Every finding on record at The Plaza at Edgemere

Based on observation, interview, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Residents #1 and #2) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 and Resident #2 did not develop wounds due to ill-fitting (too small) briefs for both, and the use of a mechanical lift sling that was too small for Resident #1. This failure could place residents at risk for pain and infection.Findings included: 1. Record review of Resident #1's admission MDS Assessment, dated 03/05/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were moderately impaired. The resident was always incontinent of urine and frequently incontinent of stool. Her diagnoses included heart failure, diabetes, and end-stage kidney disease. Record review of Resident #1's Care Plans reflected:03/19/26 The resident was incontinent of bladder.Facility Goal: The resident will remain free from skin breakdown due to incontinence and brief use.There were no interventions listed. Record review of Resident #1's Order Summary Report, dated 03/16/26, reflected:Cleanse non-pressure wound to left posterior upper thigh with wound cleanser; pat dry, apply calcium alginate, cover with dry dressing change daily and as needed. Record review of Resident #1's progress notes dated, 03/16/26 at 1:34 PM, authored by the WCN reflected:Notified by night nurse that resident had an open area to buttock, physician here, assessment done. Per resident open wound is due to [mechanical] lift. New order from physician to cleanse non-pressure wound to left posterior thigh with wound cleanser, pat dry apply calcium alginate cover with dry dressing change daily and as needed. Review of wound care notes for Resident #1, dated 03/24/26, reflected:Non - Pressure Wound of the left, posterior, upper thigh, full thickness.Wound Size (L x W x D): 0.5 x 1.2 x 0.2 cmWound progress: Improved evidenced by decreased surface area An observation and interview on 03/26/26 at 11:00 AM with Resident #1 revealed the WCN was preparing to do wound care. Resident #1 said she did not know how the wound developed and she did not know how long she had the wound. The resident had a linear, open area surrounded by redness, on the back of her left thigh. The brief was the appropriate size for the resident. 2. Record review of Resident #2's admission MDS Assessment, dated 02/11/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were intact. The resident was always incontinent of urine and stool. The resident's diagnoses included heart failure and diabetes. Record review of Resident #2's Order Summary Report dated 03/10/26 reflected:Cleanse right ischium non-pressure wound with wound cleanser, pat dry, apply calcium alginate, cover with dry dressing, change daily and as needed.Record review of Resident #2's Care Plans reflected:02/27/26 The resident was incontinent of bladder.Facility Goal: The resident will remain free from skin breakdown due to incontinence and brief use.Facility interventions: Brief use - The resident used disposable briefs. Change per schedule and as needed.3/27/26 Wound Management Wound: Right Ischium (back part of hip) Non-PressureFacility interventions included: Provide wound care per treatment order. Record review of Resident #2's progress notes dated 03/03/26 at 12:34 PM authored by the WCN reflected:Notified by floor nurse that resident had a shallow open area to right ischium. Physician here and notified. Resident seen by wound for multiple skin tears (old) and right ischium wound. New order for non-pressure wound to right ischium to apply xeroform gauze cover with dry dressing change daily and as needed. Review of wound care notes for Resident #2, dated 03/24/26, reflected:Non - Pressure Wound of the left, posterior, upper thigh, full thickness.Wound Size (L x W x D): 6 x 4.2 x 0.4 cmWound progress: At Goal An interview on 03/26/26 at 12:30 PM with Resident #2 revealed he said he developed a wound because he was wearing a brief that was too small. He said the WCN was taking care of it. He said that his briefs were now the correct size. An interview on 03/26/26 at 12:10 PM with the WCN revealed Resident #1 developed her wound due to the brief being too small and the small mechanical lift sling. The WCN said Resident #2 had a wound due to him having a very small brief. She said it was a non-pressure wound to the right ischium. She said it developed on 03/03/26. An interview on 03/26/26 at 3:45 PM with the DON revealed Resident #1 and Resident #2 had briefs that were tight and had areas that were really red. The DON said the staff changed the briefs to a larger size. The DON said the nurses and CNAs were responsible for ensuring the resident had the right sized brief. Record review of the facility's policy, Wound Treatment Management, revised 01/02/26, reflected: Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Record review of the facility policy, Resident Rights, dated 2026, reflected:8. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the fourth quarter (July 1, 2025, to September 30, 2025). The facility failed to submit complete PBJ staffing information to CMS for July 1, 2025, to September 30, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included:Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 4 (July 1, 2025- September 30, 2025). No other quarter triggered. An interview with the Administrator on 01/20/2026 at 9:30 am, revealed she was not employed by this facility during that reporting period. She stated that she was unaware of the failure to report data for that reporting period.An interview with the Executive Director on 01/20/2026 at 9:31 am revealed the facility simply did not get the data entered in the system in on time. She stated that they just missed the data entry due date. She stated there were no issues with data input or connecting to the website. She stated that they have not had any problems entering the information since then.The facility provided a policy for payroll Based Journal dated 10/31/2025 which reflected the following: .It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.Definitions: Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:The facility will electronically submit timely to CMS complete and accurate direct care staffing information including the following:The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);Resident census data; andInformation on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).When reporting information about direct care staff, the facility will specify whether the individual is an employee of the facility or is engaged by the facility under contract or through an agency.The facility will submit direct care staffing information in the uniform format specified by CMS.The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. The facility shall submit information (specify frequency), and no later than the deadline specified for the specific quarter in which the data is to be reported.Reporting deadlines:Fiscal Quarter 1 (October 1 - December 31): February 14Fiscal Quarter 2 (January 1 - March 31): May 15Fiscal Quarter 3 (April 1 - June 30): August 14Fiscal Quarter 4 (July 1 - September 30): November 14The facility will ensure all staffing data entered in the Payroll-Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and/or tied back to a contract.The facility will utilize the current submission guidelines as described in the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual.Responsibilities for data submission:The Administrator, HR Director, and Director of Nursing are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports.The Business Office Manager is responsible for verifying the accuracy of census data and collaborating with MDS Coordinator for any needed corrections. Reports available through CASPER may be utilized to assist with verifying data.(Designated individual or vendor) is responsible for submitting data and obtaining validation reports.The Administrator is responsible for reviewing validation reports and ensuring that any needed corrections are made before the quarterly deadline

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only paper towels were placed in 3 of 3 handwashing sink garbage receptacles.The facility failed to ensure that 1 of 3 handwashing sinks had a garbage receptacle.The facility failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration required for effective sanitation.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the kitchen on January 20, 2026, at 10:06 a.m., revealed the following:2 of 3 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including disposable gloves, product boxes, food, and other forms of trash.1 of 3 handwashing sinks did not have a garbage receptacle available for disposal of used disposable paper towels.On January 20, 2026, at 10:10 a.m., the Kitchen Attendant was observed testing the sanitizing water used for dishwashing; the test strip read 400 parts per million, indicating a high concentration.On January 20, 2026, at 10:33 a.m., 7 cans of green sliced olives (3 pound 7 ounces each) were observed to have large dents and compromised seals.During an interview on January 20,2026, at 10:12 a.m., with the Kitchen Attendant, she said she was unsure how to properly use the sanitizing test strip and how to interpret the results. The Director of Culinary Services provided immediate instructions and demonstrated how to properly check the chemical balance in the sanitizing water and how to read the color strip.During an interview on January 20,2026, at 10:49 a.m., the Director of Culinary Services said that all handwashing sinks were required to have a garbage receptacle, and he immediately retrieved a garbage can being used in another area of the kitchen and placed it by the sink that did not have one.During an interview on January 20, 2026, at 10:55 a.m., with the Director of Culinary Services and the Dietary Manager revealed cooks were responsible for unloading delivery trucks, and if dented cans were found, they were placed in a separate area and returned.Record review of the facility's 3 Compartment Sinks policy, with no date, revealed Procedure: .5. Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturers guidelines to prepare sanitizing solutions.Sink Setup.3. Sanitizing Compartment.Verify concentration using appropriate test strips before and during use.Step 4 - Sanitize. verify sanitizer concentration using test strips regularly.Record review of facility's food storage policy with no date, revealed nothing in the policy relating to dented cans.There was no policy on garbage receptacles in the kitchen.Review of the U.S. FDA Food Code 2022 reflected: .6-301.20 Disposable Towels, Waste Receptacle. Waste receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #14, and #71) of four residents observed for infection control in that: LVN A failed to disinfect the blood pressure cuff (used to take blood pressure), and the thermometer in between vital sign checks for Resident #14, and Resident #71. This failure could place residents at risk for spread of infection through cross-contamination. Findings included:Review of Resident #14's 5-day MDS assessment, dated 01/10/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), diabetes (increase of blood sugar), and anxiety disorder (anxious and nervous). Resident #14's BIMs score of 15 indicated the resident was alert and oriented with no cognitive impairment. The MDS revealed Resident #14 required assistance from one staff for activities of daily living.Review of Resident #14's the consolidated physician orders dated January 2026 reflected: order dated 01/05/2026, metoprolol succinate ER (high blood pressure) tablet 25mg one tab by mouth one time a day. Further review revealed physician orders to check blood pressure, every shift.Review of Resident #71's 5-day MDS assessment, dated 12/31/2025, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hip fracture (broken hip) and depression (sadness). Resident #71's had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #71 consolidated physician orders dated January 2026 reflected: order dated 01/05/2026, check vital signs every shift or for condition change.Observation on 01/22/2026 at 9:20 a.m. revealed LVN A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #14. LVN A took the blood pressure cuff to check her blood pressure, then administered Resident #14's medications. LVN A did not clean the machine prior to or after using it on Resident 14, with Sani Wipes. LVN A did use hand gel on her hands prior to collecting supplies. LVN A left the room went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass.Observation on 01/22/2026 at 9:40 a.m. revealed LVN A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #71. LVN A entered the room as the CNA informed LVN A Resident #71 had loose stools and vomiting. LVN A took the blood pressure cuff and thermometer (to measure temperature) to check her blood pressure and the electronic thermometer to check her temperature. LVN A did not clean the machines prior to or after using on Resident #71. LVN A did use hand gel on her hands prior to collecting supplies. LVN A left the room, went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare the medications Resident #71 had for her symptoms. In an interview on 01/20/2026 at 9:45 a.m., LVN A stated she was to clean all equipment that was used before and after use on each resident, to prevent the spread of infection. LVN A stated she had been in-serviced concerning the spread of infection, including cleaning of equipment in the past six months. LVN A stated with both of these residents she had just forgotten.In an interview on 01/22/2026 at 10:45 a.m. with interim DON revealed all direct care staff must clean equipment, including blood pressure cuffs, and thermometers. The interim DON stated they have Sani wipes available on all medication and treatment carts. The interim DON stated if the staff was not cleaning the equipment appropriately this could spread germs to themselves and the residents.Review of the in-services given in the past six months reflected an in-service dated August 10th, 2025, for infection control and cleaning of equipment. LVN A attended the meeting. Review of the facility's policy Medical Equipment Cleaning Procedure Policy dated June 2023, reflected, 1. Purpose: The purpose of this policy is to ensure all medical and resident care equipment is properly cleaned, disinfected, and maintained to prevent the spread of infections . This policy establishes consistent procedures for cleaning, handling, and storing medical equipment. 2. Scope: This policy applies to all employees responsible for handling or cleaning non-critical, semi critical, and shared medical equipment within the community, including but not limited to: . blood pressure cuff,. thermometer (non-disposable) . Responsibilities: . nursing staff . Ensure shared patient -care devices are disinfected between residents. 7. Frequency of cleaning. blood pressure cuffs . between each resident. reusable thermometers after each usage .

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #2) of 4 residents reviewed for care plan review and revision.The facility failed to review and revise Resident #2's care plan after he fell on [DATE] and 06/22/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. The findings included: Record review of Resident #2's Face Sheet, dated 10/09/2025, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and a history of falls. Record review of Resident #2's Quarterly MDS (tool used to measure health status) Assessment, dated 07/13/2025, reflected severely impaired cognition with a BIMS (tool used to assess cognition) score of 03. Section J (Health Conditions) indicated Resident #2 had two or more falls since admission/reentry which did not result in any injury. Record review of Resident #2's Comprehensive Care Plan, dated 07/16/2025, reflected the resident was at risk for falls related to a history of falls and gait/balance problems. The Comprehensive Care Plan indicated Resident #2 had a fall on 06/17/2025 and 06/22/2025 with no injury. An intervention to prevent a future fall was not added to the care plan after the resident fell on [DATE] and 06/22/2025. Record review of Resident #2's Incident Report, dated 06/17/2025, reflected Incident DescriptionNursing Description: Resident attempting to go to restroom without assistanceResident Description: was attempting to go to restroom and lost balance and fell onto the floorWas this incident witnessed: NImmediate Action TakenDescription: Head to toe assessment completed by nurse and treatment nurse, no c/o pain at this time. Assisted back to chair. No injuries noted. Reeducated resident to use call light to call for assist. Neuro checks started, will monitor resident over the next 72 hours for any changes. MD notified, no new orders given at this time. POA, hospice and DON notified.Record review of Resident #2's Neurological/Vital Sign Checks reflected staff monitoring and documentation after the resident fell on [DATE]. Record review of Resident #2's Incident Report, dated 06/22/2025, reflected Incident DescriptionNursing Description: Staff notified this writer that resident was on the floor on his left side of the bedResident Description: Resident Unable to give DescriptionWas this incident witnessed: NImmediate Action TakenDescription: Head to toes assessments done . able to move all extremities, 2-3 person assisted back to bed. and call light in reach, no new injuries. Will continue as plan of careRecord review of Resident #2's Neurological/Vital Sign Checks reflected staff monitoring and documentation after the resident fell on [DATE]. During an interview on 10/09/2025 at 4:46 PM, the MDS Coordinator stated she was responsible for completing the residents' comprehensive care plans. She stated the DON and ADON were responsible for acute care plans such as falls. The MDS Coordinator opened Resident #2's chart and stated she did not see a new intervention added after he fell on [DATE] and 06/22/2025. She stated residents' care plans were important, so everyone was aware of their needs.During an interview on 10/09/2025 at 5:20 PM, the DON stated she and the ADON added and updated acute care plans, including when a resident fell. She stated the MDS Coordinator completed the comprehensive care plans. The DON looked at Resident #2's chart and stated the intervention added on 06/22/2025 was to continue interventions on the at-risk plan. She stated a new intervention was not added. The DON stated a new intervention should have been added to Resident #2's fall risk care plan after each fall. She stated it was important to ensure the facility had appropriate interventions in place, and all staff were alert of interventions, to prevent falls and injury.During a telephone interview on 10/15/25 at 2:33 PM, the ADON stated Resident #2's care plan should have been updated each time he fell. She stated it was important to ensure care plans were updated and the interventions implemented were appropriate and working for the resident. Record review of the facility's policy Baseline Care Plan, undated, reflected Interventions shall be initiated that address the resident's current needs including. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk.Record review of the facility's policy Care Plan Revisions Upon Status Change, undated, reflected The comprehensive care plan will be reviewed, and revised as necessary, when a resident experience a status change. The care plan will be updated with the new or modified interventions.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 2 kitchens reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator and freezer, were properly sealed from air-borne contaminations. 2. The facility failed to clean the food storage bins in the dry food storage area in the main kitchen. The facility failed to clean the Ice Machine on both the 3rd floor (Main Kitchen) and 2nd floor (Secondary Kitchen). These failures could place residents at risk for cross contamination and air-borne illnesses. Findings included: Observations on [DATE] from 8:39 AM to 9:00 AM in the facility's main kitchen reflected: The food storage bins in the dry food storage area, were noted to have stains to the top of the container lid. Observations on [DATE] from 12:27 PM to 12:33 PM in the facility's secondary kitchen area located on the second floor reflected: Ice machine upper inside surface contained brownish sticky substance on approximately ,d+[DATE] of the surface. On [DATE], at 8:39 AM observations in the main kitchen refrigerator include the following: One large tray containing assorted sandwich and hamburger buns not properly sealed exposed to air contaminants. One large bin containing assorted breads was not properly sealed and exposed to air contaminants, not dated and no visible expiration date was observed. The findings in the main kitchen freezer included the following: One large bin containing celery not properly sealed and exposed to air contaminants. One partial roll of hamburger meat undated not properly sealed and exposed to air contaminants. One medium size bin containing tomato sauce not properly sealed and exposed to air contaminants. One medium size bin containing sauce not properly sealed and exposed to air contaminants. One large piece of cake on a tray not properly sealed and exposed to air contaminants. One large bag of grapes not properly sealed and exposed to air contaminants. Observation on [DATE] at approximately 8:45 AM the main Ice Machine on 3rd floor was noted to have, the lid and interior portion had 10 brownish and blackish thick sticky stains on the top portion of the ice bins. Observation on [DATE] at 9:00 AM of the secondary ice Machine located on the 2nd floor, the ice scooper holder had a brownish substance at the bottom of the container. Record review of the Ice Machine Cleaning Log on ,d+[DATE] showed the log to have been maintained and reflected it being serviced for January - [DATE]. September had (Out of Order) marked through it on [DATE], but did not reflect any further cleaning being done for [DATE]. In an interview with Dietary Manager on [DATE] at 11:55 AM, she advised has been the DM at this facility for 2 years and a total of [AGE] years in the food service industry. The DM advised of the concerns observed in the kitchen area. She was shown images of all the concerns observed in the kitchen. She stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. She stated the Ice Machines are supposed to be cleaned monthly. The chef is responsible to check it once a month. It also is the supervisor of the day of that shift. The supervisor checks the cleaning log. The DM advised labeling and dating are done by the person who gets it in from the delivery it is their responsibility to label it and place it properly She said a full in-service was done regarding proper labeling and cleaning logs, of kitchen items. In an interview on [DATE] at 12:30 PM, the Administrator was advised there were concerns observed in the kitchen. He was made aware of these concerns and has spoken with the DM. He advised that the issues could cause food contamination and this matter would be resolved. If items are expired you don't want to serve, it to residents. The ADMIN said the risk of all these concerns observed in the kitchen could result in residents getting. exposed to contaminated foods resulting in food borne illnesses. Review of All food handling and safety must comply with the Texas Food Establishment Rules (TFER) and the CMS and Texas Health and Human Services Commission (HHSC)of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #18 and Resident #198) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA A changed her gloves and performed hand hygiene while providing incontinent care to Resident #18. 2. The facility failed to ensure that CNA B and the MDS Nurse changed their gloves and performed hand hygiene while providing incontinent care to Resident #198. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #18's Face Sheet, dated 10/03/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #18 was diagnosed with abnormalities of gait and mobility. Review of Resident #18's Quarterly MDS Assessment, dated 06/11/2024, reflected that Resident #18 was cognitively intact with a BIMS score of 15. Resident #18's Quarterly MDS Assessment indicated the resident was frequently incontinent for bowel and bladder. Review of Resident #18's Comprehensive Care Plan, dated 09/09/2024, reflected the resident had bowel incontinence and one of the interventions was provide pericare. Observation and interview with CNA A on 10/01/2024 at 1:29 PM revealed CNA A was about to do Resident #18's incontinent care. The resident was already inside the bathroom with a sit-to-stand lift in front of her. CNA A said she was waiting for the resident to finish relieving herself. When the resident said she was finished, CNA A sanitized her hands and put on a pair of gloves. CNA A took a brief, opened it, and hanged it on the railing beside the toilet seat. CNA A took a plastic bag, opened it, and put it on the trash can. CNA A did not change her gloves after touching the trash can. CNA A raised the sit-to-stand, pulled some wipes, and cleaned the front part of the resident using a front to back technique. After cleaning the front part of the resident, CNA A pulled some wipes and cleaned the bottom of the resident. After cleaning the bottom of the resident, CNA A took the brief hanging on the railing, slid it between the resident's legs, and fixed it. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. After fixing the brief, CNA A rolled the sit-to-stand and transferred the resident to her wheelchair. CNA A stated hands should be washed or sanitized before and after doing incontinent care. CNA A said gloves should be changed after touching the waste can and after cleaning the bottom of the resident, and before touching the new brief. She said germs from the waste can and soiled brief could transfer to the new brief. She said they had in-services about infection control and hand hygiene. 2. Review of Resident #198's Face Sheet, dated 10/03/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #198 was diagnosed with chronic kidney disease and muscle weakness. Review of Resident #198's Comprehensive MDS Assessment, dated 09/03/2024, reflected Resident #198 was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated that the resident was frequently incontinent of bowel. Review of Resident #198's Comprehensive Care Plan, dated 09/13/2024, reflected the resident was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 10/02/2024 at 9:12 AM revealed CNA B and the MDS Nurse were about to do Resident #198's incontinent care. CNA B and the MDS Nurse both washed their hands and put on a pair of gloves. CNA B took a brief and a plastic bag and placed them on the side of the resident's right leg. While CNA B was preparing the brief and the plastic bag, the MDS Nurse unfastened the resident's brief and tucked it between the resident's legs. The MDS Nurse did not change her gloves after touching the soiled brief. CNA B cleaned the front part using the front to back technique. After cleaning the front part of the resident, CNA B and the MDS Nurse assisted the resident to roll to her left side. CNA B pulled the soiled brief, threw it on the plastic bag, and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took a container of cream, got a handful of cream, and spread it on the resident's bottom. She did not change her gloves before getting some cream and before spreading it on the resident's bottom. After spreading the cream, she removed her gloves, and put on a new pair of gloves. She did not sanitize her hands before putting on a new pair of gloves. CNA B put the new brief under the resident's bottom, assisted the resident to roll back, and both CNA B and the MDS Nurse fixed the brief. When incontinent was done, CNA B and the MDS Nurse transferred the resident to her wheelchair using the stand-pivot transfer. After the transfer, The MDS Nurse washed her hands and went out of the room. CNA B fixed the trash, washed her hands, and went out of the room. In an interview with the MDS Nurse on 10/02/2024 at 9:27 AM, the MDS Nurse stated hand hygiene was the basic component in the prevention of cross contamination and development of infection. The MDS Nurse said the gloves should be changed after tucking the soiled brief in between the resident's legs and/or before helping in fixing the new brief. The MDS Nurse said touching soiled items and then touching clean items could cause the transfer of germs. In an interview with CNA B on 10/02/2024 at 9:31 AM, CNA B stated she did hand hygiene before doing any care for a resident. She said, during incontinent care, the gloves should have been changed after cleaning the resident's bottom and before applying the skin protector cream. She said the cream was a form of a treatment and should be applied using clean gloves. She said hand hygiene should also be done in between changing of gloves. She said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated hand hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care. He said gloves should be changed after cleaning the residents' bottoms, after touching the trash can, before getting the new brief, and before applying any form of treatment. He said not changing the gloves after touching soiled items, or after touching soiled body parts could result in cross contamination and probable infections. He said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and when transitioning from a dirty site to a clean site. The ADON said they would do in-service about infection control. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection. She said gloves should be changed after touching the soiled brief and the trash to prevent transfer of microorganism to any clean items. She said the staff should do hand hygiene before putting on a new pair of gloves. She said the expectation was for the staff to change their gloves when going from dirty to clean and to do hand hygiene when changing the gloves. She said she will do an in-service and skills check-off about infection control and would observe the staff personally. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated staff should make sure to change their gloves after touching anything soiled and sanitize their hands before putting on new gloves. He said not changing the gloves after touching soiled items and not sanitizing the hands could contribute to cross contamination and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he would collaborate with the DON to in-service the staff about infection control. Review of facility policy, Hand Hygiene undated, revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Hand Hygiene Table . After handling contaminated objects . Before and after handling clean or soiled dressings . Before and after providing care to residents . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site . After assistance with personal body functions . e.g., Elimination. Review of facility policy, Perineal Care undated, revealed Policy: It is the practice of this facility to provide perineal care to all incontinent residents . to promote cleanliness and comfort, prevent infection . 10 . Change gloves if soiled and continue with perineal care.16. Remove gloves and discard. Perform hand hygiene.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 3 for 2024 (April 1-June 30) reviewed for administration. The facility failed to submit staffing data to CMS for (April 1- June 30). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 3 2024 (April 1 - June 30), dated 09/24/2024, revealed the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter. In an interview on 10/03/24 at 12:55 PM, ADMIN said that he was responsible for uploading the PBJ he said he was responsible for submitting the PBJ data. When he was advised the CMS reported the information was not submitted timely. He said the PBJ submission was usually reported after it was completed. He said he was aware of the reporting regulation. When asked about his understanding of the importance of reporting PBJ data, he said the purpose was to ensure the facility was accurately staffed to care for the residents. He said the facility has been fully staffed at this time, and during the time it states it not being submitted. When asked what the potential negative outcome was for not submitting the PBJ data, he said failure to report would be that it would not reflect the accuracy of staffing in connection to the census. He stated staffing was important because the staff ensures residents' needs were met. In a follow up interview with ADMIN, 10/14/2024, he advised I did all the legwork for our reporting and failed to hit send on the document to CMS. He said I would not have known had you not mentioned this, we did not receive any notices or warnings and was totally convinced I had submitted it early. He said that he thought it was done. He said after he discovered it was not completed, he submitted the PBJ data to CMS. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, reflected Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 3 date range as April 1- June 30 Policy manual reflected, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #6, Resident #15, and Resident #32) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #6's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #15's CPAP mask (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure that Resident #32's CPAP mask was stored properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #6's Face Sheet, dated 10/03/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #6 was diagnosed with hypoxemia (low blood oxygen) and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue). Review of Resident #6's Quarterly MDS Assessment, dated 07/29/2024, reflected that Resident #6 had moderate impairment in cognition with a BIMS score of 9. Resident #6's Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #6's Comprehensive Care Plan, dated 07/22/2024, reflected that the resident has oxygen therapy r/t Ineffective gas exchange and one of the interventions was OXYGEN SETTINGS: O2 @ 2-4 L/min via NC. Review of Resident #6's Physician Order, dated 08/19/2024, reflected 02 @ 2-4L/min via NC. every shift for SOB. Observation on 10/01/2024 at 9:38 AM revealed Resident #6 was in her bed, sleeping. It was observed that the resident was on oxygen therapy via nasal cannula at 3 liters per minute. It was observed that she had a portable oxygen tank beside her dresser with a nasal cannula attached to it. The nasal cannula was hanging on top of the oxygen tank and was not bagged. 2. Review of Resident #15's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #15 was diagnosed with acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood). Review of Resident #15's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #15 was cognitively intact with a BIMS score of 14. Resident #15's Comprehensive MDS Assessment indicated the resident was using a CPAP. Review of Resident #15's Comprehensive Care Plan, dated 8/15/2024, reflected the resident has oxygen therapy and CPAP AT QHS r/t COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and one of the interventions was CPAP as ordered. Observation and interview on 10/01/2024 at 9:09 AM revealed Resident #15 was in her wheelchair, awake. It was observed that a CPAP mask was inside the drawer on the resident's right-side table. The CPAP mask was not bagged. Resident #15 said she went for a surgery and was not able to use her CPAP. She said she was not sure who put the CPAP in her drawer. Observation and interview with LVN C on 10/01/2024 at 12:09 PM. LVN C stated the nasal cannula and the CPAP mask should be bagged when not in use. He said he was not sure how long Resident #6's nasal cannula was hanging on the portable oxygen tank. He said he would disconnect the nasal cannula and discard it. He said he would also put Resident #15's CPAP mask in a bag. He said the nasal cannula and the CPAP mask should be bagged to prevent cross contamination and possible respiratory infections. 3. Review of Resident #32's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Resident #32 was diagnosed with acute and chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body. Review of Resident #32's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #32 had severe impairment in cognition with a BIMS score of 07. Resident #32's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #32's Comprehensive Care Plan on 08/08/2024 reflected the resident had COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and used a CPAP at night and one of the interventions was to use CPAP as ordered. Review of Resident #32's Physician Order, dated 08/07/2024, reflected BIPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs)/CPAP 16CM02 (centimeters of water pressure setting) at bedtime AND in the morning. Observation and interview with Resident #32 on 10/01/2024 at 10:51 AM revealed Resident #32 was in his bed, awake. Resident #32 had a CPAP machine sitting on top of the resident's left-side table. There was a CPAP mask connected to the machine. The CPAP mask was not bagged. According to Resident #32, he could put it on and take it off but sometimes a staff would put it on and take it off early morning. He said he was not aware if the staff were putting it inside a plastic bag. He said nobody told him to put it in a plastic bag if he was taking it off. Observation and interview with LVN D on 10/01/2024 at 11:08 AM revealed LVN D went inside Resident #32's room to check on him. After checking on him, she went out of the room and did not notice the resident's CPAP mask was on the table and was not bagged. When asked if the CPAP mask was bagged, LVN D went inside the room and said the CPAP was not bagged. LVN D looked for a plastic bag and found one in the drawer. She put the CPAP mask inside the plastic bag. She said she did not notice the CPAP mask was not bagged. She said Resident #32 used a CPAP and she would sometimes take it off in the morning. She said the CPAP mask should not be exposed nor touching anything because it could cause cross contamination and infection. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated the nasal cannula and the CPAP masks should be bagged when not in use. He said if the nasal cannula and the CPAP mask were exposed and touching surfaces that were dirty, cross contamination and possible respiratory infections could occur. He said the expectation was for the staff to bag the nasal cannula and the CPAP masks when not in use. She said she would coordinate with the DON pertaining to respiratory care. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated the nasal cannula and the CPAP masks should be bagged when not in use to keep them clean. She said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. She said the expectation was for the staff to be mindful in making sure that the nasal cannula and the CPAP mask of the residents were bagged when not in use. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula and CPAP mask. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection and all the orders would be in the system. He said he was not a clinician but would coordinate with the DON on how to go forward about the issue of respiratory care. Record review of facility's policy, Oxygen Administration 2001 MED-PASS, Inc. (Revised October 2010) revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Policy for respiratory care specific for bagging the nasal cannula and the CPAP mask was requested on 10/03/2024 at 8:51 AM but was not provided during exit.

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #148) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LVN C did not leave Resident #148's medications inside the resident's room. This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Review of Resident #148's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included encephalopathy (a disease that affects the brain), depression, and cognitive communication deficit. Review of Resident #148's Quarterly MDS Assessment, dated 07/08/2024, reflected resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment also indicated Resident #148 had debility (weakness) and cardiorespiratory (relating to the heart and the lungs) conditions. Review of Resident #148's Comprehensive Care Plan, dated 09/09/2024, reflected the resident had impaired cognitive function or impaired thought process. Resident #148's Comprehensive Care Plan did not indicate that the resident could self-administer his medications. Review of Resident #148's Assessment for self-medication on 10/03/2024 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Review of Resident #148's Physician Order for folic acid, dated 01/06/2024, reflected Folic Acid Tablet 1 MG. Give 1 tablet by mouth one time a day for supplement. Review of Resident #148's Physician Order for gabapentin, dated 01/06/2024, reflected Gabapentin Capsule 100 MG. Give 1 capsule by mouth three times a day for Neuropathy (dysfunction of the nerve). Review of Resident #148's Physician Order for loperamide, dated 03/22/2024, reflected Loperamide HCl Capsule 2 MG. Give 2 capsule by mouth three times a day for Loose stool Hold for no stool in 24 hours. Review of Resident #148's Physician Order for multivitamins, dated 01/08/2024, reflected Multiple Vitamin Tablet. Give 1 tablet by mouth one time a day for supplementation. Review of Resident #148's Physician Order for multivitamins, dated 01/06/2024, reflected Potassium Chloride ER Tablet Extended Release 10 MEQ. Give 1 tablet by mouth one time a day for Hypokalemia (low level of potassium in the blood). Review of Resident #148's Physician Order for sertraline, dated 01/06/2024, reflected Sertraline HCl Tablet 100 MG. Give 1 tablet by mouth one time a day for depression. Review of Resident #148's Physician Order for thiamine, dated 01/06/2024, reflected Thiamine HCl Oral Tablet 100 MG (Thiamine HCl). Give 1 tablet by mouth one time a day for Supplement. Review of Resident #148's Physician Order for thiamine, dated 09/13/2024, reflected Vitamin D (Ergocalciferol) Capsule 50000 UNIT. Give 1 capsule by mouth one time a day every Tue, Fri for low vit d. Observation and interview with Resident #148 on 10/01/2024 at 9:11 AM revealed the resident was in his bed, awake. It was observed that the resident was eating breakfast using his overbed table. A small plastic cup with nine pills inside was noted on top of the overbed table. According to Resident #148, his nurse left it with him and he would take them after he was finished with his breakfast. The resident said it was not the first time that his medications were left with him. He said all he could remember was his morning pills included his vitamins and his pain pill. In an interview with Resident #148 on 10/01/2024 at 9:55 AM, resident #148 stated he already took his medications. In an interview with LVN C on 10/01/2024 at 10:12 AM, LVN C stated he left Resident #148's morning pills with him because somebody called him. He said he should have returned to the room and checked on the resident. He said he should have stayed with the resident until the resident had taken the medications. He said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. He said he would check if the resident took the medications. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated staff should never leave the medications at the bedside for the resident to take later. She said the staff must ensure the resident took his medications before leaving the room. She said so much could go wrong. She said the resident could hoard or hide the pills to avoid taking them. She said the residents could overdose on hoarded pills. The DON said she would do an in-service pertaining to not leaving the medications with a resident. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the clinicians on how to go forward to prevent untoward outcomes of leaving the medications with a resident. Record review of facility policy, Administering Medications Nursing Services Policy and Procedure Manual for Long-Term Care (C) 2001 MED-PASS, Inc. (Revised December 2012) revealed Policy Interpretation and Implementation . 16. During administration of medications . the medication cart . be kept in the doorway of the resident's room . 17. For residents . unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #19) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #19 was care planned for Hospice Care. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #19's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #19 was diagnosed with dementia. Review of Resident #19's Quarterly MDS Assessment, dated 07/18/2024, reflected Resident #19 had severe impairment in cognition with a BIMS score of 00. Resident #19's Quarterly MDS Assessment indicated the resident was receiving hospice care while a resident of the facility. Review of Resident #19's Comprehensive Care Plan on 09/04/2024 reflected no care plan for hospice. Review of Resident #19's Physician Order, dated 01/08/2024, reflected Hospice to Evaluate and treat and admit as appropriate. Review of Resident #19's Progress Note, dated 01/12/2024, reflected Resident #19 was admitted to Hospice on 1/12/24. Review of Resident #19's Progress Note, dated 08/09/2024, reflected the resident was refusing to be weighed and hospice was made aware. Observation and interview with HN on 10/01/2024 at 9:46 AM revealed HN just finished assessing Resident #19. She said the resident was on hospice since early this year for failure to thrive. Said the resident was refusing care and medications. Observation and interview with the MDS Nurse on 10/02/2024 at 11:47 AM, the MDS Nurse stated she was responsible for doing the care plan. The MDS Nurse said care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff might overlook the interventions needed by the residents. She said if a resident was receiving hospice care, there should be a care plan for it. The MDS Nurse said she knew Resident #19 was on hospice. The MDS Nurse logged on to her computer, checked the resident's profile, and confirmed that Resident #19 did not have a care plan for hospice. After confirming the resident did not have a care plan, the MDS Nurse started making a care plan for hospice care. She said it was an oversight on her part and she would make an audit of the residents' care plans. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated if a resident was in hospice, there should be a care plan for hospice care. the ADON said Resident #19 was admitted to hospice. The ADON said it was important that residents have a care plan to fully provide the care and services the residents needed. He said without the care plan, the staff would not be in sync on the care of the residents and their needs would not be addressed. He said the expectation was all the issue of the residents were care planned. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's problem lists, goals, and intervention. She said the care plan should be resident-centered and should show what specific care the resident needed. She said she knew Resident #19 was receiving hospice care but was not sure why she did not have a care plan for hospice care. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the MDS Nurse to audit the care plans of the resident. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. He said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. He said he would coordinate with the DON to make sure all the residents were care planned. Record review of facility's policy, Care Plans - Comprehensive Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 MED-PASS, Inc. (Revised September 2010) revealed Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #29) of 5 residents reviewed for dignity. The facility failed to treat Resident #29 with dignity and promote enhancement of his quality of life when the resident's catheter bag was not placed away from the door as care planned. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #29's Face Sheet, dated 10/03/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #29 was diagnosed with complete at T2 - T6 (second to sixth thoracic vertebrae) level of thoracic spinal cord (bundle of nerve fibers), paraplegia (paralysis of the lower part of the body), and neurogenic dysfunction of bladder (the normal bladder function is disrupted due to nerve damage). Review of Resident #29's Quarterly MDS Assessment, dated 09/02/2024, reflected Resident #29 was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter. Review of Resident #29's Comprehensive Care Plan, dated 08/29/2024, reflected Resident #29 had a suprapubic catheter and one of the interventions was to put the catheter away from the door. Review of Resident #29's Physician Order, dated 08/30/2024, reflected CATHETER: Suprapubic Size: 12 fr (French: unit used to indicate the size of the catheter) Balloon Size: 10 ml Diagnosis: neurogenic bladder. Observation and interview with Resident #29 on 10/01/2024 at 11:16 AM revealed the resident was in his bed, awake. Resident #29 had a catheter bag hanging at the railings below the bed. The catheter bag and its contents were visible upon entrance to the room. The catheter bag did not have a privacy bag. Resident #29 stated he had the catheter for the longest time because he had a severed spinal cord. He said he was paralyzed and unable to move from his waist down. In an interview with LVN D on 10/01/2024 at 11:41 AM, LVN D stated there should be a privacy bag for the urine drainage bag so that it will not be visible to other residents or visitors. She said without the privacy bag, the resident might be embarrassed. She said she did not notice the urine drainage bag was exposed during her rounds. She said the facility had a lot of privacy bags and she would get one to put Resident #29's catheter bag inside. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated for a resident with a catheter, there should be a privacy bag to maintain dignity. He added without the privacy bag, other residents or the resident's visitors could see the catheter bag and its contents. He said the expectation was for the staff to put a catheter bag inside a privacy bag. He said they would do an in-service about putting a catheter bag inside a privacy bag. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated the catheter bag should have been placed inside a privacy bag to avoid embarrassment and humiliation. The DON said the expectation was for the catheter bag to have a privacy bag when the resident was on the bed or in the wheelchair. She said she would do an in-service about putting the catheter bag inside the privacy bag. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated his expectation was the catheter bag was covered. He said he would coordinate with the DON on how to go forward about the issue. Observation on 10/03/2024 at 11:12 AM revealed Resident #29 was in his bed, awake. The resident's catheter bag was hanged away from the door and was placed inside a privacy bag. Review of facility policy, Resident Rights revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity . 2. During interactions with residents, staff must report, document and act upon information regarding resident preferences.

Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #32) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #32's Comprehensive MDS Assessment accurately reflected that Resident #32 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: Review of Resident #32's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Resident #32 was diagnosed with acute and chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #32's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #32 had severe impairment in cognition with a BIMS score of 07. Resident #32's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #32's Comprehensive Care Plan on 08/08/2024 reflected the resident had COPD and used a CPAP at night and one of the interventions was to use CPAP as ordered. Review of Resident #32's Physician Order, dated 08/07/2024, reflected BIPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs)/CPAP 16CM02 (centimeters of water pressure setting) at bedtime AND in the morning. Observation and interview with Resident #32 on 10/01/2024 at 9:11 AM revealed Resident #32 was in his bed, awake. It was observed that a CPAP machine was on top of the resident's right side table and a CPAP mask was attached to the CPAP machine. Resident #32 stated he would sometimes use his CPAP. Observation and interview with LVN D on 10/01/2024 at 11:08 AM revealed LVN D went inside Resident #32's room to attend to the resident. LVN D stated Resident #32 had an order for CPAP and could use it at night or in daytime. Observation and interview with the MDS Nurse on 10/02/2024 at 11:47 AM, the MDS Nurse stated she was responsible for doing the MDS Assessment. She said if a resident was using a CPAP, it should be reflected on the resident's MDS. The MDS Nurse logged on to her computer, checked the resident's profile, and confirmed that Resident #32 was had a physician's order for CPAP and it was not triggered on his MDS assessment. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in sync to provide a clear overview of the resident's current condition. She said it was an oversight on her part and she would make an audit to make sure the MDS would reflect the current condition of the residents. In an interview with the ADON on 10/02/2024 at 2:45 PM, the ADON stated if a resident was using a CPAP, it should be reflected on the system to make sure the effectiveness of the resident's use of the CPAP. He added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the DON on 10/02/2024 at 3:08 PM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. She said the care plan of the residents would be based on the assessment of the resident. She said if a resident was using a CPAP, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. She said if the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was that the residents were properly assessed not only during admission but every day to see if there were changes in condition or a resident acting different than usual. She said she would collaborate with the MDS Nurse to audit the MDS Assessments and make the appropriate changes. In an interview with the Administrator on 10/03/2024 at 8:06 AM, the Administrator stated the current condition of the resident should be reflected in the system to address the current needs of the resident. He said she would coordinate with the DON to evaluate the situation. Record review of facility policy, Conducting an Accurate Resident Assessment revealed Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . qualified health professionals correctly document the resident's medical . problems.

Based on observation, interview, and record review, the facility failed to accurately reflect the residents status for 1 of 9 residents (Resident #3) reviewed for accuracy of MDS assessments). Resident #3 ' s MDS assessment dated [DATE] did not address the residents ' visual impartments. This failure could place residents at risk of inaccurate and incomplete assessments which could result in residents not receiving care to meet their highest level of functioning and psychosocial wellbeing. Findings Included: Record review of Resident #3's face sheet, dated 08/22/2022, revealed a [AGE] year-old female admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 which indicated her cognition was intact. On her MDS Section B1000 Vision, revealed a score of 0, indicating Adequate (sees fine detail, such as regular print in newspapers and books) and indicated no corrective lenses contacts, glasses, or magnifying glass) were used. Section V of the MDS indicated visual function, was not trigged as a Care Area and required no. Care Planning. Record review of Resident #3 ' s care plan dated 07/26/22, revealed Resident #3 has a potential for activity participation, with her strengths being listening to audio books, music, news, and Sunday Services. The goal was that Resident #3 attended and participated in activities of interest. Interventions were, the resident will attend activities, the resident will be helped from and to activities of daily interest, provide a boombox and audio books for her to listen to in her room. The resident was care planned for vision impairment. Record review of Resident #3 ' s Care Profile listing undated, indicated the resident wore glasses. Record review of Resident #3's physician's orders, dated 07/14/2022, revealed the resident May be seen by optometrist. There were no other orders addressing eyesight. Review of Resident #3 ' s Physician MD progress note dated 08/17/22, indicated under the section titled Physical Exam: Eyes no redness. EOMI PERRL. (PERRLA = pupils equal, round, and reactive to light and accommodation. EOMI= extra-ocular motion intact.) During an observation and interview on 08/22/2022 at 10:50 AM, Resident #3 was sitting in her wheelchair in the dark in her room. Resident #3 disclosed she was legally blind and could not see faces of people nor the colors of her nails. She stated t she does recognize voices and shadows of the staff that provide care at the facility. She stated she does not wear glasses. Interview with RN-N on 08/22/22 at 1:47 PM, revealed she was aware Resident #3 was legally blind, and the staff assisted with ambulating the resident to the restroom upon her request. She stated Resident #3 does not wear glasses, she was aware of her visual impairment from care plan and interactions. In an interview with RN M, on 08/22/22 at 3:25 p.m., revealed he worked with Resident #3 on 2nd shift, he stated she was legally blind. He stated he had not contacted her doctor to address vision impairment. He stated she needed assistance to get to the restroom. He stated she does not wear glasses. In an interview with the ADON on 08/22/22 at 3:35 p.m., revealed she was aware Resident #3 had a vision impairment of being legally blind. She stated the Resident ' s vision should have been addressed on the initial care plan or first care plan and communicated to the MDS Nurse for updates to the care plan She stated that it was important for the vision impairment to be documented to prevent a lapse in care and aids form the health care staff to prevent a decline. It was her expectation for the MDS assessment to be accurate to provide the necessary l implementations and interventions for staff to perform. Interview with the MDS Nurse on 08/22/22 at 3:40 p.m., revealed she was in the process of educating the nursing staff on the protocol of initial care plans, and care profiles to assure the MDS quarterly assessments were completed accurately. She does not know Resident #3 and have not been able to review her MDS. She stated the care plan would not address all of the resident ' s needs initially, however by the first care plan this should be updated. She stated the nurses are responsible for identifying communicating the residents needs and it was her expectation for this to be done timely to provide the highest practicable level of care for the resident. What were her expectations for MDS accuracy? Interview with the interim DON on 08/22/22 at 3:55 p.m., revealed it was her expectation for the health team to address all resident needs upon admission and update additional needs and conditions to the care team to assure the resident receives the level of care needed to assure t there was no regression in skills. It was her expectation for the MDS to be accurate to assure proper care is provided to the resident to meet her specific needs and for the staff to provide the appropriate accommodations and interventions. She stated that if the MDS was incorrect this could cause the resident to regress from not receiving the proper support and assistance therefore causing a possible regression. A review of the facility policy, Comprehensive Care Plan dated 09/30/19 revealed the community will develop comprehensive, person-centered care plans that are culturally competent and describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing; Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: When the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. The facility MDS policy was requested from the DON and ADON, and it was not provided before exiting the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: DA-A failed to wear a hair restraint covering his beard in Kitchen A, where residents on the third floor residing in rooms 342-398 were served their meals. DA- A was observed on 07/13/22 9:00 AM to 2:00 PM not wearing a beard restraint and 07/14/22 at 9:30 AM and again at 11:10 AM. These failures could place residents at risk of foodborne illness. Findings included: Observation on 07/12/22 at 10:00 AM during the initial tour of Kitchen A, A (DA-A) was observed preparing lunch trays for residents in rooms 342-398 on carts. He was observed not wearing a beard restraint, therefore, exposing the side of his face where hair (beard) was exposed. Observation on 07/13/22 at 9:30 AM in Kitchen A, DA-A was observed not wearing a hair restraint covering his beard. Interview on 07/13/22 at 9:30 AM DA-A, revealed that the facility provides hair and beard restraints for staff working in the kitchen to prevent hair exposure to food. He stated that he did not have a beard restraint on because he wore a surgical masked that covered his beard and did not believe he needed a beard restraint while working in the kitchen and preparing food. DA-A stated that the mask did not cover the sides of the facial hair between the ear and jaw. Observations on 07/13/22 at 11:10 AM, DA-A was observed in Kitchen A without a beard hair restraint. Interview on 07/12/22 at 3:30 PM with DA-B, revealed it was the facility's policy for all dietary staff to wear hair restraints including beard restraints. DA-B stated that the facility uses hairnets to cover the beard. DA-B stated that all members working in Kitchen A not wearing beard/hair restraints. Interview on 07/12/22 at 3:30 PM with DA-C, revealed that all dietary staff were required to wear hair restraints including beard restraints. DA-C stated that the facility uses hairnets to cover the beard. DA-C stated that wearing hair restraints were required to prevent hair from falling in the food while being served and prepared. DA-C denied observations of staff members in Kitchen A that were not wearing beard restraints. Interview on 07/13/22 at 9:30 AM with Dietary Coach D (DC-D) and DA-A, DC-D stated that the facility did have hair nets for dining staff to wear during food prep. Observation on 07/13/2022 at 11:10 AM, revealed DA-A not wearing a hair restraint for beard, while in the kitchen preparing lunch for residents with DC-D, DC-E, DA-B, and DA-F. Upon acknowledgement of investigator, DA-A left the kitchen immediately. Interview on 07/13/22 at 12:30 PM Dietary Manager (DM), revealed that was told by DC-E that DA-A was asked to wear a hair restraint over his beard, while working in the kitchen preparing and serving food. She stated that it was the facility policy to wear a hair restraint to cover hair, ears, and beards, or the staff would be expected to shave their facial hair/beard. DM stated that in the event a staff did not want to wear a beard restraint., they would be sent home or chose to shave. DM stated that DA-A was sent home on suspension pending follow up for not following the hair restraint guidelines. DM stated that she was not aware that DA-A had been asked multiple times to wear a beard restraint while working, that this was the facility policy to prevent hair from falling in the food, creating unsanitary conditions that could lead to food borne pathogens affecting residents. DM stated that the facility provided beard restraints for staff, therefore, all staff should wear restraints. Interview on 07/13/22 at 2:00 PM Dietary Director (DD), revealed that she was not aware that DA-A was not wearing a hair restraint to cover his beard. DD stated that it was her understanding that food standards for beard restraints applied to beards that were over 1/4 inches wide. DD stated that staff working in the kitchen should wear hair restraints covering their head and ears to prevent unsanitary conditions while preparing food. DD stated that the facility does have hair restraints available for staff. DD stated that she would review the policy and standards. DD did not return with update. Interview on 07/14/22 at 8:52 AM with DC-D, revealed DC-C stated that he contacted the DM to report that DA-A needed to wear a beard restraint while working in the kitchen. DC-D stated that he was the direct supervisor to DA-A, and it was his understanding that beard restraints were worn when the facial hair exceeds ¼ inches. DC-D stated that hair restraints are required in the kitchen to prevent hair from falling in the food, serving area, and utensils. DC-D stated uncovered hair can fall in the food and could lead to sickness or exposure to bacteria of the residents. DC-D stated that he could not think of the word used that would lead to transfer of bacteria leading to unsanitary conditions. Interview on 07/14/22 at 9:28 AM with DC-E, revealed that all staff are required to wear hair restraints covering their ears and head to prevent foodborne allergens and particles of hair from falling in the food. DC-E stated that beard restraints was required for dietary staff and that the facility does have sufficient supply of hair restraints for all facility dietary staff and anyone entering the kitchen areas. DC-E stated that staff not wearing hair restraints can lead to cross contamination to services and foods in the kitchen. DC-E denied observation of DA-A standing in the kitchen without a beard restraint. DC-E stated that it was all leadership staff responsibility to assure all dietary staff were dressed according to guidelines for covid and dietary preparation to prevent illnesses to residents. Interview on 07/14/22 at 10:45 AM with DA-F, revealed that all dietary staff are required to wear hair restraints including beards to cover hair on head and face. DA-F stated that the facility provides beard restraints for staff working in the kitchen to prevent hair exposure to the food and service areas. He stated that he chooses to shave his beard to be incompliance with dietary rules. DA-F stated that he observed DA-A wearing a hair net over his beard last week, however he did not wear a restraint to cover his beard 7/12/22 and 7/13/22. DA-F stated that it was unsanitary to not cover hair, as it would lead to food borne allergens and sickness if hair particles land in the food serving area. Interview on 07/14/22 at 11:00 AM with DON revealed that it was her expectation for dietary staff to wear hair restraints including covering the beard while working in the kitchen and dining services for the resident, because failing to wear the restraints could lead to hair and additional bacteria contaminating the food and serving area. Interview on 07/13/22 at 11:10 AM with Administrator revealed that it was her expectation for dietary staff to comply in sanitation and food service policies for the residents to have the best experience in dining and food nourishment, which was to wear hair restraints that cover facial and head hair, to prevent contamination of the food and service area. Review of Dietary Policies and procedures Titled Personal Hygiene and Professional Appearances Dated 05/08/2019, stated that all culinary members who are responsible for food preparation and/or service shall wear hair restraints. Subsection titled Hair Restraints: During food preparation, team members hall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that cover the body hair, which are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and single service items. All loose hair needs to be covered with hats or nets. Front of the house servers shall tie their hair back during service. All long and loose hair needs to be styled to be away from contact with exposed food, clean equipment, utensils, lines, and single service items. Standards Followed: We adhere to the current DFS Food Code guidelines. E-CFR 21 117.10(b) Cleanliness. All persons working in direct contact with food, food-contact surfaces, and food-packaging materials must conform to hygienic practices while on duty to the extent necessary to protect against allergen cross-contact and against contamination of food. The methods for maintaining cleanliness include: Wearing outer garments suitable to the operation in a manner that protects against allergen cross-contact and against the contamination of food, food-contact surfaces, or food-packaging materials. Maintaining adequate personal cleanliness. Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints.

Based on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions in one of one kitchens. The facility failed to ensure hand hygiene was performed prior to handling food. The facility failed to remove expired food and to discard foods according to use by date. The facility failed to label and date items. The failures placed residents at risk for food borne illness and contamination. Findings included: Observation on [DATE] at 10:43 AM revealed inside of a walk-in refrigerator were containers without name of food items including, zucchini and cauliflower. The walk- in refrigerator contained turkey stock with a use by date of [DATE]; creamy coleslaw with a use by date of [DATE]; shredded cheese with a use by date [DATE]. There were opened, unlabeled and undated tortilla wraps on a top shelf. There were tortillas that were unlabeled and undated next to the wraps. Observation on [DATE] at 10:47 AM inside a one door refrigerator was a half-gallon of half and half with a use-by printed date of [DATE]. Observation on [DATE] at 11:05 AM revealed Cook A entered the kitchen to begin her shift. She put on gloves and proceeded to help Cook B cook hamburgers for the lunch meal service. Cook A did not perform hand hygiene before donning of her gloves. Observation on [DATE] at 11:05 AM Dietary Aide C entered the kitchen without washing his hands and started opening and looking at food inside of the hot food cart. Observation on [DATE] at 10:27 AM the DM and Dietary Aide C entered the kitchen and started doing tasks without performing hand hygiene. DM took the temperature of the soup. Without donning gloves Dietary Aide C got the soup from the hot cart to transport it to second floor. Observation on [DATE] at 10:44 AM Dietary Aide D entered the kitchen without performing hand hygiene and went to the walk-in refrigerator to get cold foods for the lunch meal service. She obtained beet salad, fruit, and regular salad to put on the food cart. Dietary Aide D obtained food from the hot food cart to transport to another satellite kitchen on a different floor. Observation on [DATE] at 10:50 AM Dietary Aide C entered the kitchen without performing hand hygiene to obtain food from the hot cart. Without donning gloves he took the food out and checked to see what was in the food cart. Observation on [DATE] at 11:02 AM Dietary Aide C returned to the kitchen without performing hand hygiene and was checked to see if the food was ready in the hot cart. Observation on [DATE] at 11:10 AM Cook A entered the kitchen without performing hand hygiene and began to help clean up from the lunch meal service. She was putting up spices used for lunch and items used to cook with from lunch meal service. Observation and interview on [DATE] at 2:14 PM revealed in the walk-in refrigerator there was a tub of cauliflower with a sticker indicating lunch AM use by [DATE], zucchini was dated [DATE]. The cauliflower and zucchini were not spoiled. There was an unlabeled liquid in a tall plastic tub dated [DATE]. An interview with Cook E identified the unlabeled liquid as chicken broth. An interview on [DATE] at 2:19 PM the DM identified the unlabeled broth dated[DATE] in a tall plastic tub as turkey stock. The DM stated she made the stock this morning [[DATE]] and should have re-labeled the stock. The DM stated she was unaware of the unlabeled/dated wraps on shelf in the walk-in refrigerator. Interview with the DM on [DATE] at 3:30 PM revealed any staff member entering the kitchen should wash their hands immediately regardless of task and job description. Hand hygiene should be performed to prevent cross contamination. She was unaware of the expired foods. Staff should perform hand hygiene before placing on a pair of gloves. Interview with RD/LD on [DATE] at 4:00 PM revealed the facility used a printer to date the foods. The RD/LD stated the printer was putting the wrong use by dates on the foods. The RD/LD stated the printer was fixed today. Review of the facility's policy on Personal Hygiene and Professional Appearance, dated [DATE], reflected: Policy: All culinary team members who are responsible for food preparation and/or service shall wash hands frequently and adequately, wear clean uniforms, wear gloves, limit jewelry, and wear hair restraints. Procedures: Handwashing Team members shall wash their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment, and utensils, and unwrapped single service items. Where to wash: Team members shall wash their hands in a handwashing sink and may not clean their hands in a sink used for food preparation, ware washing, or utility functions. When to wash: Team members shall wash their hands: After touching their body, hair or clothing; After using the restroom After coughing, sneezing, using a disposable tissue, using tobacco, eating or drinking; After handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; After entering and leaving food preparation areas; When switching between working with raw food and working with ready-to-eat food; Before putting on gloves for working with food; Before preparing food for residents with allergies or intolerances; After handling dirty service water; and After engaging in other activities that contaminate the hands. Review of the facility's policy on Date marking and labeling food, dated [DATE], reflected: Policy: All food shall be labeled with product name and dated to ensure quality and safety of the food served to residents. Procedures: Culinary services team members shall use the following product description and date marking practices: All packaged items will have a received date, opened date and discard date. All prepared items will have product name, prepared date, and discard date. Received, opened/prepared, and discard dates should have separate distinctive methods. For example, received date has a label from a date gun, open date is a white label, and discard date is a green date gun label. Product description and dates can be written on the original container, on a sticker, on tape, or using a date marking tool. Records must be legible. House-prepared time and temperature control for safety foods shall be dated with a four-day discard date (date of production plus three days). All received foods shall be dated with the date of receipt before storage. All food past its discard date or manufacturer's use-by-date shall be discarded immediately. Open packaged foods will be dated with the discard date as below (total days includes opening day): Dairy products (milk, yogurt, cottage cheese): 7 days Condiments (ketchup, mustard, mayo, pickles, sauerkraut): 30 days Purchased salad dressings: 30 days Hard or block cheese: 14 days Dry and frozen goods: 6 months The Culinary services leader will: 1. Daily, review labeling and dating in the refrigerators, freezers, and storage rooms. 2. Take corrective action if product description and dating is out of compliance . According to the Food Code 2017 reflected: 2.301.14 When to wash Food employees shall clean their hands and exposed portions of their arms as specified under § ,d+[DATE].12 immediately before engaging in food preparation including working with exposed Food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in ,d+[DATE].11(B); (D) Except as specified in ,d+[DATE].11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat foods; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the Hands. ,d+[DATE].11 Food Labels. (A) food packaged in a food establishment, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient.

Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 7 residents (Resident #202) reviewed for respiratory care in that: The facility failed to ensure Resident #202's oxygen tubing and a humidifier bottle were dated and labeled. The facility failed to ensure they had portable oxygen available to residents. These deficient practices could affect residents who received oxygen therapy and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings were: Review of Resident #202's face sheet, reflected an admitted on 5/22/2020 and readmission on 2/28/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #202's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .O2 as 2L/Min via NC continuous and or as needed to maintain SPO2 >92% every shift . An observation on 04/22/2021 at 12:42 PM, revealed the room labeled for empty oxygen tanks had 19 empty portable oxygen tanks. The room labeled for full oxygen tanks had 6 empty portable oxygen tanks. In an interview on 04/22/2021 at 11:50 AM, Resident #202 stated she had to be on oxygen all the time because of her [CONDITION(S)]. She stated she could be off of the oxygen for a little while, but she had a big concern for yesterday [4/21/2021] and today [4/22/2021] because they don't have any portable [oxygen] tanks and it's really hard to get out of my room. She stated she was admitted to the facility on [DATE] in the evening. She stated she went out earlier to the common area across the hallway because that was as far as my tube will let me go. She stated she had asked several staff members about the portable oxygen tanks and that nobody seems to know when the portable tanks would be available. She stated yesterday, 4/21/21, she was told they would be at the facility today, 4/22/2021, and today they say tomorrow. An observation on 4/22/2021 at 12:00 PM with RN F revealed Resident #202's oxygen nasal cannula tubing nor her humidifier bottle were labeled or dated. In an interview on 4/22/2021 at 12:10 PM, RN F stated the oxygen tubing and humidifier bottle should have been dated by the nurse who admitted the resident into the facility. The nurse also stated the facility ran out of portable oxygen tanks yesterday (4/21/2021) and since the resident was on continuous oxygen, she needed to remain on her oxygen concentrator at all times. She stated Resident #202 was always on the [oxygen]. She cannot tolerate a lot of the activities, her [oxygen] goes down. She gets really winded and worked up and starts hyperventilating. RN F stated Resident #202 had mentioned to her this morning that she wanted to go out but she couldn't because she doesn't have the portable [oxygen]. RN F stated she had worked at this facility since October 2019, and they had never been out of portable oxygen tanks before . When asked if she had notified anyone that they were out of portable oxygen tanks, RN F stated that the DON was aware because Resident #202 portable oxygen was noted to be low on Tuesday, 4/21/2021, and the DON had helped her look for portable oxygen tanks at that time. In an interview on 4/22/2021 at 12:46 PM ADON G stated she had worked at the facility for one month and one week. When asked what the process was for ensuring a supply of oxygen tanks, she stated, What I know, the former DON would do the orders, and they would bring them. One room has full [oxygen tanks] and one has the empty tanks. She stated the previous DON would take inventory, but she did not know the frequency. She stated when the previous DON left, the interim DON came one week later. She said the previous DON left the last week of March [2021]. ADON G said she was not aware they were out of portable oxygen tanks. She said, Sometimes the nurses report when they are getting low, and I have not received any reports that they were low or they were out. She stated her expectation was that nurses reported when they were running low on oxygen tanks. She stated even with being out of portable oxygen tanks, they still had the oxygen concentrators. She stated, The issues we might run into is the residents might not be able to go out. When asked if she had been made aware of any residents complaining they could not go out because of no portable oxygen tanks, she stated, No, from you is the first I've heard anything about it. In an interview on 4/22/2021 at 1:44 PM the DON said it was the nurses' responsibility to change the oxygen tubing. She also stated the nurse who initiated the oxygen should date the tubing and other equipment associated with oxygen. When asked, what could occur if tubing/equipment was not dated, she said, We won't have an idea when it needs to be changed . and it's not good for the patient. When asked the frequency of changing the tubing, the DON stated it should be changed every day, but stated she was new to the facility and it was only her second week and she was still learning a lot of that stuff. In an interview on 4/23/2021 at 8:12 AM, the Administrator said The E cylinders [size of portable oxygen tank] were supposed to be delivered Wednesday [4/20/2021]. [Receptionist H] had called the day before [4/19/21] when I told him to, but he order the wrong thing. He ordered CO2 tanks, so I told [the oxygen supplier] to cancel that and ordered 6 E tanks . We weren't using the E tanks and the DON changed it to will call so we had to call to get them to delivered. In an interview on 4/23/2021 at 9:04 AM, Receptionist H said he had worked at the facility 4 years. He said from time to time the nurses will tell me that they are running low [on oxygen] and I call [the oxygen supplier], or if there are too many empty tanks I'll call them to pick them up. I'll go check the closet if it's been a while. It's been a while since I worked this floor, I had been working the down stairs at the front desk. This week has been my first week back on this floor. The nurses should be checking that they have enough oxygen. Monday [4/19/2021] I was asked to call [the oxygen supplier] to pick up and to deliver [oxygen]. On Monday [the oxygen supplier] told me they'd try to make it in by tomorrow [4/20/2021]. Yesterday [4/22/2021] she [the administrator] told me an order was coming, but they haven't arrived yet. Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated , revised November 2011, reflected in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Distilled water used in respiratory therapy must be dated and initialed when opened and discarded after twenty-four (24) hours .change the oxygen cannulae and tubing every seven (7) days, or as needed .keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use

Based on observation, interview and record review the facility failed to ensure the resident's environment remained as free of accident hazards as is possible for 1 of 1 residents (Resident# 202) reviewed for accidents, in that: The facility failed to ensure Resident #202's oxygen tubing was not on the floor in the hallway creating a fall hazard. This deficient practice could place residents at risk of injury and a decline in physical health. The findings were: Review of Resident #202's face sheet reflected an admitted on 5/22/2020 and readmission on 2/28/2021, with diagnoses that included: chronic systolic [CONDITION(S)], chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, chronic kidney disease, anxiety disorder, and [CONDITION(S)]. Review of Resident #202's physician order report, dated 3/1/2021-3/16/2021, reflected an order for Change oxygen tubing and bubblers every day shift every Wed[nesday] .O2 as 2L/Min via NC continuous and or as needed to maintain SPO2 >92% every shift . An observation on 04/22/21 at 10:34 AM revealed Resident #202 was sitting in her wheelchair in the common area across the hallway approximately four feet from her room. She was wearing an oxygen nasal cannula and the tubing was lying across the hallway floor into her room. Her oxygen concentrator was in the resident's bathroom. Observed four facility staff members walk over Resident #202's oxygen tubing on the floor. Observed one facility staff member redirected one resident walking in the hallway to walk in the opposite direction because of the oxygen tubing on the floor. The resident remained there until 10:58 AM until a staff member assister her to her room . In an interview on 4/22/2021 at 11:50 AM Resident #202 stated she had to be on the oxygen all the time because of her [CONDITION(S)]. She stated she could be off of the oxygen for a little while, but that she had a big concern for yesterday [4/21/2021] and today [4/22/2021] because they don't have any portable [oxygen] tanks and it's really hard to get out of my room. She stated she was admitted to the facility on [DATE] in the evening. She stated she went out earlier to the common area across the hallway because that was as far as my tube will let me go. She stated she had asked several staff members about the portable oxygen tanks and that nobody seems to know when they portable tanks will be available. She stated that yesterday, 4/21/2021, she was told they would be at the facility today, 4/22/2021, and today they say tomorrow. She stated nobody had tripped over her oxygen tubing and that's a concern, but it's the only way I can get over there. In an interview on 4/22/2021 at 12:10 PM RN F stated the facility ran out of portable oxygen tanks yesterday (4/21/2021) and since Resident #202 was on continuous oxygen, she needed to remain on her oxygen concentrator at all times. She stated if the resident's oxygen tubing was on the floor someone could trip, because we have a lot of ambulatory residents, and it could come undone and she [Resident #202] wouldn't be getting O2 [oxygen]. She stated her expectation was if a CNA or staff member saw the oxygen tubing running across the hallway, they should return [Resident #202] to her room. They could also move the concentrator closer, but they would tell [a nurse] so that we can move the concentrator. She stated Resident #202 was always on the [oxygen]. She cannot tolerate a lot of the activities, her [oxygen] goes down. She gets really winded and worked up and starts hyperventilating. RN F stated Resident #202 had mentioned to her this morning that she wanted to go out but she couldn't because she doesn't have the portable [oxygen]. RN F stated she had worked at this facility since October 2019, and they have never been out of portable oxygen tanks before. In an interview on 4/22/2021 at 12:46 PM ADON G stated she had worked at the facility for one month and one week. When asked what the process was for ensuring a supply of oxygen tanks, she stated, What I know, the former DON would do the orders, and they would bring them. One room has full [oxygen tanks] and one has the empty tanks. She stated the previous DON would take inventory, but she did not know the frequency. She stated when the previous DON left, the interim DON came one week later. She said that the previous DON left the last week of March [2021]. ADON G said she was not aware they were out of portable oxygen tanks. She said, Sometimes the nurses report when they are getting low, and I have not received any reports that they were low or they were out. She stated her expectation was that nurses report when they were running low on oxygen tanks. She stated even with being out of portable oxygen tanks, they still had the oxygen concentrators. She stated, The issues we might run into is the residents might not be able to go out. When asked if she had made aware of any residents complaining they cannot go out because of missing oxygen tanks, she stated, No, from you is the first I've heard anything about it. When asked what her concern would be if a resident's oxygen tubing was running across the hallway, she said, That's a fall hazard for the residents or anybody. When asked what she would expect if staff noted a resident's oxygen tubing on the floor in the hall, she said she would expect them to pull the concentrator closer to the resident and have the resident stay on the side with the concentrator, that way it would not make it a fall hazard for anyone. In an interview on 4/22/2021 at 1:44 PM when asked what could happen if oxygen tubing was dragging the floor the DON stated, she was not sure of the policy but it shouldn't be balled up on the floor. Review of the facility's policy titled Safety and Supervision of Residents, dated revised July 2017, reflected in part, Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards

Based on observation and, interview, and record review, the facility failed to ensure the daily nurse staffing data was posted for 1 of 18 postings reviewed. The facility did not post the nursing staffing information daily to include the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. This failure could cause residents and families to not be aware of the staffing being provided in the facility. Findings included: Observation on 4/20/2021 at 9:15 AM revealed there was no posting in the facility of the daily nursing staff. Observation on 4/21/2021 at 9:30 AM revealed there was no posting in the facility of the daily nursing staff. Observation on 4/22/2021 at 9:30 AM revealed there was no posting in the facility of the daily nursing staff. Interview on 4/23/2021 at 11:36 AM with the Administrator revealed the facility had recently been remodeled and the posting was taken down during COVID-19 . The daily staffing should be posted so residents are visitors are aware of the daily staffing. There is no policy on postings.

Based on observation, interview and record review, it was determined the facility failed to ensure one (CNA A) of two CNAs demonstrated competency in skills and techniques necessary to care for residents' needs as identified through resident assessments, and described in the plan of care to assist one (Resident #1) during the provision of incontinence care. 1. CNA A did not cleanse perineal area, mons pubis, labia, separate the labia nor cleanse the urethral meatus when providing incontinent care. This failure placed three residents at risk for receiving improper incontinent care from CNA A, and the one nurse aide at risk of not being competent to provide incontinence care for the residents. A total of three residents required incontinence care. Findings included: The MDS dated [DATE] reflected Resident #1 was a [AGE] year old female with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had impaired decision making ability, was able to relate some of her needs, and she had problems making herself understood. Regarding Activities of Daily Living she required one person for bed mobility, transfer, dressing, grooming and personal hygiene. Resident #1 was incontinent of bladder and bowel. Observation on 05/04/17 at approximately 9:31 a.m., revealed CNA A preformed incontinence care on Resident #1. The CNA communicated well with the resident explaining every step of the process. CNA A did not cleanse the mons pubis, the labia, separate the labia, nor visualize and cleanse the urethral meatus. CNA A had the resident turn on her right side, cleansed the soiled feces off of her buttocks, changed gloves and put cream on her buttocks. CNA A did not wash her hands nor cleanse the perineal area. She put the brief on the resident, adjusted her clothes, bed linens and made sure the resident was comfortable. CNA A was interviewed on 05/04/17 at 9:51 p.m., and when asked why she did not cleanse the mons pubis, labia, urethral meatus or the perineal area she said I just got nervous. Interview with the DON on 05/04/17 at 11:47 a.m. regarding her expectations of her staff and incontinence care she would expect them to use the correct technique, explain to the resident, provide dignity and report anything unusual. Review of the Perineal Care Policy 2016 Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Policy Explanation and Compliance Guidelines: All staff members involved in performing perineal care to residents will promote cleanliness, prevent infections to the extent possible, prevent and assess for skin breakdown and promote comfort . 8. Don gloves . 10 If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper then remove. a. cleanse buttocks, anus, front to back; vagina to anus in females, scrotum to anus in males using a piece of cloth or wipes. b. dry thoroughly . 12. a. Cleanse perineum from front to back. b. Cleanse labia folds, urethral meatus, and vaginal orifice using clean portion of cloth or new cloth with each stroke . Perry and Potter's Clinical Nursing Skills and Techniques, Fifth Edition, 2004, Chapter 6, Personal Hygiene and Bed Making, pages 128-130 reflected: Female perineal care: help client flex knees and spread legs . Wash labia majora. Use non-dominant hand to gently retract labia from thigh; with dominant hand wash carefully in skinfolds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry area thoroughly . Separate labia with non-dominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke. Use separate section of cloth for each stroke. Cleanse thoroughly around labia minora, clitoris, and vaginal orifice. Review of CNA's A Skills Nursing Assistant Skills Checklist dated 01/23/17 reflected she was evaluated and performed the skills to standard on 01/23/17 During an interview with the DON on 05/04/17 at approximately 4:30 p.m. she revealed CNA A was responsible for three residents who were incontinent on the hall she was working. During an interview with the

Based on interview and record review, it was determined the facility failed to ensure residents were free of significant nedication errors for one (Resident #15) of 15 residents reviewed for medications regime RN A failed to contact the hospital, after Resident #15 was readmitted , to clarify if there were any new physician orders. RN A failed to transcribe an order for [REDACTED].#15 missed a total of 57 doses of the [MEDICATION NAME]. These failures resulted in Resident #15 having a second [MEDICAL CONDITION] with a transfer to the hospital emergency room for evaluation. These failures could create a potential for 24 residents, who could residing in Rooms 48-71 and whom RN A would be responsible for obtaining and transcribing physician orders, whether from new admissions or re-admissions from the hospital, not to receive physician-ordered medications which could result in serious medical complications [REDACTED]. Findings included: The MDS assessment dated [DATE] reflected Resident #15 was a [AGE] year-old female who had been admitted to the facility on [DATE] with diagnoses, which included Altered Mental Status, [MEDICAL CONDITIONS] of Liver, Gastro-[MEDICAL CONDITION] Reflux Disease and [MEDICAL CONDITION]. Resident #15 was identified as being alert and oriented. The MDS also reflected that Resident #15 had been discharged from the facility on 05/24/16 back to the assisted living facility. The nurses' notes dated 05/17/16 reflected Resident #15 was alert and oriented, was able to verbalize needs and to make herself understood, she required limited assistance with activities of daily living including grooming, transfers and toileting , she was able to ambulate with the use of a walker and able to feed herself. Review of the nurses' notes dated 04/21/16 at 8:00 AM reflected the DON brought Resident #15 back to her room and she stated she had a [MEDICAL CONDITION] episode in the dining room. The resident was assisted into bed, and she was exhibiting some altered speech, low tone, skin was clammy and she was voicing weakness and a headache. Vital signs were taken and the physician was notified and he ordered her to be sent to the emergency room for further evaluation. At 9:30 AM the resident was transported by ambulance to the emergency room . Per the nurses' notes dated 04/22/16 at 6:00 PM. Resident #15 returned from the hospital to the facility. She was wheeled in by the wheelchair van driver accompanied by her son. The notes further reflected no new orders were noted in the discharge paperwork and the resident resumed her routine medication regime. Review of the nurses' notes dated 05/21/16 at 8:45 AM revealed that Resident #15 was experiencing [MEDICAL CONDITION] activity during the breakfast meal in the main dining room. The resident was transported to her room. Multiple attempts to bring the resident back into a state of alertness were unsuccessful after 30 seconds. Resident was observed with her head hyper-extended back and her entire body was flaccid. Her eyes were closed and her mouth was agape, skin clammy and cool to touch. Resident #15's pulse was faint and 48 and respirations were slow and shallow. The notes further reflected the resident remained unconscious to multiple nurses calling her name and ice placement to hands and back of neck. Resident #15 experienced [MEDICAL CONDITION] activity for less than two minutes. Resident was observed opening/closing her eyes and making attempts to speak unsuccessfully. The resident's pulse became stronger (68) and respirations were prominent and unlabored, her oxygen saturation was 98%. Resident #15 reported no headache, only generalized body weakness and was feeling tired. The resident was unable to recall precise events of [MEDICAL CONDITION] activity. She stated she was aware that the event occurred and stated All I remember is bright lights then what sounded like birds chirping. Then I remember someone picking me up and sitting me in a wheelchair. I don't remember as much as I did the last time I had this happen. The nurses' notes dated 05/21/16 at 10:20 AM, the nurse spoke to the resident about her [MEDICAL CONDITION] history. She reported her last trip to the hospital being in April (04/21/16 and that she returned to the facility with a new order for [MEDICATION NAME] for [MEDICAL CONDITION]. The nurse also documented that there were no orders on the resident's EMAR. The resident showed the nurse the new order for [MEDICATION NAME] 500 mg, to be given twice a day, Diagnosis: [REDACTED]. The nurses' notes dated 05/21/16 at 10:45 AM reflected Resident #15 was transferred by ambulance to the hospital. The nurses' notes dated 05/21/16 at 2:45 PM reflected the resident had returned to the facility with new medication instructions for [MEDICATION NAME] administration. The resident's son handed the nurse the handwritten order for the [MEDICATION NAME] from the hospital. The nurses' notes dated 05/22/16 at 8:45 AM reflected Resident #15 received her initial dose of [MEDICATION NAME] 500 mg one tablet as well ar the MAR for May 2016. Review of the facility's Provider Investigation Report dated 05/25/16 reflected the facility became aware of the medication error on 05/21/16. The error was that Resident #15 did not receive the physician-ordered [MEDICATION NAME] (anti-convulsant) from 04/22/16 throught 05/21/16. The report revealed that Resident #15 was originally admitted to the facility from an acute care facility on 04/19/16. Resident #15 was noted on 04/21/16 to have a possible [MEDICAL CONDITION] activity and was sent out to the emergency room for evaluation. The report reflected the notes from the hospital showed there was no obvious cause for [MEDICAL CONDITION] activity but that Resident #15 had a history of [REDACTED]. At that time, the emergency room prescribed [MEDICATION NAME] 500 mg. one tablet twice a day. The resident was kept overnight for observation. Upon re-admission to the facility on [DATE], the charge nurse reported that no new orders were given to him from the hospital and he resumed all previous orders. The report reflected that the referral packet from the hospital which was sent electronically to admissions was scanned into the resident's clinical record on 04/25/16. Referral packets are not generally audited as they do not typically contain discharge orders, however in this incident the order for Resident #15 to receive the [MEDICATION NAME] was found in the referral packet which was scanned into the resident's medical record on 04/15/16. The report reflected on 05/21/16 the staff observed a change of condition in Resident #15and she was noted to have possible [MEDICAL CONDITION] activity. Resident #15 was sent to the emergency room for evaluation. The resident returned to the facility on the same day with orders to resume [MEDICATION NAME] 500 mg, twice a day. Resident #15 was discharged back to the assisted living facility on 05/24/16. The facility report revealed that a transcription error had occurred which led to the omission of a medication. Review of the physician discharge orders from the hospital dated 04/22/16 revealed an order for [REDACTED]. The emergency room Provider Notes date 04/21/16 reflected the following notation: As far as acutely concerning causes, those are ruled out. CT head neg.(negative) for bleed/mass. Ua clean. Na -wnl. I don't have an obvious cause for [MEDICAL CONDITION] activity. Description is not convincing for [MEDICAL CONDITION] given that she knew what was occurring with head being tossed back. However, she did have a speech change that resolved that could be counted as post-ictal. Regardless, pt.(patient) should be admitted at least overnight . Review of the discharge paperwork from the emergency room dated 05/21/16 revealed Resident #15 was seen for convulsions and was sent back to the facility with a prescription for [MEDICATION NAME] 500 mg. and it was to be give twice a day. Review of the MARs for April and May 2016 did not reflect that Resident #15 received any [MEDICATION NAME] from 04/22/16 until 05/22/16. Review of the History and Physical dated 04/25/16 revealed that Resident #15 had a [MEDICAL CONDITION] on the morning of 04/21/16 and was transported to the hospital and was monitored for 24 hours. The resident was started on [MEDICATION NAME] and returned to the facility on [DATE]. The physician also noted [MEDICAL CONDITION], c/w [MEDICATION NAME]. Has neuro appt. The physician's progress notes dated 04/28/16, 05/02/16, 05/05/16, 05/09/16 and 05/12/16 all had the documentation she was seen as a follow-up for [MEDICAL CONDITION] and [MEDICAL CONDITION], c/w [MEDICATION NAME]. Has neuro appt. Review of the Medication Error Occurrence Report dated 05/21/16 reflected that Resident #15 had reported to the nurse that she was supposed to be taking [MEDICATION NAME] for [MEDICAL CONDITION] since her last hospitalization , 04/21/16. The resident also told her the nurse at the facility told her she was getting her [MEDICATION NAME] and that it was a light pink pill. The nurse showed the resident all her pills and she identified Vitamin B-12 as her [MEDICATION NAME] medication. At 3:10 PM on 05/26/16 an interview was conducted with RN A. He stated Resident #15 came back from the hospital the evening of 04/22/16 with her son. He stated he went in to assess the resident, she said she was doing okay. He asked her if she had any paperwork from the hospital she told him just what paperwork was for her. She did let him scan the paperwork, but would not give it to him. He stated he did not see any new orders so he resumed her previous orders. RN A stated he knows now if he should receive a resident from the hospital without paperwork and orders he is to the call the hospital and find out about the orders and have them fax them over to the facility. At 9:45 AM on 05/27/16 an interview was conducted with ADON B. She stated she did not find out about the medication error for Resident #15 until LVN D called her this last weekend, (05/21/16). She confirmed they did not have any knowledge about Resident #15 and her to receive [MEDICATION NAME]. At 11:45 AM on 05/27/16 an interview was conducted with the DON. She stated usually when a resident was sent back from the hospital; the hospital would call and give report to the nurses. The hospital would also send a packet back with the resident which would have the patient's instructions and orders. When Resident #15 was readmitted the nurse looked at her paperwork at the time of re-admission, and did not see an order for [REDACTED].#15 was alert and she told the nurse she did not have any new orders. The DON stated the nurse should have called the hospital to check to see if there were any orders. At 1:45 PM on 05/27/16 an interview was conducted with ADON B. She stated LVN D called her on Saturday. 05/21/16 and told her about Resident #15 not getting her [MEDICATION NAME]. LVN D stated that the resident told her she was supposed to be on [MEDICATION NAME] for [MEDICAL CONDITION] since her last hospitalization . LVN D checked and she found the order for the [MEDICATION NAME] on the hospital records but it had not been transcribed to the orders or to the MARs at the facility. At 1:50 PM on 05/27/16 an interview was conducted with LVN D. She stated she had been on duty on the morning of 05/21/16 when Resident #15 had her last [MEDICAL CONDITION]. She said she was assessing the resident when she came out of the [MEDICAL CONDITION] and the resident told her she had another [MEDICAL CONDITION] before and had to go to the hospital. Resident #15 told her when she went to the hospital they started her on [MEDICATION NAME] and kept her overnight. Resident #15 told LVN D that she had been getting her [MEDICATION NAME]. LVN D stated she pulled all of Resident #15's medications from her cabinet and asked her to show her which pill she was taking. Resident #15 identified the Vitamin B-12 as the one which she thought was [MEDICATION NAME]. LVN D stated she called ADON B and reported it to her and then she also reported it to the weekend supervisor. LVN D stated when a resident returns from the hospital without paperwork, she would call the hospital and talk to the nurse to get the orders. At 2:00 PM on 05/27/16, an interview was conducted with the Medical Records Director and she stated when a resident came back from the hospital their records were usually with them in a brown envelope. She also stated the nurses would either have it at the desk on the unit or would put it in her box at her office. She could not remember where she got Resident #15's records but she did remember scanning them into the computer. At 10:00 AM on 05/27/16, the DON stated that there were no residents in the facility at that time who had a [DIAGNOSES REDACTED]. ADON B provided a list of the room assignments for which RN A would have been responsible for on 04/22/16 when Resident #15 was readmitted to the facility. RN A was assigned Resident Rooms 48 through 71. He would have been responsible for transcribing any admissiion orders or re-admission orderes for the residents who resided in those rooms. There was a potential for a total of twenty-four residents who could reside in those rooms. CMS Form 672, Resident Census and Conditions of Residents, completed on 05/25/16 reflected there were 69 residents in the facility.