Every finding on record at The Waters of Johnson City, LLC

Based on facility policy review, medical record review, observation, and interview, the facility failed to perform tracheostomy (trach) (a surgically created opening in the front of the neck leading to the windpipe/trachea for breathing) care to maintain infection control practices during trach care for 1 resident (Resident #11) of 1 resident reviewed for tracheostomies and the facility failed to ensure oxygen was administered according to Physician's Orders for 1 resident (Residents #25) of 10 residents reviewed for oxygen (O2) therapy. The findings include: Review of the facility's undated policy titled, Respiratory: Tracheostomy Care policy, revealed .cleaning a tracheostomy site and tube keeping site and tube free from mucus build-up .maintain tube patency reducing risk of infection and maintaining skin integrity at stoma site .Verify physician's orders .Assemble equipment .Perform hand hygiene .Position the plastic trash bag to receive contaminated disposable items .Establish sterile field on over-bed table .Put on sterile latex free gloves and personal protective equipment .when performing tracheostomy care keep dominate hand sterile and non-dominate hand clean .Discard dressings into plastic trash .Cleanse under tracheostomy flanges .Use cotton tipped applicator .to remove any encrusted material .Dry area .While still wearing sterile gloves remove inner cannula with sterile 4 x [by] 4 and discard 4 x 4 and inner cannula .Insert new inner cannula . Review of the facility's policy titled, Suctioning policy, revised 9/2013, .Open sterile catheter . Avoid contamination .Open saline solution .Apply gloves .Upon completion of use, discard disposable items . Review of the facility's policy titled, Guidelines for Enhanced Barrier Precautions (EBP) An Extension of Personal Protective Equipment (PPE) policy, revised 12/2022, .Ensure that additional and appropriate PPE is utilized, when indicated .Tracheostomy .This includes all required Hand Hygiene before and after donning [applying]/doffing [taking off] gloves . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Subdural Hemorrhage, Hemiplegia and Hemiparesis, Chronic Respiratory Failure, and Tracheostomy. Review of a Physician's Order for Resident #11 dated 8/3/2026, revealed .Trach care every shift for tracheal hygiene and as needed for tracheal hygiene .Trach suctioning as needed for tracheal hygiene and removal of secretions . Review of a comprehensive care plan for Resident #11 dated 8/4/2026, revealed .I am at risk for complications because I have a tracheostomy .Change tracheostomy per facility protocol .See MAR [Medication Administration Record] .for trach specifications .tracheostomy care per MD [Medical Doctor] order and facility protocol .I require suctioning due to increased secretions in respiratory tract related to .tracheostomy status .Observe for the need for suctioning . Review of a Physician's Order for Resident #11 dated 8/4/2026, revealed .Change Trach Collar/Ties Daily and PRN [as needed] .Change Trach Inner Cannula every day shift . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #11 had a tracheostomy. During an observation on 8/18/2026 at 8:08 AM, revealed Licensed Practical Nurse (LPN) B performed trach care for Resident #11.1. LPN B donned gown and non-sterile gloves. 2. LPN B stopped the resident's tube feeding, flushed the Percutaneous Endoscopic Gastrostomy (PEG) tube [opening into the stomach to allow nutrients and calories], discarded the remaining tube feeding, removed and discarded the non-sterile gloves, and failed to sanitize the hands.3. LPN B re-applied clean non-sterile gloves, Resident #11's trach was suctioned, tracheostomy care equipment was collected from multiple bedside nightstands and placed on the resident's bed, the non- sterile gloves were removed and LPN B failed to sanitize the hands.4. LPN B re-applied clean non-sterile gloves removed the trach strap, the 4x4 gauze was removed from underneath the trach, the trach was cleaned, a sterile 4x4 gauze and clean trach strap was applied, the non-sterile dirty gloves were discarded, and the hands were sanitized. During an interview on 8/18/2026 at 8:28 AM, LPN B confirmed she had not applied sterile gloves when she performed trach care for Resident #11 and did not sanitize her hands when she changed non-sterile gloves multiple times. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Chronic Obstructive Pulmonary Disease (COPD), and Heart Failure. Review of an Order Summary Report for Resident #25 dated 7/22/2025, revealed .Oxygen use at . Flowrate .[2.5] liter/minute via [by] nasal cannula .every shift . Review of an annual MDS assessment dated [DATE], revealed Resident #25 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #25 received oxygen. Review of a comprehensive care plan for Resident #25 dated 7/29/2026, revealed .at risk for impaired gas exchange .Administer oxygen as prescribed . During an observation on 8/19/2026 at 8:22 AM, Resident #25 was lying in bed and the oxygen was not in place. During an interview on 8/19/2026 at 8:24 AM, Registered Nurse (RN) C confirmed Resident #25's oxygen was not in place. RN C checked Resident #25's Oxygen saturation (amount of oxygen in the bloodstream) and it was 98% (Normal levels typically range from 95-100%). During an interview on 8/19/2026 at 12:53 PM, the Director of Nursing (DON) confirmed tracheostomy care was not performed for Resident #11 according to the facility's policy and infection control protocol practices. The DON confirmed all residents with a physician's orders for oxygen should have oxygen in place and confirmed the physician's order for oxygen for Resident #25 was not being followed.

Based on facility policy review, observations, and interviews, the facility failed to ensure medications were securely stored in 1 medication cart of 4 medication carts observed, the facility failed to ensure expired over the counter (OTC) medications were disposed of and not available for resident use in 1 of 4 medication carts observed, and the facility failed to ensure expired laboratory blood collection tubes were disposed of and not available for resident use in 1 of 2 medication rooms observed. The findings include: Review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, undated, revealed .Medications .are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel .Medication rooms, carts, and medication supplies are locked or attended by .licensed nurses .Outdated, contaminated, or deteriorated drugs .will be immediately withdrawn from stock . During an observation on [DATE] at 2:56 PM, revealed a medication cart was located against the nurse's desk on the Faith Way hallway, the drawers were facing the hallway, the medication cart was unlocked and unattended. Registered Nurse (RN) D confirmed the medication cart was unlocked, unattended, and medications were not secured. During a medication storage observation and interview on [DATE] at 7:50 AM, with RN D revealed one bottle of OTC ocular (eye) vitamins with an expiration date of 7/2026, one bottle of OTC allergy relief medication with an expiration date of 7/2026, and one bottle of OTC multivitamins with an expiration date of 7/2026 on the Faith Way medication cart. RN D confirmed the OTC medications were expired and available for resident use. During a medication storage observation and interview on [DATE] at 3:20 PM, with RN D revealed 8 green laboratory blood collection tubes with an expiration date of [DATE] and one yellow laboratory blood collection tube with an expiration date of [DATE] in the Faith Way medication room. RN D confirmed the blood collection tubes were expired and available for resident use. During an interview on [DATE] at 12:52 PM, the Director of Nursing (DON) confirmed medication carts should be secured at all times, OTC medications, and laboratory supplies should be discarded when expired.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was within reach for 3 residents (Resident #51, Resident #72, and Resident #55) of 73 residents observed. The findings include: Review of the facility's policy titled, Use of Call Light, dated 2006, revealed .be sure to position the call light conveniently for the resident to use .Tell the resident where the call light is .Ensure resident's call light is placed securely on the bed and remains within resident's reach . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes Mellitus, and Heart Failure. Review of a comprehensive care plan for Resident #51 dated 5/1/2026, revealed .requires assistance with ADLs .decreased cognitive ability r/t [related to] heart failure .Keep call light within reach . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and required partial/moderate assistance with ADL's (Activities of Daily Living) and personal hygiene. During an observation on 8/17/2026 at 3:10 PM, Resident #51 was lying in bed, the call light was on the floor and out of reach of the resident. During an interview on 8/17/2026 at 3:11 PM, Certified Nursing Assistant (CNA) A confirmed Resident #51's call light was on the floor and not within the resident's reach. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Diabetes Mellitus, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #72 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #72 required substantial/maximal assistance with ADLs and personal hygiene. Review of a comprehensive care plan for Resident #72 dated 6/25/2026, revealed .I have a self care deficit .require assistance with ADLs .Keep call light within reach . During an observation on 8/17/2026 at 3:15 PM, Resident #72 was lying in bed, the call light was on the floor and out of reach of the resident. During an interview on 8/17/2026 at 3:17 PM, CNA A confirmed Resident #72's call light was on the floor and not within the resident's reach. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Chronic Obstructive Pulmonary Disease, and Chronic Pain. Review of a comprehensive care plan for Resident #55 dated 6/17/2026, revealed .requires assistance with ADLs .decreased cognitive ability .Keep call light in reach . Review of an annual MDS assessment dated [DATE], revealed Resident #55 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #55 was dependent for ADLs and personal hygiene. During an observation on 8/18/2026 at 10:30 AM, Resident #55 was lying in bed, the call light was on the floor and out of reach of the resident. During an interview on 8/18/2026 at 10:32 AM, the Director of Nursing (DON) confirmed Resident #55's call light was on the floor and not within the resident's reach. During an interview on 8/19/2026 at 12:52 PM, the DON stated call lights should be within residents' reach. The DON confirmed Resident #51's, #72's, and #55's call light was not accessible for resident use.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to complete dialysis communications records for 1 resident (Resident #38) of 1 resident reviewed for dialysis. The findings include: Review of the facility's undated policy titled, Community Hemodialysis, revealed .Purpose .to ensure coordination of care for residents requiring hemodialysis .all residents .with needs for hemodialysis will have .a dialysis communication sheet .to communicate .information regarding the dialysis session . Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease, Hemiplegia, and Stroke. Review of a Physician's Progress note dated 1/28/2025 revealed Resident #38 began dialysis treatments during a hospital stay from dates 1/9/2025 to 1/27/2025 and was to continue dialysis services long term. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident received dialysis services. Review of the Physician's Orders for Resident #38 dated 2/19/2025 revealed .Dialysis .two times per week . Review of a comprehensive care plan revised 2/20/2025, revealed Resident #38 had a Dialysis Care Plan. During an interview and observation on 2/25/2025 at 8:10 AM, Resident #38 stated she went to dialysis services two days a week and had received treatments for a month. The resident further stated she did not take a dialysis communication sheet with her to dialysis services. During an interview on 2/25/2025 at 8:24 AM, Licensed Practical Nurse (LPN) A, stated she would send a face sheet with diagnoses and a list of medications with Resident #38 when the resident went to the dialysis treatments. The LPN was not aware a dialysis communication sheet was to be completed and sent with the resident to dialysis services. During an interview on 2/25/2025 at 8:48 AM, the Medical Records Director stated there was no documentation of dialysis communication sheets for Resident #38. During an interview on 2/25/2025 at 8:50 AM, the Director of Nursing (DON) stated it was the facility's expectation to send dialysis communication sheets with residents to dialysis services for each dialysis treatment. The DON confirmed dialysis communication sheets for Resident #38 had not been completed.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 dumpster (Dumpster A) of 2 dumpsters observed. The findings include: Review of the facility's policy titled, Trash Disposal, dated 8/23/2023, revealed .The Food Service department will dispose of trash appropriately and maintain the dumpster area for cleanliness and prevention of rodents .will ensure that the dumpster lids are closed .no trash is on the ground surrounding the dumpster . During an observation of the outside dumpster area on 2/23/2025 at 10:38 AM, with the Assistant Director of Dietary, revealed 2 dumpsters for waste disposal. Further observation revealed dumpster A lid was not closed and resulted in the dumpster's contents being left open to the elements and the potential exposure to pests. Further observation revealed the area around dumpster A had 1 trash bag of unknown contents (1/4 full) hanging from the top of the dumpster, 3 used disposable gloves, 1 milk carton, and multiple pieces of paper debris (various sizes) present on the ground. During an interview on 1/23/2025 at 10:48 AM, the Certified Dietary Manager confirmed the lid for dumpster A was not closed and the outside dumpster area was not maintained in a sanitary condition.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 residents (Residents #9, #32 and #38) of 15 residents reviewed for EBP. The findings include: Review of the facility's policy titled, GUIDELINES for ENHANCED BARRIER PRECAUTIONS (EBP), revised 12/2022, revealed .It is the policy of the facility to ensure .appropriate PPE (Personal Protective Equipment) is utilized when indicated .gowns and gloves .Resident(s) with an indwelling medical device including .Central Venous Catheters [tube inserted into large vein of chest allowing immediate access to bloodstream for hemodialysis] .Indwelling Catheters .wounds . Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Obstructive and Reflux Uropathy, Diabetes Mellitus, and Dementia. Review of the Physician's Orders for Resident #9 dated 10/29/2024 revealed .Change indwelling [urinary] catheter . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had an indwelling catheter. During an observation on 2/23/2025 at 1:52 PM, revealed Resident #9 had an indwelling urinary catheter. Continued observation revealed there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. Medical record review revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Diabetes Type 2, and Obstructive Reflux Uropathy. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 had a pressure ulcer wound. Review of the Physician's Orders dated 2/21/2025 for Resident #32 revealed the resident had an order for wound care for a pressure ulcer wound on the right heel. During an observation on 2/23/2025 at 1:51 PM, Resident #32 had a pressure ulcer wound on the right heel. Further observation revealed there was no EBP signage posted or PPE available in or outside the resident's room. Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease, Hemiplegia, and Stroke. Review of a quarterly MDS assessment dated [DATE], revealed the resident received dialysis services. Review of the Physician's Orders for Resident #38 dated 2/19/2025, revealed .Dialysis .two times per week . During an observation on 2/23/2025 at 1:52 PM, revealed Resident #38 had a central venous hemodialysis access port on the right side of the chest. Continued observation revealed there was no EBP signage or PPE available in or outside the resident's room. During an observation and interview on 2/23/2025 at 4:42 PM, the Assistant Director of Nursing (ADON) observed the doors for Residents #9, #32, and #38 and confirmed there was no EBP signage posted or PPE available inside or outside the residents' room. During an interview on 2/24/2025 at 10:00 AM, The DON stated it was the expectation residents with indwelling catheters, wounds, and central venous hemodialysis access ports have EBP signage posted and PPE available in or outside the resident's room. The DON confirmed EBP signage was not posted, and PPE was not available in or outside the room for Residents #9, #32, and #38 prior to 2/23/2025.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 2 residents (Resident #30, and Resident #14) of 6 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Guidelines For PASRR Process, dated 517/2023, revealed .PASRR [PASARR] is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility .PASRR has 3 goals: 1. Identify people, including adults, (residents), with mental illness .2. To ensure appropriate placement, whether in the community or in the nursing facility .3. To ensure people, (residents), receive the required services for mental illness . Review of a PASARR Level 1 screen for Resident #30 dated 1/22/2020, revealed the resident had 2 mental health diagnosis which included Anxiety Disorder, and Depression (mild or situational). Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with new mental health condition of Post Traumatic Stress Disorder and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 1/27/2025, revealed Resident #30 had an active diagnosis which included Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). Review of the Comprehensive Care Plan revision on 8/18/2023 revealed Resident #30 had a care plan for Major Depressive Disorder and PTSD. Review of the medical record revealed a new PASARR for Resident #30 was not submitted after the new mental health diagnosis was added of Post Traumatic Stress Disorder and Major Depressive Disorder. 50407 Medical record review revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including PTSD, Hemiplegia, and Heart Failure. Review of a PASARR for Resident #14 dated 5/11/2017, revealed .Level 1 Form .no documented diagnosis of major mental illness .no known mental health behaviors . Review of a comprehensive care plan dated 8/27/2024, revealed Resident #14 had a Care plan for .Trauma .PTSD . Review of a quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Psychiatric Notes for Resident #14 dated 2/21/2025 revealed, .Psychiatric . Evaluation .PTSD . Review of a Psychiatric Nurse Practitioner Note for Resident #14 dated 2/21/2025, revealed, .Psychiatric Periodic Evaluation .PTSD . During a record review and interview on 2/24/2025 at 3:20 PM, the Administrator stated it was his expectation a new PASARR was to be completed after a new mental diagnosis. During further interview the Administrator, confirmed the facility failed to refer Resident #30 and Resident #14 to the state designated agency for PASARRS after identifying new mental health conditions.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a care plan for 1 resident (Resident #9) and failed to implement a care plan for 2 residents (Residents #32 and #38) for Enhanced Barrier Precautions (EBP) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, updated 9/18/2018, revealed .It is the policy of the facility to ensure .every resident has a .Care Plan completed and implemented .to promote continuity of care .communication among .staff .increase resident safety .to meet the resident's medical .nursing needs .develop .objectives along with appropriate interventions .to achieve .greatest degree of .safety . Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Obstructive and Reflux Uropathy, Diabetes Mellitus, and Dementia. Review of the Physician's Orders for Resident #9 dated 10/29/2024 revealed .Change indwelling [urinary] catheter . Review of a comprehensive care plan dated 12/11/2024, revealed Resident #9 had an Indwelling Foley Catheter care plan. Further review revealed interventions included EBP. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had an indwelling urinary catheter. During an observation on 2/23/2025 at 1:52 PM, Resident #9 had an indwelling urinary catheter. Continued observation revealed there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. Medical record review revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Diabete, and Obstructive Reflux Uropathy. Review of a comprehensive care plan dated 10/4/2024, revealed Resident #32 had a care plan for a pressure ulcer on the right heel. Further observations revealed EBP had not been developed prior to 2/24/2025. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had a pressure ulcer wound. Review of the Physician's Orders dated 2/21/2025, for Resident #32 revealed the resident had an order for wound care to the right heel for an unhealed stage 4 pressure ulcer. During an observation on 2/23/2025 at 1:51 PM, Resident #32 had a pressure wound on the right heel. Observation revealed there was no EBP signage posted or PPE available in or outside the resident's room. Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease, Hemiplegia, and Stroke. Review of a quarterly MDS assessment dated [DATE], revealed Resident #38 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident received dialysis services. Review of the Physician's Orders for Resident #38 dated 2/19/2025 revealed .Dialysis .two times per week . Review of a comprehensive care plan revised 2/20/2025, revealed Resident #38 had a Dialysis Care Plan. Further review revealed EBP had not been developed on the care plan. During an observation on 2/23/2025 at 1:52 PM, Resident #38 had a central venous hemodialysis access port [tube inserted into large vein of chest allowing immediate access to bloodstream for hemodialysis] on the right side of chest. Continued observation revealed there was no EBP signage or PPE available in or outside the resident's room. During an observation and interview on 2/23/2025 at 4:42 PM, the Assistant Director of Nursing (ADON) observed the doors for Residents #9, #32, and #38 and confirmed there was no EBP signage posted or PPE available inside or outside the residents' rooms. During an interview and observation on 2/24/2025 at 10:00 AM, the DON stated it was the expectation residents with indwelling catheters, wounds, and central venous hemodialysis access ports have EBP signage posted and PPE available in or outside the resident's room. The DON reviewed the care plans for Residents #9, #32, and #38 and confirmed EBP was not developed and/or implemented prior to 2/24/2025.

Based on facility policy review, medical record, observation, and interview the facility failed to secure medications for 1 resident (Resident #4) of 19 residents reviewed for medication storage. The findings include: Review of the facility's policy titled, Medication Self Administration, undated, revealed .Residents who request to self-administer drugs will be assessed .the assessment results will be discussed with the attending physician and an order obtained to self-administrator if appropriate .bedside storage of prescription and non-prescription drugs is permitted when the assessment demonstrates the practice is safe . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Hypertensive Heart Disease with Heart Failure, and Diverticulosis of Intestine. Review of the Admission Minimum Data Set (MDS) assessment for Resident #4 dated 2/5/2025, revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan revision date of 2/6/2025, revealed Resident #4 was not assessed or care planned for self-medication storage and self-administration. Review of the active Physicians Orders dated 2/24/2025, revealed Resident #4 did not have an active order to self-administer drugs. During an observation and interview on 2/23/2025 at 1:01 PM, Resident #4 was observed in room watching television. Continued observation revealed a 15 milliliter (ml) bottle of artificial tears, a 1 ounce (oz) tube of zinc oxide, and a bottle of 100 triple magnesium vitamins half-empty. Resident #4 stated her son brought the medication to her and she administered them herself. Continued observation revealed Resident #4 did not have a roommate. During multiple observations throughout the survey revealed no residents with wandering behaviors noted on the unit/hall where Resident #4 resided. During an observation, interview, and record review on 2/23/2025 at 1:04 PM, the Assistant Director of Nursing (ADON) observed the medications in Resident #4's room. The ADON confirmed the medications were available for resident-self administration and confirmed the artificial tears, zinc oxide, and triple magnesium vitamins were not secured in resident room. The ADON confirmed Resident #4 had not been assessed for medication storage and self-administration of medications.

Based on facility policy review, medical record review, observation and interview, the facility failed to label and date oxygen tubing for 1 resident (Resident #176) and failed to change the oxygen tubing and humidifier bottle weekly for 1 resident (Resident #2) of 18 sampled residents reviewed receiving oxygen. The facility failed to properly store hand-held nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for 2 residents (Resident #2 and Resident #176) of 24 sampled residents reviewed receiving respiratory treatments. The findings include: Review of the undated facility Policy and Procedure titled, Oxygen Administration, revealed .It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Procedure: 4. Tubing, humidifier bottles and filters will be changed and maintained no less than weekly and PRN (as needed). Each will be labeled with date, time and initialed by staff completing this service to equipment . Review of the undated Policy and Procedure titled, Administering Nebulizer Therapy, revealed .Purpose: To provide accurate and safe administration of medications requiring nebulization to residents .Procedure: 2. Each resident requiring nebulized medication will have a nebulizer machine at the bed side with individual connecting tubing with mask or mouthpiece. The connecting tubing will be changed on a weekly basis and will be cleaned and covered after each use . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, Diabetes Mellitus, Acute and Chronic Respiratory Failure, Asthma, and Chronic Obstructive Pulmonary Disease (COPD). Review of a Care Plan for Resident #2 initiated 1/17/2019 and revised 9/8/2024, revealed .risk for decreased cardiac output .Interventions .Oxygen per physician order .patient may self-administer nebulizers after set up by the nurse . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Order Summary Report for Resident #2, dated 2/24/2025, revealed current orders for .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG [milligrams]/3 ML [milliliters] 3 ml inhale orally every 6 hours as needed for SOB [Shortness of Breath] or Wheezing via [by way of] nebulizer .Oxygen use at: Flowrate: (2)L [liters]/min[minute] via NC [nasal cannula] .Change oxygen tubing and humidifier bottle every night shift every Wed [Wednesday] . During an observation in Resident #2's room on 2/24/2025 at 8:00 AM, revealed Resident #2 sitting up a wheelchair in her room. The humidifier bottle and oxygen tubing were dated 2/13/2025. Continued observation revealed the handheld nebulizer mouthpiece, dated 2/13/2025, was uncovered, not stored in a bag, and lying on the bedside table. During an observation and interview in Resident #2's room on 2/24/2025 at 10:30 AM, revealed the humidifier bottle and oxygen tubing connected to the concentrator was dated 2/13/2025. Continued observation revealed nebulizer equipment, dated 2/13/2025, was uncovered, not stored in a bag, and lying on the bedside table. Licensed Pratical Nurse (LPN) B confirmed the oxygen tubing and humidifier bottle were dated 2/13/2025. Continued interview with LPN B confirmed the handheld nebulizer mouthpiece was dated 2/13/2025, was uncovered, and not stored in a bag. LPN B stated the nebulizer should be stored in a plastic bag and everything is supposed to be changed once a week; usually on Wednesdays, on night shift. Medical record review revealed Resident #176 was admitted to the facility on [DATE] with diagnoses including COPD, Centrilobular Emphysema, and Acute Respiratory Failure. Review of a quarterly MDS assessment dated [DATE], revealed Resident #176 scored 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Comphrensive Care Plan for Resident #176 dated 2/14/2025, revealed .altered respiratory status r/t [related to COPD .Provide oxygen as ordered . Review of the Order Summary Report for Resident #176, dated 2/24/2025, revealed current orders for .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 1 vial orally three times a day for COPD .Wean supplemental oxygen saturation as able to RA (room air) to maintain oxygen saturation at/above 90% . During an observation in Resident #176's room on 2/24/2025 at 8:30 AM, revealed Resident #176 lying in bed wearinga nasal cannula. The resident's oxygen tubing was undated. Continued observation revealed handheld nebulizer equipment, dated 2/19/2025, was uncovered, not stored in a bag, and lying on the bedside table. During an observation and interview in Resident #176's room on 2/24/2025 at 9:02 AM, revealed Resident #176 lying in bed wearing a nasal cannula. The resident's oxygen tubing was not labeled or dated. Continued observation revealed handheld nebulizer equipment, dated 2/19/2025, was uncovered, not stored in a bag, and lying on bedside table. LPN B confirmed the oxygen tubing was not labeled or dated. Continued interview with LPN B confirmed the handheld nebulizer equipment was uncovered and not stored in a bag. During interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 2/24/2025 at 4:20 PM, the ADON confirmed the oxygen tubing, and humidifier should be labeled and dated and the nebulizer should be stored in a bag after each use. The DON confirmed the oxygen tubing and humidifier was not changed weekly.

Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure an allegation of abuse was reported timely to the State Survey agency for 1 resident (Resident #7) of 13 residents reviewed for abuse. The findings include: Review of the facility's undated Policy titled, ABUSE PREVENTION PROGRAM, showed .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .of a resident, or an allegation of suspected abuse .of a resident by a 3rd party .Reporting .IF YOU SUSPECT ABUSE .Notify a Supervisor/Nurse Immediately .ABUSE REPORTING .All personnel must promptly report any incident or suspected incident of resident abuse .Administrator or person in charge of the facility will notify the following .immediately. State Licensing and Certification Agency . Review of the medical record showed Resident #7 was originally admitted to the facility on [DATE] with diagnoses including Heart Failure, Down Syndrome, and Anxiety Disorder, the resident was readmitted on [DATE]. Review of the facility's investigation showed on 5/25/2023 at 9:00 AM, Licensed Practical Nurse (LPN) #3 contacted Assistant Director of Nursing (ADON) #3 and reported Resident #7 had been agitated and aggressive the previous night around 5:00 AM throwing things and grabbing papers from behind the nurses desk LPN #3 stated LPN #1 made the comment this is why people abort their children A statement by LPN #1 showed .On 05/25/2023 around 4:30 am .this nurse was sitting at the computer behind the nurse's station .the resident [Resident #7] came up behind me attempting to take the paperwork I was working on .Resident left from behind the nurse's station and came to the front when he began grabbing the folders off the desk .this is when I mumbled to myself this is why people have abortions .it was a poor choice of words made in a moment of frustration . LPN #1 was suspended pending investigation. Further investigation showed LPN #1 had been mocking and agitating Resident #7 and the facility substantiated the verbal abuse allegation. LPN #1 was terminated. The State Licensing and Certification Agency was notified at 11:00 AM on 5/25/2023 (6 hours after the alleged incident occurred). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #7's Brief Interview of Mental Status (BIMS) score was 3 indicating the resident had severe cognitive impairment. During an interview on 1/10/2024 at 11:10 AM, The Regional Nurse Consultant stated .she [LPN #3] didn't report it immediately it wasn't until after she had already gone home and thought about it .it was late reporting . During a telephone interview on 1/30/2024 at 11:20 AM, [LPN #3] stated it was the end of our shift around 5 something in the morning .I reported to my ADON once I left work, I didn't immediately report it, it was probably a couple of hours after I left .

Based on review of a facility policy, medical record review, facility documentation, and interview, the facility failed to follow a physician's order for medication administration for 1 resident (#2) of 4 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, GUIDELINES FOR PHYSICIAN ORDERS, . dated 6/18/2023, showed .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the residents stay in the facility as the orders are received . Review of the facility's medication administration policy titled, MEDICATION ADMINISTRATION, showed .Purpose: To ensure that resident medications are administered in a timely manner . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Paranoid Schizophrenia, Dysphagia, and Thrombocytopenia Purpura, the resident discharged to the hospital on 9/1/2023. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2's Brief Interview of Mental Status (BIMS) score was 12 indicating the resident had moderate cognitive impairment. Review of facility's Appointment/Consultation Form for Resident #2 showed .Date of Appt. [appointment] 8/29/23 [8/20/2023]Time 12:00 pm .Appt with: Cancer Center .New Orders .continue Prednisone [corticosteroid] 20 mg [milligram] daily through 9/5 [9/5/2023] . Review of Physician orders and Medication Administration Records (MARS) for Resident #2 showed an order for .predniSONE Tablet 20 MG [milligram] .one tablet .one time a day .Start Date .08/25/2023 .End Date .08/29/2023 . Documentation showed no new order for prednisone on 8/29/23 and there was no documentation prednisone was given on 8/30 or 8/31/2023. Review of facility's Record of Conversation form for Resident #2 showed .9/1/2023 .[Licensed Practical Nurse] [LPN #2] .[Resident #2] missed two doses of prednisone due to order this nurse put in the system did not save and order ended on 8/29/23 causing resident to miss prednisone on 8/30 and 8/31 .Employee Comments .[Resident #2's] sister came to me with new orders from doctors appointment stated she was looking for [Assistant Director of Nursing] [ADON #1] Informed her [ADON #1] was in a meeting but that I could take the orders and put them in and let [ADON #1] know orders were put into computer paper work given to [ADON #1] . Review of the facility's incident report for Resident #2 showed .9/1/2023 .Sister [Resident #2's sister] had given nurse orders from the cancer center to input into PCC [point click care] Orders were not saved correctly, and resident missed two doses of his prednisone .Immediate Action Taken .Prednisone was given stat and order restarted. Cancer center was notified and asked for labs to be obtained and results reported to the cancer center as soon as received .No injuries observed at time of incident .No injuries Observed post incident . Review of progress notes for Resident #2 showed .9/1/2023 .Resident has missed two doses of his prednisone, MD and cancer center notified and both agreed to give stat dose and obtain labs stat, then send results to cancer center as soon as results received .Resident was showing no s/s [signs/symptoms] of adverse reaction . Review of laboratory reports for Resident #2 showed on 8/24/2023 the residents platelet count was 561, on 8/29/2023 the platelet count was 116, and on 9/1/2023 the platelet count was 24 with the normal reference ranges being 150 to 450. Review of the facility's electronic audit trail report on 1/10/2023 with the Regional Nurse Consultant showed no documentation of any orders put in for resident #2 on 8/29/2023. During a telephone interview on 1/10/2023 at 9:30 AM, [LPN #2] stated .I know it was a Tuesday [8/29/2023] I was working on my last med [medication] pass at 4:00 PM [Resident #2] had been out for an appointment that day and his sister come up the hall with him because he had come back from his appointment .she come up to me letting me know she had orders and she was wanting to give them to [ADON #1] I told her [ADON #1] was in a meeting .I told her I could take the orders and told her that I would put those in and that I would give the papers to [ADON #1] to let her know that they were in .she handed me the paper that had the prednisone order on it .I put the order in on the computer on my cart [medication cart] .then I took the paper up to [ADON #1] and I told her I put the order in . During an interview on 1/10/2024 at 11:10 AM, the Regional Nurse Consultant stated .they [facility staff] called me on 9/1 [9/1/2023] when they figured out they had the med error I believe it was the DON [DON #4] she was the DON at the time .when I went in and looked into point click care I didn't see that the order was there at all .I went to our audit trail report it will show me basically everywhere that a user has been in the record by date and time I looked only on his [Resident #2] record to see if she [LPN #2] had put the order in because she was saying that she put the order in .I went and pulled the order listing report for the prior 3 days to make sure it didn't get put onto another residents profile and it was not there .she could have put it in and not hit save and it wouldn't have triggered a record for the audit trail report because you have to complete a function .whatever she done it would have automatically took her back to the order listing tab and at the top of that tab there was an active prednisone order which is probably what she thought she had just put in .I truly believe she thought she put the order in she had told me she put the order in I don't think she hit save .we had no computer downtime during that time and we had no other concern or computer issues during that time frame I think it was user error .I've never seen orders just disappear and I've used this computer program for over 2 years . During an interview on 1/10/2024 at 1:45 PM, Physician #1 stated .he [Resident #2] was taking the medication [Prednisone] for his platelets the idea is to help with your platelets it was to keep the platelets from dropping .he was on prednisone intermittently a lot .it was just to be continued so if oncology thought he needed a change in the dose I think that would have been a more significant miss .they didn't make a medicine adjustment they were just going to continue the same dose and it [platelets] still dropped .on the 24th [8/24/2023] it [platelets] was 561 he was placed on 20 mg prednisone on 8/25 and despite this his platelets still dropped to 116 on 8/29 even after he received those doses .what I'm saying he was on it and his platelets still dropped and so they were still going to drop despite the missed doses in my opinion and the reason I say that is because he was already on prednisone for 5 days and that is when it dropped over 400 .the prednisone already wasn't working for him .on 9/1 his platelets was 24 and that is when he went to the hospital .the 2 missed doses did not affect his labs it was going to happen . During an interview on 1/31/2024 at 1:00 PM, ADON #1 stated .it was with [LPN #2] .[Resident #2] sister would bring the paperwork back with her from his doctor's appointment .she usually brought it to me [ADON #1]or the [Director of Nursing] DON and I was in a meeting .she had told [LPN #2] she couldn't find me and [LPN #2] said I will take care of it and I will give [ADON #1] the packet the packet was what we sent with him and the orders from the cancer center would be on the front of the packet .when she [LPN #2] brought me the packet she said I've taken care of it I've put the order in its already done .just by glancing in his orders the prednisone order was there but he got it all the time and they would either lower it keep it the same or increase it depending on his platelet count .I did not actually open the order in the computer to see that it was there and extended for another week that was what was on the order and what had happened is he missed two doses of the prednisone because apparently it wasn't put in correctly .I was approached by his sister and she said he had missed two doses of prednisone she come in and asked if he had had his prednisone that's how she knew he hadn't had it .the first thing we do is call [Physician #1] and the cancer center doctor and they said to go ahead and give him a stat dose where he had missed it for that day draw blood and they would go from his platelet count .he didn't have any adverse effects . During an interview on 2/1/2024 at 9:45 AM, the Administrator stated .[LPN #2] said she put it in the system but there is no history like what we can pull up to see what the order was it doesn't show that she even had went to that screen at all .yes he [Resident #2] ended up missing 2 dosed of the prednisone .

Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to prevent abuse for 1 resident (#7) of 13 residents reviewed for abuse. The findings include: Review of the facility's undated Policy titled, ABUSE PREVENTION PROGRAM, showed .It is the policy of this facility to prevent resident abuse .Verbal abuse: Any use of oral .language that willfully includes disparaging and derogatory terms to residents .within the hearing distance .regardless of their .ability to comprehend or disability . Review of the medical record showed Resident #7 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Down Syndrome, and Anxiety Disorder. Review of the facility's investigation showed on 5/25/2023 at 9:00 AM, Licensed Practical Nurse (LPN) #3 contacted Assistant Director of Nursing (ADON) #3 and reported Resident #7 had been agitated and aggressive the previous night around 5:00 AM throwing things and grabbing papers from behind the nurses desk LPN #3 stated LPN #1 made the comment this is why people abort their children A statement by LPN #1 showed .On 05/25/2023 around 4:30 am .this nurse was sitting at the computer behind the nurse's station .the resident [Resident #7] came up behind me attempting to take the paperwork I was working on .Resident left from behind the nurse's station and came to the front when he began grabbing the folders off the desk .this is when I mumbled to myself this is why people have abortions .it was a poor choice of words made in a moment of frustration . LPN #1 was suspended pending investigation. Further investigation showed LPN #1 had been mocking and agitating Resident #7 and the facility substantiated the verbal abuse. LPN #1 was terminated. Review of progress notes for Resident #7 showed .05/26/2023 .Social Service Note .conducted a wellness check on resident. Resident was at the nurses station visiting with the nurse and doing well nursing staff voiced resident is at his normal baseline and no signs or symptoms of distress . Review of PSYCHIATRIC PERIODIC EVALUATION for Resident #7 showed .6/1/2023 .Patient was involved in an incident with the nurse who has since been dismissed from the facility. No signs of psychosocial harm at this time. He continues at his baseline resting in room .6/22/2023 .Patient stable . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #7's Brief Interview of Mental Status (BIMS) score was 3 indicating the resident had severe cognitive impairment. During an interview on 1/10/2024 at 11:10 AM, the Regional Nurse Consultant stated .we did end up substantiating verbal abuse because she [LPN #1] admitted she made the comment, and she was antagonizing him [Resident #7] . During a telephone interview on 1/30/2024 at 11:20 AM, LPN #3 stated it was the end of our shift around 5 something in the morning [5:00 AM] I think and our shift ends at 6 [6:00 AM] .the resident [Resident #7] came out of his room and he was upset and he started grabbing binders and stuff that he could reach and throwing them .she [LPN #1] started antagonizing him and mocking him .she made a comment about this is why people have abortions in reference to the patient having downs syndrome .he likes to yell and make loud noises and she was just pretty much mocking him in that way .I got him to let me roll him out from behind the desk .she [LPN #1] stayed behind the nurses station and he was on the other side and after a little bit he went back to his room .she didn't have any more contact with him . Attempted a telephone interview with LPN #1 on 1/30/2024 at 11:40 AM, without success. A voice message was left and no return call was received.

Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure an allegation of abuse was reported to the State Survey Agency for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, ABUSE PREVENTION PROGRAM revised 1/2019 showed .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .of a resident .When an alleged or suspected case of abuse .against a resident is reported to the facility Administrator .or DON [Director of Nursing] in the Administrator's absence will notify the following persons or agencies of such incident .within 2 hours of the incident .State Licensing and Certification Agency [State Survey Agency] . Review of the medical record showed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Type 2 Diabetes Mellitus, Restlessness and Agitation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 9 indicating the resident had moderate cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of the facility's investigation showed on 2/23/2023 in the afternoon Resident #1's church member spoke with the Social Services Director (SSD) and reported Resident #1 was making statements that she had been violated and held against her will. The SSD notified the Administrator, the DON, and the Psychiatric Nurse Practitioner. Interviews conducted with Resident #1 showed the resident was inconsistent with her story. Resident #1 was assessed by the Psychiatric Nurse Practitioner. Resident interviews and skin assessments were conducted, and no alleged perpertrator was identified. The facility was unable to substantiate the allegation of abuse as reported by Resident #1. The allegation of abuse was not reported to the State Survey Agency. During an interview on 3/8/2023 at 9:10 AM, the SSD stated .on the 23rd of February her [Resident #1] church member came to my office and told me that [Resident #1] was making statements that she had been violated and held against her will .I went and told the DON . During an interview on 3/8/2023 at 9:40 AM, the DON stated .it was on the 23rd of February a church member had been visiting her [Resident #1] and she stopped by my office and said [Resident #1] said she was being held against her will and was being violated .we didn't report it we just treated it as a continuation of her [Resident #1's] psych [psychiatric] issue .

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide showers as scheduled for 1 resident (#56) of 15 residents reviewed for bathing. The findings include: Review of the facility's undated policy titled, Activities of Daily Living, showed .Residents are given routine daily care .by a C.N.A. [Certified Nursing Assistant] or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL [Activities of Daily Living] care is provided throughout the day, evening and night as care planned and/or as needed .ADL care of the resident includes: Assisting the resident in personal care such as bathing, showering, dressing .Do all required ADL documentation as required per policy and regulations Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #56 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #56 was frequently incontinent of bladder and bowel. Review of the Care Plan dated 12/24/2021, showed .at risk for adverse effects and alteration in ADL self care r/t [related to] need for assistance with ADL's and personal care .ADL need for assistance may vary throughout course of day .Bathing - baseline is at one person assist . Review of the Shower List showed Resident #56 was scheduled for showers on Tuesdays and Fridays on dayshift. Review of Resident #56's Bathing report dated 1/5/2022 - 1/20/2022, showed the resident did not receive a shower during the period of 1/11/2022 - 1/20/2022. Observation and interview on 1/18/2022 at 11:59 AM, revealed Resident #56 lying on the bed. Resident #56 appeared unkept with facial hair present and dirty fingernails. Resident #56 stated he has only received 1 shower since he was admitted to the facility. Observation on 1/19/2022 at 8:30 AM, revealed Resident #56 lying on the bed. Resident #56 appeared unkept with facial hair present and clean fingernails. Review of a Nursing Progress Note dated 1/19/2022 at 10:00 PM, showed .received a shower and shave this evening; no needs voiced. During an interview on 1/20/2022 at 1:16 PM, the Director of Nursing (DON) stated Resident #56 was to receive showers twice weekly on Tuesdays and Fridays. Facility documentation showed Resident #56 received a shower on 1/10/2022. The DON provided Resident #56 with a shower on 1/19/2022. Further interview confirmed the resident did not receive a shower during the 8-day period of 1/11/2022 - 1/18/2022.

Based on facility policy review, medical record review, observation, and interview the facility failed to properly store a nebulizer [device used to administer inhaled medications] mask and tubing in a sanitary manner and failed to change oxygen tubing for 1 resident (#56) of 3 residents reviewed for respiratory care. The findings include: Review of the facility's undated policy titled, Oxygen Administration, showed .Tubing, humidifier bottles and filters will be changed, cleaned and maintained no less than weekly and PRN [as needed]. Each will be labeled with date, time and initialed by staff completing this service to equipment . Review of the facility's undated policy, titled, Administering Nebulizer Therapy, showed .Each resident requiring nebulized medication will have a nebulizer machine at the bed side with individual connecting tubing with mask or mouthpiece. The connecting tubing will be changed on a weekly basis and will be cleaned and covered after each use . Review of [name of facility] Cleaning Schedule, undated, showed .Wednesday: Change O2 [oxygen] tubing, water bottles, and nebulizer masks. (All of these must be labeled with date and initial and put into assigned bags) . Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact and received oxygen therapy. Review of the care plan revised on 12/24/2021, showed .at Risk for alteration in respiratory status r/t [related to] [CONDITION(S)] and [CONDITION(S)]. Oxygen use per MD [Medical Doctor] order .O2 therapy per orders, change O2 tubing per facility protocol and as needed .Medication per orders. Observe for effectiveness and potential side effects . Observations on 1/18/2022 at 11:59 AM, 1/19/2022 at 8:30 AM, and 1/19/2022 at 1:48 PM, showed Resident #56 lying on the bed with humidified oxygen at 3 liters by nasal cannula. The oxygen tubing and humidification bottle were undated. Resident #56 had a nebulizer machine on the bedside table with the mouthpiece and tubing uncovered, undated, and open to air. During observation and interview on 1/19/2022 at 1:50 PM, in Resident #56's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #56's oxygen tubing and humification bottle were unlabeled and undated and the nebulizer mouthpiece and tubing were uncovered, undated, and open to air. During an interview on 1/20/2022 at 3:09 PM, the Director of Nursing (DON) stated it was the facility's expectation that oxygen tubing be changed weekly and labeled with date, time, and initials of the staff who changed it. The DON stated it was the facility's expectation that nebulizer tubing and mouthpieces be changed weekly, labeled with the date it was changed, and stored in a bag in between uses. The DON confirmed Resident #56's undated oxygen supplies and uncovered and undated nebulizer supplies did not follow the facility's policy.

Based on medical record review, review of facility documentation, review of hospital documentation and interview, the facility failed to ensure care planned interventions of fall mats were in place to prevent injury from falls for 1 resident (Resident #1) of 3 residents reviewed for falls. The facility's failure to ensure fall mats were in place resulted in Resident #1 sustaining a [MEDICAL CONDITION] (Harm). The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident was severely cognitively impaired, and the resident required extensive assistance of 2 staff members for bed mobility. Medical record review of Resident #1's Comprehensive Care Plan for falls, last revised 11/4/2020, showed Resident #1 was at risk for falls with an intervention added 9/19/2020 .fall mats (mats placed on the floor beside the bed to prevent injury) . Medical record review of Resident #1's November 2020 Medication Administration Record (MAR) showed .Resident to have floor mats beside bed every shift for safety intervention .start date .9/20/2020 .d/c (discontinue) date .11/13/20 . Medical record review of Resident #1's Fall Risk assessment dated [DATE], showed a score of 12, indicating Resident #1 was a high risk for falls. Review of a facility falls investigation dated 11/18/2020, showed Resident #1 had a witnessed fall from bed, resulting in a femoral (hip) fracture on 11/18/2020 at 2:14 PM. Further review revealed, .This nurse was called to resident's room where she was observed laying on her left side on the floor beside bed. The bed was in high position as resident was being changed at the time of the fall. Resident is complaining of severe left hip, knee and 'tailbone' pain . The investigation stated .Reviewed fall on 11/18/2020 with IDT (Interdisciplinary Treatment Team) .Resident was then sent out to ER (emergency room ) .to eval (evaluate) and treat per NP (nurse practitioner) order. Resident obtained a non-displaced left intertrochanteric femoral fracture ([MEDICAL CONDITION]) . Medical record review of Resident #1's hospital History and Physical dated 11/18/2020, showed Resident #1 was evaluated at a local hospital and was diagnosed with [REDACTED]. During a phone interview on 12/3/2020 at 2:25 PM, Certified Nursing Assistant (CNA) #1 stated she was providing incontinence care for Resident #1 when Resident #1 rolled out of the bed onto the floor. CNA #1 stated the fall mats were not in place at the time of the resident's fall from the bed. During a phone interview with Licensed Practical Nurse (LPN) #1 on 12/3/2020 at 3:29 PM, LPN #1 stated she was the nurse on the hall when Resident #1 fell and fractured her hip. LPN #1 stated, .The CNA called me to the room .she'd been providing care, had the bed raised up (in the high position) .(the resident) was laying left side of her body on the right side of the bed . LPN #1 stated fall mats were supposed to be on either side of the bed, and the fall mats were not in place when Resident #1 fell on the bare floor. During a phone interview on 12/3/2020 at 5:12 PM, the Assistant Director of Nursing (ADON) stated she was on the IDT team that reviewed falls and the root cause of Resident #1's fall was .she was being changed and fell over (the side of the bed) . During a phone interview on 12/7/2020 at 12:51 PM, the Director of Nursing (DON) indicated there was not a specific reason the fall mats were not documented on the MAR after Resident #1's return from the hospital on [DATE]. The DON confirmed the fall mats were supposed to be in place at the time of Resident #1's fall from the bed .it wasn't something that we removed in the IDT meetings . The DON confirmed the fall mats were supposed to be in place, regardless if it was on the MAR .The care plans are available for the nurses to see and know . During a phone interview on 12/7/2020 at 1:11 PM, the DON confirmed the fall onto the bare ground resulted in Resident #1's [MEDICAL CONDITION].

Based on medical record review, review of facility documentation, review of hospital documentation, and interview, the facility failed to ensure the appropriate level of staff assistance was provided during incontinence care, and failed to ensure fall mats were in place to prevent injury from falls for 1 resident (Resident #1) of 3 residents reviewed for falls. The facility's failure resulted in Resident #1 sustaining a [MEDICAL CONDITION] (Harm). The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Continued review showed the resident was coded for 2 staff assistance with bed mobility. Medical record review of Resident #1's comprehensive care plan for falls, revised 11/4/2020, showed .(Resident #1) is at risk for falls .Interventions .9/19/2020 .fall mats . Medical record review of Resident #1's November 2020 Medication Administration Record (MAR) showed .Resident to have floor mats beside bed every shift for safety intervention .start date .9/20/2020 .d/c (discontinue) date .11/13/20 . Medical record review of an Admission/Readmission Screener dated 11/13/2020, showed the resident was coded as requiring extensive assistance for bed mobility. Medical record review of Resident #1's Fall Risk assessment dated [DATE], showed a score of 12, indicating Resident #1 was a high risk for falls. Medical record review of a Nurse's Note dated 11/14/2020, documented .The resident is .extensive assist x (times) 2 (staff) for bed mobility .extensive assist x 1 (staff) for toileting .(Resident #1) is incontinent of urine and is incontinent of bowel . The Nurse's Note was signed by Registered Nurse (RN) #1. Medical record review of a Nurse's Note dated 11/14/2020, documented .The resident is .extensive assist x2 for bed mobility .extensive assist x2 for toileting, and is not mobile (bedbound) .(Resident #1) is incontinent of urine and is incontinent of bowel . The Nurse's Note was signed by Licensed Practical Nurse (LPN) #3. Medical record review of a Nurse's Note dated 11/15/2020, documented .The resident is .extensive assist x1 for bed mobility .extensive assist x1 for toileting, and is not mobile (bedbound) .(Resident #1) is incontinent of urine and is incontinent of bowel . The Nurse's Note was signed by LPN #4. Medical record review of a Nurse's Note dated 11/15/2020, documented .The resident is .extensive assist x2 for bed mobility .extensive assist x2 for toileting, and is not mobile (bedbound) .(Resident #1) is incontinent of urine and is incontinent of bowel . The Nurse's Note was signed by LPN #3. Medical record review of a Nurse's Note dated 11/16/2020, documented .The resident is .extensive assist x1 for bed mobility .extensive assist x1 for toileting, and is not mobile (bedbound) .(Resident #1) is incontinent of urine and is incontinent of bowel . The Nurse's Note was signed by LPN #5. Medical record review of Physical Therapy evaluation and Plan of Treatment dated 11/17/2020 showed .Functional Assessment .Bed Mobility .Rolling = Max (maximum) . Review of a facility falls investigation dated 11/18/2020, showed Resident #1 had a witnessed fall from bed, resulting in a femoral (hip) fracture on 11/18/2020 at 2:14 PM. The investigation showed .This nurse was called to resident's room where she was observed laying on her left side on the floor beside bed. The bed was in high position as resident was being changed at the time of the fall. Resident is complaining of severe left hip, knee and 'tailbone' pain .Reviewed fall on 11/18/2020 with IDT (Interdisciplinary Treatment Team) .Resident was then sent out to ER (emergency room ) .to eval (evaluate) and treat per NP (nurse practitioner) order. Resident obtained a non displaced left intertrochanteric femoral fracture ([MEDICAL CONDITION]). New intervention in place for resident to be a 2 person assist during care . Medical record review of Resident #1's hospital History and Physical dated 11/18/2020, showed, .Today the patient was being cleaned by nursing home staff when she fell .and landed on the floor on her left side .three-view of the left hip revealed nondisplaced left intertrochanteric femoral fracture ([MEDICAL CONDITION]) . Medical record review of Fall Risk assessment dated [DATE], showed the resident scored a 12, indicating she was at a high risk for falling. Medical record review of a Nurse's Note dated 11/23/2020, showed .(Resident #1) readmitted .two assist with .bed mobility .she is incontinent of b/b (bowel and bladder) . Medical record review of Resident #1's December 2020 MAR showed the fall mats as a falls intervention had not been added to the MAR. During a phone interview on 12/3/2020 at 2:00 PM, Certified Nursing Assistant (CNA) #2 stated it varied whether Resident #1 required 1 or 2 staff members for assistance .She could help and would sometimes over-roll .Sometimes she was out of it, and I was afraid she'd flip out of the bed . During a phone interview on 12/3/2020 at 2:25 PM, CNA #1 confirmed she was providing incontinence care by herself for Resident #1 at the time of the fall.She used to be a 1 person assist (because) she could roll on own and tries to help a lot with rolling .now she is a 2 person assist (since Resident #1's fall on 11/18/2020) . CNA #1 stated the resident was incontinent of both bowel and bladder, wore a brief, and since the resident helped with rolling, CNA #1 usually changed the resident without assistance. The CNA confirmed, .I was in the process of changing her .I thought I had her centered .I had one hand on her, was wiping her . The CNA stated the fall mats were not in place at the time of the fall. During a phone interview on 12/3/2020 at 3:14 PM, LPN #2 stated, .As far as (Resident #1) she has always been an extensive assist. That means 1 person (assisting her) and after the fall (she's) a (2 person assist) . During a phone interview on 12/3/2020 at 3:29 PM, LPN #1 stated she was the nurse on the hall when Resident #1 fell and fractured her hip. LPN #1 stated, .The CNA called me to the room .she'd been providing care, had the bed raised up (in the high position) .(the resident) was laying left side of her body on the right side of the bed . LPN #1 stated fall mats were supposed to be on either side of the bed and the fall mats were not in place at the time of the fall. LPN #1 confirmed Resident #1 was assessed on the MDS assessment as requiring 2 staff members for bed mobility at the time of the fall, and the resident fell on the bare floor while being assisted by one CNA. During a phone interview on 12/3/2020 at 5:02 PM, MDS Nurse #1 confirmed Resident #1 was coded as a 2 person assistance based off the highest need for assistance during the look back period. The nurse indicated Resident #1's need for assistance varied and stated .she was already at risk for a fall like that . During a phone interview on 12/3/2020 at 5:12 PM, the Assistant Director of Nursing (ADON) stated she was on the IDT team that reviewed falls and the root cause of Resident #1's fall was .she was being changed and fell over (the side of the bed) . The ADON stated .(Resident #1) has always been a 1 person assist .(she) has no lower trunk control, which is another reason to have a 2 person assist . Further interview confirmed that per the MDS, Resident #1 should have had 2 person assistance at the time of the fall. During a phone interview on 12/3/2020 at 5:51 PM, the Director of Nursing (DON) stated the cause of the fall was Resident #1 being rolled too far. During a second phone interview on 12/7/2020 at 12:51 PM, the DON indicated there was not a specific reason the fall mats were not documented on the MAR after the Resident #1's return from the hospital on [DATE]. The DON confirmed the fall mats were supposed to be there .it wasn't something that we removed in the IDT meetings . The DON confirmed the fall mats were to be in place, regardless if it was on the MAR. The care plans are available for the nurses to see and know . During phone interview at 1:11 PM, the DON confirmed the fall onto the bare ground resulted in Resident #1's [MEDICAL CONDITION].

Based on review of facility policy, observation, and interview, the facility failed to follow infection control measures on 2 of 3 hallways observed. The findings include: Review of the facility policy COVID-19 PPE (Personal Protective Equipment) Zones Guidelines, effective 9/3/2020, showed .Red Zone (Confirmed positive COVID-19) .Full PPE (gown, N95 mask, face shield or goggles, gloves as usual). Shoe and hair coverings may be worn but are not mandatory according to the CDC (Center for Disease Control and Prevention) .Yellow Zone (Potentially/presumed positive for COVID-19, new admissions, readmissions, symptomatic, potentially or directly exposed) .Gown, N95 mask, face shield or goggles, gloves as usual .Gowns cannot be worn throughout the unit and must be changed room to room the staff can don their gown upon entering and doff upon exiting . Observation on the Joy Way Long Hall (the Yellow Zone) on 12/2/2020 at 2:29 PM, showed Certified Nursing Assistant (CNA) #3 entered a resident room and did not don a gown before assisting the resident with a water pitcher. During an interview on 12/2/2020 at 2:36 PM, CNA #3 confirmed she forgot to don her gown. During this interview, it was observed the CNA was wearing one strap of the N95 respirator mask underneath her chin, and not pulled over and affixed behind the head. CNA #3 confirmed she had one strap underneath her chin and CNA #3 did not reposition the strap. Observation on 12/2/2020 at 2:44 PM, while standing on the yellow unit looking out the glass double doors across the breezeway, through the glass double doors that open onto the COVID-19 positive unit, showed a staff member working with no face mask, shield, or goggles. The staff member was approximately halfway down the hall, and was observed walking up the hall towards the glass double doors. The staff exited the COVID-19 positive hall and stepped into the breezeway, lugging a yellow trash can. Booties were observed over the staff member's shoes. During this observation, CNA #3 confirmed the identity of the staff member as CNA #4 and the location as being the COVID-19 positive hall. During an interview with the Director of Nursing (DON) and the Administrator on 12/2/2020 at 3:05 PM, and 3:37 PM, the DON confirmed staff were to don a gown when entering a resident room on Joy Way Long Hall, and confirmed the observation was a breach in infection control practices. The DON also confirmed .We did education, we did fit testing about wear .That (wearing 1 strap underneath the chin) is not something that is acceptable . Interview confirmed working on the COVID-19 positive hall without proper PPE was a breach in infection control practices.

Based on review of facility policy, medical record review, and interview, the facility failed to notify the resident representative of change in the condition for 1 resident (#1) of 3 residents reviewed for notification of change in condition. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Order Listing Report showed [MEDICATION NAME] (an antifungal medication) 5 milliliter (ml) four times a day was ordered on [DATE] for oral thrush and [MEDICATION NAME] (antifungal medication) 150 milligram (mg), one time only for yeast on 8/3/2020. During a telephone interview on 8/25/2020 at 9:03 AM, Resident #1's representative stated she was unaware Resident #1 was receiving treatment for [REDACTED]. During an interview on 8/25/2020 at 11:49 AM in the conference room, the Director of Nursing (DON) stated Resident #1 had been treated for [REDACTED].