wheelchair, next to her bed. Resident #1 was noted to be surrounded by over a dozen personal photographs. During an interview with Resident #1 on 10/05/24 at 12:05PM, she stated she had recently moved into the room in which she was currently staying. She stated she moved to the room because she was Covid-19 negative; her previous roommate tested positive for Covid-19 and so did the resident who previously resided in the room in which she was currently staying. Due to the Covid-19 outbreak, their rooms were temporarily switched. Resident #1 stated none of her personal decor moved from her permanent room into this new room in which she was temporarily staying. She stated she knew no one in the personal photographs that surrounded her. Resident #1 stated she wanted her personal decor to be moved into the room that she was temporarily residing in, until the Covid-19 outbreak had passed. During an interview with the Administrator on 10/06/24 at 11:42AM, he stated Resident #1 temporarily moved into a different room due to the Covid-19 outbreak at the facility. He said he was under the impression that the majority of Resident #1's personal belongings, including personal photographs that were not secured to the walls, had moved with her from her permanent room into her temporary room. He said Resident #1 was expected to move back to her previous/permanent room on 10/07/24. The Administrator stated he was not sure of the risks that could be posed to a resident by not having their own personal belongings and/or decor, as he was not a psychologist. Review of the facility's Statement of Resident Rights policy, undated, reflected, .Residents do not give up any rights when entering a nursing community. The community must encourage and assist them to fully exercise their rights . and .The resident has a right: . 14. To keep and use personal property .

Based on observation, interview, and record review, the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. 1. The facility failed to ensure food items stored in the refrigerator were properly labeled with the contents after being removed from the original packages and dated to reflect when the food items were opened. 2. The facility failed to ensure food items stored in the refrigerator were properly discarded based on expiration date. 3. The facility failed to store ground meat and pot roast were wrapped in plastic wrap away from the original packaging with liquids flowing onto the tray with other items and had turned to a dark/grey color. These failures could place all residents at risk for food contamination and food borne illness. Findings included: Observation of the refrigerator on 09/10/24 beginning at 9:34 AM revealed the following: - observation of bucket of green beans with no label or date; - a tray holding a box of chicken, ground meat, pot roast, and a large brisket that was towards the tray, the tray had dark red liquid that resembled blood that had drained from the brown colored ground meat and pot roast; and - observation of the ground meat and pot roast revealed items had turned to a dark/grey color and they were wrapped in plastic wrap away from its original packaging, not labeled, dated, or sealed properly while being stored. Observation and interview on 09/10/24 at 9:35 AM with the Dietary Manager revealed the tray was stored at the bottom of the fridge for thawing meat to be used in the future. The Dietary Manager stated the brisket was to be used later in the week. The Dietary Manager stated the liquid at the bottom of the tray was from the ground meat and pot roast. However, he did not know how long it had been on the tray because there was no label or date. The Dietary Manager stated the box on the tray had chicken in it. According to the Dietary Manager, his expectations were that the cooks would label and date anything that was taken out of its original packaging. The Dietary Manager stated he and the cooks did a walk through daily to look for items to remove after 7 days of being opened and placed in the refrigerator, and to ensure the refrigerator was wiped down and cleaned. The Dietary Manager stated not properly labeling, dating, or sealing food items could place the food at risk leading to bacterial growth and cross contamination. Observation on 09/11/24 at 1:34 PM of the kitchen's steamtable, revealed the far-left compartment had a few inches of water in it as well as food particles which included a green bean, diced carrots, and elbow macaroni noodles. The steamtable compartments to the right already had containers of covered food in them to be served during lunch. Interview on 09/11/24 at 1:35 PM with the [NAME] revealed the steam table was cleaned twice per week. The [NAME] stated she was responsible for adding water to the table to keep food warm during serving times. The [NAME] stated she was responsible for cleaning out the steam table, however she was not sure how long the food particles had been in the steam table. The [NAME] stated not cleaning out the steam table of food particles placed residents at risk of food contamination and illness. Observation and interview on 09/11/24 at 1:37 PM with the Dietary Manager revealed the steam table was cleaned twice a week by the cooking staff. The Dietary Manager stated the cook was to drain the water after each cleaning and serving, and ensure there was no water or food left that may have fell . Observation of the steam table in the kitchen during lunch with The Dietary Manager revealed the steam table with food particles (several carrots, macaroni, green beans) in the water. The Dietary Manager stated the team was working on getting the steam table cleaned to prevent particles in the food and cross contamination. Interview on 09/12/24 at 4:40 PM with the Administrator revealed the Dietary Manager was responsible for overseeing the kitchen area and ensuring food was properly labeled, dated, sealed, stored and served in a way to prevent food contamination and food borne illness. Administrator stated he expected all staff in the kitchen to follow guidelines which would not place residents at risk of illnesses. Review of the facility's policy dated 06/01/19, titled Food Storage, reflected: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. Review of the facility's policy dated 10/01/18 titled Sanitizing Equipment In-Place, reflected: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for cleaning equipment in place in order to ensure that all equipment is thoroughly cleaned and sanitized to minimize the risk of food hazards. Unplug electrically powered equipment . Remove any fallen food particles and scraps. Wash, rinse and sanitize removable parts using the manual immersion method described in Policy 04.005. Wash the remaining food-contact surfaces, and rinse with clean water. Wipe down with a chemical sanitizing solution mixed according to the manufacturer's directions. Protect all food-contact surfaces of fixed equipment from contamination. Protect all food-contact surfaces of fixed equipment from contamination.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (1 nurses medication cart for 400 hall and medication aide cart for 400 and 200 halls) of 3 carts and 1 refrigerator in the medication room reviewed for pharmacy services. The facility failed to ensure expired intravenous medications, 3 bottles ampicillin-sulbactam 3 gm/100 ml with expiration dates of 09/03/24, 8 bottles ampicillin-sulbactam 3gm/100mls with expiration dates of 09/07/24, 3 bottles Piperacillin /tazobactam with expiration dates of 09/06/24 and 4 bottles meropenem 1 gm/100mls with expiration dates of 08/18/24, in the Medication Room refrigerator and 11 vials of hydroxyzine with expiration dates of July 2024 in the nurse and 7 sachets of pantoprazole sodium delayed release on the medication aide medication carts with expiration dates of July 2024 were removed and destroyed. The failure placed residents at risk of receiving medications that were ineffective. Findings included: Observation on 09/11/24 2:25 PM of the 200 hall Medication aide cart with MA K revealed 7 sachets of pantoprazole sodium delayed release with an expiration date of 07/24 (July 2024). Interview on 09/11/24 at 2:30 PM with MA K revealed it was her responsibility to check the cart for expired medications. She stated she checked the cart once a month for expired medications and she could not recall when she last checked her cart. She stated by failing to remove the expired medication, they could be administered and cause reactions, and the resident would not get the required therapy. She stated she had done training on checking carts for expired medications. Observation on 09/11/24 at 2:39 PM of the 400 Hall nurse medication cart with LVN A revealed 11 vials of hydroxyzine with expiry date of 07/24 (July 2024). Interview on 09/11/24 at 2:50 PM with LVN A revealed it was all nurses' responsibility to check and remove expired medications from the cart. She stated she checked her cart every shift, but she had not checked when she reported in the morning. She stated she was aware the medications were discontinued a long time and they were supposed to have been removed from the cart and put on the pharmacy destruction box. She stated by failing to remove the expired medication, they could be administered and cause medication error and adverse effect on residents She stated she had done in-services on medication administration and removing of expired medications. Observation on 09/11/24 at 3:00 PM of the Medication Room refrigerator with LVN B revealed the following: 8 bottles ampicillin-sulbactam 3 gm/100 ml expiry date 09/07/24 3 bottles ampicillin-sulbactam 3 gm/100 ml expiry date 09/03/24 4 bottles meropenem 1 gm/100 ml expiry 08/18/24 3 bottles Piperacillin/tazobactam with expiry date 09/06/24 Interview on 09/11/24 at 3:20 PM with LVN B revealed all nurses were responsible to check the refrigerator but the ADON's were responsible for the refrigerator and medication checks. Interview on 09/11/24 at 3:25 PM with ADON P revealed it was her responsibility and the other ADON J to check the refrigerator, and also nurses were responsible. She stated ADONs are supposed to go behind the nurses to check whether they were removing the expired medications from the refrigerators and carts. She stated she had checked refrigerator two weeks ago. She stated by failing to check for the expired medications, they could be administered and would not be effective. For review ADON B stated she had offered training to staff regarding removing expired medications, but she could not recall when and no training documents were produced for review. Interview on 09/12/24 at 12:09 PM with ADON J revealed it was her responsibility and the other ADON P to check the refrigerator. She stated she had checked refrigerator, on 09/11/24 and all expired intravenous medication were missed. She stated she did not check on the bottles, she only checked on packages that were showing the medications were current. She stated failure to check the carts and the refrigerator for expired dates if administered they will not be effective.The ADON J stated also nurses were responsible of checking for expired medications when they open the refrigerator. She stated ADONs were supposed to go behind the nurses to check whether they were removing the expired medications from the refrigerators and carts. She stated by failing to check for the expired medications, they could be administered and would not be effective. She stated the facility had offered training to staff but she could not recall when. Interview on 09/12/24 at 3:41 PM with the DON revealed the ADONs were responsible to check for expired medication in the refrigerators every two weeks. She stated her ADONs overlooked, and they failed to see the expired medications in the carts and the refrigerator. The DON stated she was responsible for supervision, and she had directed her ADONs to check the carts and refrigerator when the surveyors entered the facility, but it seemed the chain of command failed because her expectation was her ADONs would be the ones to supervise the nurses and medication aides to ensure all expired medications were removed from the carts and the refrigerator. She stated the pharmacist also checked the carts on 08/22/24, and she also missed the expired medications in the cart and the refrigerator. She stated if staff were not checking the refrigerator and medication carts for expired medications and medications were administered to residents, they would not be effective. Review of the facility's Administering Medications policy, revised April 2019, reflected the following: . 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing based on the comprehensive assessment for 1 of 4 residents (Resident #22) reviewed for pressure ulcers. The facility failed to ensure the DTI on Resident #22's right and left buttocks across the sacrum was covered with a dressing. This failure could place residents at risk of pain and lead to systemic infections causing harm for residents. Findings included: Review of Resident #22's face sheet dated 09/12/24 reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included diabetes (high blood sugar) and other specified non-inflammatory disorders of vulva and perineum. Review of Resident #22's quarterly MDS assessment dated [DATE], reflected Resident #22 had a BIMS score of 06, reflecting the resident's cognition was severely impaired. She was at risk of developing pressure ulcers. The IDT was from a blister. Review of Resident #22's care plan revised date 03/11/24 reflected: Focus: The resident has actual impairment to skin integrity of the right buttocks (blister) 8/19/24 DTI of the sacrum. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal sign and symptoms of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #22's physician orders dated 08/19/24 reflected: Clean wound on left and right buttock/sacrum with normal saline or wound cleanser. Dry. Apply a hydrocolloid bandage and change [Monday-Wednesday-Friday] and as needed one time a day every Mon, Wed, Fri. Observation with LVN G on 09/12/24 at 10:16 AM of the DTI on Resident #22's right and left buttocks wound did not have a dressing on it. LVN G stated she was not aware Resident #22 did not have a dressing on. Observed Resident #22's brief to be wet. No signs of infection noted. Observation and interview on 09/12/24 at 10:30 AM revealed Resident #22 was lying in bed. Resident #22 stated she was doing well. Resident #22 stated she developed some blisters on her buttocks, and they turned into wounds. Resident #22 stated she was not aware the dressing was off. Interview on 09/12/24 at 10:39 AM with CNA D revealed she was the CNA assigned to Resident #22. She stated between 6:00 AM - 6:30 AM, she provided incontinenc care to Resident #22, and she noticed the resident did not have a dressing on her wound. She stated she knew she was supposed to notify the nurse or the treatment nurse, but she did not, it slipped her mind, and she forgot to notify the nurse. She stated Resident #22 did not complain of pain. CNA D stated she should have notified the nurse. She stated the risk of not having a dressing on would be infection. Interview on 09/12/24 at 2:43 PM with LVN G revealed Resident #22 had a physician's order to cleanse and cover the wound three days in a week Monday Wednesday and Friday. She stated she was not made aware that Resident #22's dressing had come off. She stated when she completed wound care yesterday (09/11/24) on Resident #22, she had applied a dressing over it. She stated her expectations were for the nurses to monitor the dressing every shift and if the dressing came off, they had PRN treatment orders to follow. She stated the potential risk if the dressing comes off would be a decline in the wound status and infections. She stated she had not done training to staffs because she was newly hired. Interview on 09/12/24 at 3:44 PM with the DON revealed her expectations were for her staff to follow orders and as needed orders. If the dressing came off when completing perineal care, the aides were to notify the nurse, and the nurses were to apply a new dressing. The DON stated she had not completed in-services on wound care. She stated the risk of not having a dressing could lead to an infection and wound margins increasing. Review of facility policy Personal Care revised February 2018, reflected the following: 6. If a splint or dressing or patch (medication) comes off, gets wet or soiled report this to the nurse.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #30) of six residents reviewed for resident rights. The facility failed to ensure Resident #30's wheelchair was free of debris. This failure could place residents at risk of not having a safe, clean, comfortable, and homelike environment. Findings included: Record review of Resident #30's Admission Record dated 09/12/24 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease without dyskinesia (neurodegenerative disease that affects both motor and nonmotor systems of the body), bilateral primary osteoarthritis of hip (inflammation and injury to a joint causing a breakdown of cartilage tissue), difficulty in walking, muscle weakness, lack of coordination, unsteadiness on feet, wedge compression fracture of vertebra (when one side of vertebra collapse), and wedge compression fracture of lumbar vertebra (collapse of a vertebra, due to weakening of the vertebra). Record review of Resident #30's quarterly MDS assessment, dated 08/31/24, reflected a BIMS score of 5 indicating severe cognitive impairment. His Functional Status evaluation indicated he required assistance with wheelchair, dependent on staff for toileting, substantial assistance with dressing and personal hygiene. Record review of Resident #30's undated care plan, reflected he had an ADL self-care deficit, with goal to include current level of function, interventions including Resident to have bilateral lateral support placed in wheelchair daily. Resident has the potential for skin impairment related to decreased mobility, incontinence. Goal: Resident will have no skin breakdown related to incontinence. Interventions include to reposition resident on CNA rounds. Observation on 09/10/24 at 3:20 PM revealed Resident #30 sitting in his wheelchair. The wheelchair was observed to be dirty with visible debris and dirt on his wheelchair. Observation on 09/11/24 at 12:20 PM revealed Resident #30 sitting in his wheelchair, the wheelchair was observed to be dirty with visible debris and dirt on his wheelchair. Interview and observation on 09/12/24 at 11:19 AM with LVN A revealed if the aides were to notice anything wrong with resident's wheelchair, they were to alert the nurse, and depending on what was reported, the nurse will alert the housekeeping supervisor. Observation of Resident #30's wheelchair revealed it was dirty with chucks of debris on both sides of the resident's seat. LVN A reported aides were supposed to wipe down resident wheelchairs if they were dirty. LVN A stated aides were responsible for keeping wheelchairs as clean as possible. LVN A stated Resident #30 was placed at risk of infection when his wheelchair was not wiped down or kept clean. Interview and observation on 09/12/24 at 12:17 PM with CNA C revealed she was currently working with Resident #30, CNA C stated she assisted Resident #30 with transfers in and out of his wheelchair. Observation of Resident #30's wheelchair revealed it was dirty with chunks of debris on both sides of the resident's seat. CNA C stated she would normally look at wheelchairs and clean if needed. CNA C stated it was been busy, she did not notice Resident#30's wheelchair was not clean. CNA A stated she did not know of any risk to residents if their wheelchair was dirty, not cleaned, or wiped down. According to CNA C, Resident #30 did not have any pressure ulcers or open wounds. Interview on 09/12/24 at 3:00 PM with the ADON revealed the overnight nursing team should have been checking resident wheelchairs every night to ensure they were clean. The ADON stated her expectations were that nursing staff did a quick wipe down to ensure wheelchairs were clean and operating appropriately. The ADON stated nurses and nurse aides were responsible to assist residents with clean wheelchair and environments, and not doing so, placed residents at risk of dignity issues and not having a properly functioning wheelchair which could cause hazards to the resident. Interview on 09/12/24 at 3:24 PM with the DON revealed her expectations were for nursing staff to ensure resident wheelchairs were wiped down and clean. The DON stated there was no specific time to clean them; it should be done throughout the day. The DON stated, if needed, nursing staff could report to the maintenance department to hose them down so they could be cleaned. The DON stated not keeping wheelchairs cleaned could place residents at risk of hygiene issues and could infect or re-infect residents with illness and adverse reactions. Record review of the facility's policy Hazardous Areas, Devices and Equipment, revised July 2017, reflected: All hazardous areas, devices and equipment in the community will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: a. Equipment and devices that are left unattended or are malfunctioning. b. Devices and equipment that are improperly used or poorly maintained.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and #2) of eight residents reviewed for infection control. The DON failed to follow up on Resident #1 when the resident reported a positive COVID-19 test she had performed on herself, and she also was symptomatic. This failure placed the residents at risk of not having their COVID-19 symptoms treated, and possibly infecting other residents. An Immediate Jeopardy was identified on 12/29/22 at 4:50 PM. While the Immediate Jeopardy was removed on 12/30/22, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Findings included: Observation on 12/29/22 at 9:00 AM revealed all staff and visitors were observed wearing N-95 masks. Interview on 12/29/22 at 9:10 AM, the Administrator stated the facility had two residents in isolation for being positive for COVID-19, and three residents in isolation for being unvaccinated or having an unknown COVID-19 status. Observation on 12/29/22 at 2:05 PM revealed Residents #1 and #2 were not on any isolation precautions. Interview on 12/29/22 at 2:05 PM with Resident #1, she stated she performed a home COVID-19 test on herself, after her family brought it to her, because she was not feeling well. She tested herself on 12/27/22, and the test was positive. She notified CNA A of her positive result. The DON came to her room and stated the home test could not be relied on for accuracy, they had a lot of false positives. Resident #1 also stated her former roommate, Resident #3, had tested positive for COVID-19 and had been moved to an isolation room, and her current roommate, Resident #2, had a family member that told them he tested positive for COVID-19 on Tuesday 12/27/22. Resident #1 stated she told the DON she had a sore throat, cough, and loss of taste. Interview on 12/29/22 at 2:10 PM with Resident #2, she stated her family member began to have flu like symptoms on 12/23/22. The family member came to visit her on 12/24/22 for a few minutes and left. On 12/26/22, her family member went to the emergency room because he was feeling worse, and he tested positive for COVID-19. He called her on 12/27/22 to let her know he was positive for COVID-19, and he had also notified the facility staff. Interview on 12/29/22 at 2:25 PM, the DON stated she had been made aware of the positive test on Resident #1, but she had not followed-up with their own testing because the Medical Director advised them to only test those residents that had symptoms of COVID-19, and Resident #1 only had a slight cough. She stated the home tests were known to have a lot of false positives. She stated if an employee reports a positive home test, they had to come to the facility to be tested again. The DON listed the symptoms of COVID-19 as cough, fever, runny nose, body aches, and loss of taste or smell. She denied knowing Resident #1 had reported anything other than a cough and again confirmed coughing was a sign of COVID-19. Interview on 12/29/22 at 3:07 PM with the family member of Resident #2, he stated after he notified the resident of his positive status, he called the facility to notify them. He did not know who he spoke with, but he suggested Resident #2 and her roommate be tested since he had visited on 12/24/22. Interview on 12/29/22 at 3:10 PM, CNA A stated Resident #1's voice had been very hoarse and had asked her if she was feeling ok. Resident #1 had reported she had a sore throat, cough, and no sense of taste. Resident #1 informed CNA A she had a home test kit that her family had brought to her on 12/26/22. CNA A stated she had watched Resident #1 perform the self-test and had set a timer on her phone so they would know when to check for results. CNA A remained in the room giving Resident #2 a bed bath, when the timer went off Resident #1 had stated the test was positive. CNA A looked at the results and reported them to RN B. RN B was busy and asked her to notify the DON. CNA A notified the DON of the positive results and the resident's symptoms. The DON had stated home tests were not reliable and went to speak with the resident. CNA A stated Residents #1 and #2 had not been placed on isolation status by the end of her shift. Interview on 12/29/22 at 3:25 PM, RN B stated she had been made aware of Resident #1's positive test and her symptoms. She had seen the DON enter Resident #1's room, and when she came out she, did not order the resident to be placed on isolation. RN B did not have any interactions with Residents #1 or #2 before the end of her shift. She reported the information to her relief. On 12/29/22 at 4:50 PM, the Administrator was notified that an Immediate Jeopardy had been identified, and he was provided the Immediate Jeopardy template. The facility submitted the following acceptable Plan of Removal on 12/30/22 at 12:06 PM: The facility failed to place a resident in isolation with known COVID-19 exposure (her roommate) and who had a positive result from self-administered COVID-19 test. The resident expressed symptoms of COVID-19 (sore throat, cough, and loss of taste) to her CNA who notified the DON. 1. Immediately 12/29/2022 5:10 PM the Charge Nurse went and tested both residents. They were both positive and placed in isolation. 2. Immediately 12/29/2022 5:26 PM the DON began COVID-19 19 testing for all residents in the building. 3. Company Director of Resident Care Services and Education will in-service DON on signs/symptoms of COVID-19, testing when a resident and/or family reports symptoms, or reports a positive test conducted outside the facility. 4. Inservice all staff with respect to signs and symptoms of COVID-19 19, documenting, and reporting all signs and symptoms to the DON and the Administrator. Inservice will initiate 12/29/22 and will be ongoing until all staff receive the in-service either in-person or via phone prior to the start of/beginning of shift. 5. The content of the in-service will be validated with random staff weekly x4 weeks and then every other week x4 weeks utilizing post index card questions with respect to signs/symptoms of COVID-19 19. All staff will be reeducated based on the results of the post index card questioning. 6. Every morning as part of morning meeting process the DON/IDT will review the 24-hour report for changes in condition and all new orders, change orders, and initiate any COVID-19 testing where applicable. 7. In between morning meetings, staff will report any potential signs/symptoms to nurse management/RN on duty to determine need for COVID-19 testing. 8. If resident or family reports self-testing outside the facility, the facility will test the respective resident for COVID-19. The facility will then take appropriate action based upon results of COVID-19 test. 9. Facility will implement transmission-based precaution measures to ensure residents are moved with known COVID-19 exposure, symptoms of COVID-19, or positive COVID-19 test results are tested to prevent further spread of the infection. 10. The facility will ensure sufficient PPE is available at a 10 day burn rate available based on current isolation standards and is utilized for residents in isolation. The facility has access to 3 contracted vendors and sister facilities that provide PPE supplies if access becomes an issue. 11. The physician for the respective resident(s) that test positive will be notified immediately and to request and additional orders. 12. The QAPI committee will review the plan and the results and modify as needed for the next 3 months. Completion Date: 12/30/22 and on-going Monitoring of the Immediate Jeopardy included: Interview on 12/30/22 at 9:50 AM, the Administrator stated all residents of the facility had been tested by the DON on 12/29/22. A total of seven more residents had tested positive, including Residents #1 and #2. Isolation precautions had been put in place. Residents with a positive result for COVID-19 were cohorted together or in single rooms. Residents with negative results but exposure to a positive roommate, were also cohorted and placed on isolation precautions. The Administrator stated he had been unaware of Resident #1 reporting a positive test until notified of the Immediate Jeopardy. He stated he relied on his clinical team to inform him of any COVID-19 positive residents. Observation on 12/30/22 at 10:45 AM with the DON revealed seven new residents with isolation precautions in place and PPE outside their rooms. Interview on 12/30/22 at 12:36 PM, Housekeeper C she stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:38 PM, Housekeeper D stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:40 PM, Cook E stated he had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. He was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:45 PM, Dietary Aide F stated he had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. He was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:47 PM, Cook G stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:48 PM, Dietary Manager stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:50 PM, Housekeeping Supervisor stated he had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. He was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 12:55 PM via phone, LVN H stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:00 PM via phone, CNA I stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:05 PM, CNA J stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:10 PM, the Marketing Director stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:15 PM, the Social Worker stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:20 PM, RN K stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:23 PM, CNA L stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:26 PM, CNA M stated she had been in-serviced on COVID-19 precautions, isolation and signs and symptoms. She was able to verbalize the symptoms of COVID-19. Interview on 12/30/22 at 1:30 PM, the DON stated she had been in-serviced via phone by the Director of Resident Care Services on signs and symptoms of COVID-19, what to do if a resident has symptoms of COVID-19, what to do if family reports a positive test, and when to perform COVID-19 testing. Interview on 12/30/22 at 1:44 PM, with Physician N she stated she had not been notified until 12/29/22 about Resident #1's positive COVID-19 status. She was unaware the resident had performed a self test on 12/27/22. She stated had she known earlier she would have placed the resident on isolation status earlier and ordered continued testing. She did not order anti-viral treatment. Interview with the facility's Medical Director was unsuccessful, phone calls were not returned prior to exit on 12/30/22. The Administrator was notified the Immediate Jeopardy was removed on 12/30/22 at 2:50 PM the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Review of the facility's policy COVID-19-19 Infection Prevention and Control Measures, dated July 2020, reflected: .2. Anyone entering the facility, including staff, is screened and traiged for signs and symptoms and exposure to others with COVID-19 infection. .4. Residents are screened daily for fever and symptoms of COVID-19-19. Residents with fever or symptoms of COVID-19-19 are provided with a face mask, immediately isolated and placed on appropriate transmission-based precautions.