Every finding on record at The Woodlands Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 5 (#R2, #R3, #R4, #R5, and #R7) of 10 Sampled Residents. The facility failed to ensure Resident's received proper assistance for elimination and bed mobility.Findings:Review of the facility policy on 03/16/2026 at 1:22 p.m. titled Activities of Daily Living, Supporting and dated 03/2018 read in part. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (bathing, dressing, grooming, and oral care); 2. Mobility (transfer and ambulation, including walking); 3. Elimination (toileting); 4. Dining (meals and snacks); and 5. Communication (speech, language, and any functional communication systems). Interview on 03/12/2026 at 4:20 a.m. with S6CNA revealed she worked the 7:00 p.m. - 7:00 a.m. shift fulltime. S6CNA revealed the facility had only been staffing 1 CNA to work the 7:00 p.m. shift on X hall. S6CNA stated she was overworked and gets no help. S6CNA revealed the 2 CNAs from Y hall come to help round on her back half of the X hall. S6CNA stated she was unable to complete all of her assigned duties for her shift revealing she had approximately 7 residents to get up in the morning. S6CNA stated she had not gotten these residents up, and the residents had to wait on the 7:00 a.m. CNA's to finish serving breakfast until they could get them up. S6CNA revealed she had spoken to her supervisor on numerous occasions about her concerns of not being able to accomplish her duties alone, but nothing had changed and the facility informed her it was because the census was low.A random selection of residents was observed with CNA staff to assess for ADL care. #R2Record Review revealed Resident #R2 was admitted to the facility on [DATE]. Resident #R2 had diagnoses that included in part. Epilepsy, Urinary Incontinence, Falls, and Generalized Weakness.Review of Resident #R2's Quarterly MDS with ARD of 02/05/2026 revealed Resident #R2 had BIMS of 03, indicating severe cognitive impairment. Resident #R2 was dependent on staff for toileting and required substantial/maximal assistance from staff for bed mobility.Review of Resident #R2's Care plan with target completion date of 05/19/2026 read in part.The resident has an ADL self-care performance deficit related to: Other Lack of Coordination secondary to effects of CVA. Interventions included; Resident requires assistance with bed mobility. Observation on 03/12/2026 at 4:34 a.m. with S6CNA of Resident #R2, in his room revealed Resident #R2 had bilateral lower legs and feet dangling off the end of his bed. S6CNA revealed, S7CNA and S8CNA from Y Hall had just changed Resident #R2's adult brief, but left him dangling off bed. S6CNA revealed she was the only CNA on X hall and she could not reposition Resident #R2 by herself as the resident required 2 person assist for bed mobility. #R3Record review revealed Resident #R3 was admitted to the facility on [DATE] and had diagnoses that included in part. Retention of Urine, Urinary Tract Infection, and Generalized Muscle Weakness.Review of Resident #R3's Quarterly MDS with ARD of 01/22/2026 revealed Resident#R3 had BIMS of 04 which indicated severe cognitive impairment. Resident #R3 required substantial/maximal assistance of staff for toileting.Review of Resident #R3's Care plan with target completion date of 06/03/2026 read in part.The resident has an ADL self-care performance deficit related to traumatic hemorrhage of cerebrum. Interventions included in part: Resident requires assistance with personal hygiene, and toilet use. Observation on 03/12/2026 at 4:36 a.m. of Resident #R3 in her room with S6CNA revealed a strong urine odor. S6CNA checked Resident #R3's adult brief and confirmed the resident was wet and needed to be changed. S6CNA revealed she had not had a chance to do rounds on this resident yet. #R4Record review revealed Resident #R4 was admitted to the facility on [DATE] and had diagnoses that included in part. Neuromuscular dysfunction of bladder, Hemiplegia and Hemiparesis following CVA, Generalized muscle weakness, and Pressure Ulcer of Sacral Region-Stage 3.Review of Resident #R4's Quarterly MDS with ARD of 12/19/2025 revealed Resident #R4 BIMS was not assessed due to being never or rarely understood. Resident #R4 was totally dependent of staff for ADL care.Review of Resident #R4's Care plan with target completion date of 06/24/2026 read in part.The resident has an ADL self-care performance deficit related to hemiplegia affecting right side, confusion, impaired mobility, and poor activity tolerance. Interventions: Resident is totally dependent in toilet use. Observation on 03/12/2026 at 4:38 a.m. of Resident #R4 in his room with S6CNA revealed a strong BM odor. S6CNA checked Resident #R4's adult brief and confirmed Resident had a BM and needed to be changed. Resident #R4 observed with foley catheter with 1300cc of urine, S6CNA revealed the catheter bag needed to be emptied, but she had not had a chance yet. Interview on 03/12/2026 at 4:43 a.m. with S9LPN on X hall confirmed residents who require assistance with ADL's should be assisted timely and the above observed residents should be free of soiled adult briefs or ADL needs. #R5Record review revealed Resident #R5 was admitted to the facility on [DATE] and had diagnoses that included in part. Congestive Heart Failure, Urinary Tract Infection, Cerebral Infarction, and Chronic Kidney Disease. Review of Resident #R5's Quarterly MDS with ARD of 03/05/2026 revealed Resident #R5 had BIMS of 05 which indicated severe cognitive impairment. Resident #R5 required substantial/maximal assistance of staff for toileting.Review of Resident #R5's Care plan with target completion date of 05/03/2026 read in part.The resident has an ADL self-care performance deficit related to impaired balance, muscle wasting/atrophy and contracture of left hand. Interventions: Resident requires assistance with toilet use. Observation on 03/12/2026 at 4:51 a.m. of Resident #R5 in his room revealed a BM odor. S7CNA and S8CNA checked the resident's adult brief and confirmed resident had a BM and needed to be changed. #R7Record Review revealed Resident #R7 was admitted to the facility on [DATE] and had diagnoses that included in part. Schizophrenia, Mild Intellectual Disability, Personal History of Urinary Calculi, Full incontinence of Feces, and Unspecified Urinary Incontinence.Review of Resident #R7's Quarterly MDS with ARD of 02/27/2026 revealed Resident #R7's BIMS was not assessed due to being never or rarely understood. Resident #R7 was totally dependent of staff for ADL care.Review of Resident #R7's Care plan with target completion date of 05/28/2026 read in part.The resident has an ADL self-care performance deficit r/t Schizophrenia, Mild Intellectual Disability. Interventions: Resident requires assistance with toilet use. Observation on 03/12/2026 at 4:58 a.m. of Resident #R7 in his room revealed a urine odor. S7CNA and S8CNA checked the resident's adult brief and confirmed the resident's brief was saturated with urine and needed to be changed. Interview on 03/12/2026 at 5:00 a.m. with S7CNA revealed most of the residents on Y Hall get up prior to 7:00 a.m. shift coming on. S7CNA revealed they did not have time to help S6CNA on X hall get any resident up, as they had to get the Y hall residents up. Interview on 03/12/2026 at 5:03 a.m. with S10LPN revealed she and other staff had spoken to the CNA supervisor regarding the staffing concerns they had at night and was informed that they were working on getting more staff. S10LPN revealed although there was enough staff on Y hall, when the 2 Y Hall CNAs leave to round on the X hall, she was alone and could not assist residents that required 2 person assist. S10LPN confirmed residents who require assistance with ADL's should be assisted timely and the above observed residents should be free of soiled adult briefs or ADL needs.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (#R1 and #R6) of 10 Sampled Residents.Findings: #R1 Observation on 03/12/2026 at 4:29 a.m. of Resident # R1, in her room revealed a strong BM odor upon entrance. S6CNA revealed the 2 Y Hall CNAs had just changed Resident #R1. Observation with S6CNA revealed a large amount of smeared BM throughout the resident's bed linen. S6CNA revealed the 2 Y Hall CNAs should have changed Resident #R1's bed linen when they changed the brief during toileting care, but had not. #R6Observation on 03/12/2026 at 4:54 a.m. of Resident #R6, in her room revealed a strong urine and BM odor and uncontained soiled clothing near the door area of the room and pants on the floor with BM present. Resident #R6 revealed staff had not been by to check on her, and she was up and going to get coffee. Interview on 03/12/2026 at 5:03 a.m. with S10LPN confirmed residents who require assistance with ADLs should be assisted timely and Resident #R1 and Resident #R6's rooms should be free of soiled linen and BM on clothing.

Based on interviews and record review, the facility failed to identify a situation as an alleged violation involving abuse, and immediately report the alleged violation involving abuse to the administrator of the facility for 1 (Resident #1) of 10 sampled residents. Findings: Review of the facility's policy on 03/16/2026 at 1:22 p.m. titled Abuse and Neglect- Clinical Protocol dated 10/15/2022 read in part.Altercations between residents should be reviewed as a potential situation of abuse. Both residents having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. It is important to remember that abuse included the term willful which means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as defined in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse- the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical Abuse - this includes but is not limited to hitting, slapping, pinching, and kicking. Interview on 03/12/2026 at 6:43 a.m. with Resident #1 revealed she had an altercation with Resident #2, on Saturday 03/07/2026. Resident #1 revealed she was in her room, in bed and heard a noise. Resident #1 revealed she heard someone in her bathroom, so she got up to check. Resident #1 revealed she saw Resident #2 in her bathroom, and stated He shoved the bathroom door open on me and screamed for me to get out of his room. Resident #1 revealed Resident #2 then shoved her against the wall. Resident #1 stated she fell, and Resident #2 was on top of her and began to pull her hair. Resident #1 stated Resident #2 called her a Stupid b*tch! Resident #1 revealed she yelled for help. Resident #1 stated S4LPN and S11CNA came to help her when she yelled for help, and got Resident #2 away from her. Resident #1 revealed she slapped Resident #2 when he called her a b*tch and she informed S4LPN of what happened regarding Resident #2 shoving her, pulling her hair, and calling her a b*tch. Record review of Resident #1's medical record on 03/12/2026 at 7:38 a.m. revealed no documentation of an incident, or abuse allegation between Resident #1 and Resident #2. Interview on 03/16/2026 at 9:45 a.m. with S1Administrator confirmed the facility had no SIMS reports since last survey on 02/19/2026 and there had been no recent resident to resident abuse allegations reported to her. Interview on 03/12/2026 at 10:35 a.m. with S2DON and S3ADON revealed staff had not made them aware of any abuse allegations regarding Resident #1 and Resident #2. S2DON acknowledged staff were to report abuse allegations. S2DON revealed staff had not reported any abuse allegations to administration regarding Resident #1 and Resident #2. Interview on 03/16/2026 at 10:55 a.m. with S4LPN revealed she did not report, or complete an incident report related to Resident #1's abuse allegation as she did not think, or feel it required reporting. S4LPN confirmed she received abuse and incident reporting training from the facility. S4LPN stated she did not think the incident between Resident #1 and Resident #2 was verbal abuse as she only heard Resident #2 mumble the B word as she was escorting him away from Resident #1, and she did not think Resident #1 heard. S4LPN stated she felt verbal abuse would be if he kept on repeating bad words or repeating/loudly stating things to someone. S4LPN stated because she did not witness or see physical contact between the residents there was no need to report. S4LPN acknowledged Resident #1 reported to her and alleged Resident #2 shoved her, pulled her hair, and called her a b*tch, and the allegation should have been reported, but was not. Telephone interview on 03/17/2026 at 11:12 a.m. with S5RN revealed she was the RN weekend supervisor. S5RN revealed on 03/07/2026, S4LPN informed her that Resident #1 reported to S4LPN that Resident #2 had went into Resident #1's room, and put his hands on Resident #1. S5RN revealed Resident #1 did not state to her specifically what occurred, as the resident had reported this to S4LPN, and S4LPN informed her that she had already taken care of the situation. S5RN revealed S4LPN reported to her that she had separated the residents, and contacted the physician about Resident #2's increase in behaviors. S5RN revealed she did not feel Resident #1's abuse allegation needed to be reported because the resident had no injuries, and she did not witness the incident. S5RN confirmed she received abuse training on hire and annually. S5RN confirmed abuse allegations require reporting.Interview on 03/17/2026 at 2:00 p.m. with S2DON confirmed any allegation of abuse required reporting by staff, so that a proper investigation could be completed. S2DON acknowledged that Resident #1's abuse allegation had not been reported to administrator by staff, and should have been.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1(#73) of 1 resident reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly labeled, and stored. Findings: Review of the Facility's Oxygen Administration policy with a revision dated of 02/2025 read in part . the purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention, associated with respiratory therapy task. Steps in the procedure: 5. Store in a covered device (i.e. plastic bag, kangaroo pouch) between use. Review of Resident #73's 09/2025 Physician Orders read in part.08/26/2025: Oxygen at 2 liters per nasal cannula as needed for shortness of breath and hypoxia. Observation on 09/02/2025 at 12:30 p.m. revealed Resident #73's nasal cannula lying on the floor, without a bag. Observation on 09/03/2025 at 10:26 a.m. revealed Resident #73's nasal cannula lying on the floor, without a bag. Resident #73 stated that he used the oxygen last night on 09/02/2025. An interview on 09/03/2025 at 10:34 a.m. with S11 LPN confirmed that Resident #73's oxygen tubing was lying in the floor without a bag. S11 LPN stated that all oxygen tubing should be dated and kept in a bag when not in use, but had not been.

Based on record review and staff interviews, the facility failed to ensure the plan of care had been revised for 1 (Resident #7) of 39 resident care plans reviewed. Findings: Review of facility's Advance Directives policy on 09/03/2025 at 2:38 p.m. revealed the following in part.The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Resident #7Record review revealed an admission date of 06/21/2021 and re-entered on 12/14/20222 with admitting diagnosis of Traumatic Subdural Hemorrhage without Loss of Consciousness, subsequent encounter. Annual MDS (Minimum Data Set) dated 08/01/2025 revealed a BIMS (brief interview of mental status) score of 99 which indicated Resident #7's cognition was severely impaired. Review of Resident #7 Care Plan with initiate date of 06/20/2023 and next review date of 11/07/2025 revealed a problem of Resident #7 had elected a Full Code status with an intervention to inform all caregivers of full code status.Review of Resident #7 Physician Orders on 09/03/2025 at 1:42 p.m., revealed an order of DNR (Do Not Resuscitate) with selective treatment every shift started on 06/03/2025.During an Interview on 09/03/2025 at 2:46 p.m. with S15LPN (Licensed Practical Nurse) revealed Resident was a DNR status. After reviewing the care plan S15LPN confirmed Resident #7's care plan had not been updated to reflect the DNR status ordered on 06/03/2025.

Based on observation, interview and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life for 2 (Resident #2 and Resident #27) of 39 sampled residents. The facility failed to:1. Ensure Resident #2 received incontinence care before meal service, and2. Ensure Resident #27 received her meal along with the other residents at the lunch table. Findings: Review of a facility policy titled “Assistance with Meals” on 09/04/2025 at 10:48 a.m. revealed in part… facility staff will serve resident trays and will help residents who require assistance with eating for dining room residents and residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Resident #27 Record review revealed an admission date of 03/06/2025 with admitting diagnosis of Unspecified Protein –calorie malnutrition, cognitive communication deficit, other lack of coordination, unspecified dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; altered mental status, unspecified. Review of the resident’s Quarterly MDS (Minimum Data Set) dated 08/07/2025 revealed the resident required substantial/maximal assistance for eating. The resident did not have a BIMS (Brief Interview Mental Status) due to unable to interview due to rarely or never understood. On 09/03/2025 at 11:05 a.m., a dining observation was conducted during lunch on Hall X. Resident #27 was observed sitting at a table throughout the meal service. Residents were observed being served, eating, and then exiting the dining area, while Resident #27 remained un-served. On 09/03/2025 at 11:40 a.m., an interview was conducted with S13CNA. When asked if she was finished serving the Hall X, she stated, “We have to feed Resident #27, so her tray is fixed last.” On 09/03/2025 at 11:48 a.m., an interview was conducted with S12LPN who stated she was unaware Resident #27 had not been served with the other residents at her table. S12 LPN confirmed that all residents seated at the table with Resident #27 had been served and completed their meal and Resident #27 had not been served. Resident #2 Review of Resident #2’s medical record revealed an admission date of 06/02/2023 with diagnoses including, in part…Memory Deficit Following Cerebral Infarction, Parkinson's Disease, Depression, Alzheimer's Disease, Dementia, Muscle Wasting And Atrophy, and Protein-Calorie Malnutrition. Review of Resident #2’s Significant Change MDS with an ARD of 07/14/2025 revealed a BIMS Score of 3, indicating severe cognitive impairment. Resident #2 required substantial/maximal assistance with eating and was always incontinent of bowel and bladder. Observation of Resident #2 on 09/04/2025 at 7:50 a.m. revealed the resident was lying in bed, uncovered, and turned slightly to the left. Resident #2’s brief was bulging posteriorly. There was a strong odor of feces in the room. Observation of Resident #2 on 09/04/2025 at 8:19 a.m. revealed the resident was lying in bed, uncovered, and turned slightly to the left. Resident #2’s brief was bulging posteriorly. There was a strong odor of feces in the room. Interview with S10CNA on 09/04/20225 8:25 a.m. revealed she had just attempted to feed Resident #2 breakfast and stated Resident #2 “did not eat anything”. Observation of Resident #2 on 09/04/2025 at 8:30 a.m. revealed the resident was lying in bed, uncovered, and turned slightly to the left. Resident #2’s brief was bulging posteriorly. There was a strong odor of feces in the room. Observation of resident #2 on 09/04/2025 at 8:35 a.m. accompanied by S9LPN revealed Resident #2’s brief contained feces and there was a strong odor of feces in the room. S9LPN confirmed Resident #2 should have received incontinence care prior to being served/fed his breakfast, but had not been. S9LPN revealed the presence of feces could have contributed to Resident #2 not consuming breakfast, stating “I wouldn’t want to eat if I was sitting in that”. S9LPN confirmed Resident #2’s dignity had not been maintained, but should have been. Interview with S2DON on 09/04/2025 at 2:00 p.m. confirmed Resident #2 should have been provided with incontinence care prior to staff attempting to feed resident breakfast.

Number of residents sampled: Number of residents cited: [NAME], RUBY (7) Ford, [NAME] - Advance Directives No NotesBRITT, RUBY (7) Ford, [NAME] - RESIDENT NOTE [DATE] 1:42 PM Record Review: Res admitted on [DATE] and re-entered on [DATE], DOB [DATE], 93yo, W/F, DNR with selective treatment code status, DX: Traumatic Subdural Hemorrhage without Loss of Consciousness, subsequent encounterDX in part:Transient Cerebral Ischemic Attack, Unspecified, Unspecified Dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Cognitive Communication DeficitMDS:Annual MDS with ARD date of [DATE] revealed in part.Section C: BIMS 99, indicating severe impaired cognitionSection E: No behaviorsSection GG: Eating-setup or clean-up assistance; oral hygiene-dependent; toileting hygiene-dependent; shower/bathe self-dependent; upper body assistance-substantial/maximal assistance; lower body assistance-dependent; putting on/taking off footwear-dependent; personal hygiene-supervision or touching assistance; roll left to right- substantial/maximal assistance; sit to lying-partial/moderate assistance; lying to sitting on side of bed-substantial/maximal assistance; sit to stand-substantial/maximal assistance; chair/bed to chair transfer-substantial/maximal assistance; tubs/shower transfer-substantial/maximal assistance; wheel 50 feet with two turns-partial/moderate assistance; wheel 150 feet-partial/moderate assistanceCare Plan:Date initiated on [DATE] and next review date of [DATE].XXX[DATE]-Care Plan reviewed and revealed in part.Problem: Resident/RP has elected a FULL CODE status Interventions:Inform all Care givers of FULL CODE status Notify MD and family as soon as possible begin CPR and call 911 Review code status with family Q and each CP changeOrders:[DATE]-DNR (DO NOT RESUSCITATE) *WITH SELECTIVE TREATMENT*every shiftMDS nurse, LPN Interview on [DATE] @ 2:46 p.m.[NAME] stated resident has a code status of DNR. She also viewed the Care Plan section in resident electronic chart showed resident had a Full Code status. She acknowledged the code status recently changed to DNR status and the Care Plan was incorrect.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure:1. Nursing carts were free of loose pills for 1 (Cart A) of 3 (Cart A, Cart B, and Cart D) carts reviewed; and2. Medications were labeled with the date they were opened.Observation of Cart A on 09/03/2025 at 12:45 p.m., with oversight from S9LPN, revealed the following, in part. 2 unidentified and loose tablets in the bottom of the 2nd drawer of the cart; 3 unidentified and loose tablets in the bottom of the 3rd drawer of the cart; 1 opened Albuterol 90mcg/inh inhaler without an open date; and 1 opened Trelegy Ellipta 100mcg/62.5mcg/23mcg inhaler without an open date.Interview with S9 LPN during the observation confirmed there were 5 unidentified and loose tablets in Cart A, but there should not have been. S9LPN confirmed the Albuterol and Trelegy Ellipta inhalers had been opened and used, but were not labeled with the date they were opened. Interview with the facility's contract pharmacist on 09/04/2025 at 2:39 p.m. revealed Albuterol inhalers are to be discarded 12 months after opened, and Trelegy Ellipta inhalers are to be discarded 6 weeks after opened. The facility's contract pharmacist confirmed the Albuterol and Trelegy Ellipta inhalers should have been labeled with the date they were opened.

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. The facility failed to:1. Ensure Enhanced Barrier Precautions (EBP) were utilized from 1 (Resident #102) of 3 (Resident #1, Resident #76, and Resident #102) residents reviewed for infection control;2. Ensure proper hand hygiene and gloving was followed during meal service on Hall Z;3. Ensure staff followed proper infection prevention and control practices during wound care for 1 (Resident #2) of 3 (Resident #2, Resident #3, and Resident #103) residents reviewed for pressure ulcers. Findings: Review of a facility policy on 09/03/2025 at 2:15 p.m. titled, “Implementation of Standard and Transmission-Based Precautions” dated 03/2024 revealed the following in part…Infection control measures are implemented in attempts to prevent the spread of communicable diseases. 3. Enhanced-Barrier Precautions (EBP): Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities to transfer MDRO to staff hands and clothing. I. Examples of Enhanced-Barrier Precautions residents: indwelling medical devices-include central lines, urinary catheters, feeding tubes, and tracheostomies/vents. II. Enhanced-Barrier Precautions are indicated during: dressing, bathing/showering, etc. Review of a facility policy on 09/03/2025 at 3:17 p.m. titled, ‘Handwashing/Hand Hygiene” with a revision date of 12/22/2023 revealed the following in part…This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 60%-90% alcohol; or soap (antimicrobial or non-antimicrobial) and water for the following situations: M. After removing gloves. O. Before and after eating or handling food. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 1. Resident #102 Review of Resident #102’s medical record revealed an admission date of 06/05/2009, with diagnoses that included in part… Aphasia Following Cerebral Infarction, Moderate Protein-Calorie Malnutrition, Dementia, Severe, Without Behavioral Disturbance, and Gastrostomy Status. Review of Resident #102’s Quarterly MDS with an ARD of 08/07/2025 revealed a BIMS score of 99, which indicated severe cognitive impairment. Resident #102 was dependent on staff for oral hygiene, toileting hygiene, and shower/bathing. Eating was not attempted for Resident #102 due to medical condition or safety concerns. Resident #102 received 51% or more of proportion of total calories through a tube feeding. Review of Resident #102’s plan of care revealed in part . (Initial Date: 03/29/2024) Focus: At risk for EBP, at increased risk of MDRO acquisition due to peg tube. Interventions: Post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE. Provide patient standard precautions using gowns and gloves during dressing, bathing transferring providing hygiene, changing linens, changing briefs, assisting with toileting, etc. Observation on 09/02/2025 at 9:32 a.m. revealed an EBP sign posted on the wall of the doorway of Resident 102’s room. In an interview on 09/03/2025 at 1:05 p.m., S4 LPN revealed that residents with EBP require the use of gown and gloves with direct care. These residents included those with a peg tube. S4 LPN stated that staff are to observe the resident’s doorway and note the EBP signage/requirements, obtain PPE supplies (gown and gloves) from the clean linen closet, and then provide direct care to that resident after the gown and gloves are applied. In an interview on 09/03/2025 at 1:43 p.m., S6 CNA revealed she provided care to Resident #102 from 7:00 a.m. – 7:00 a.m. today. S6 CNA stated that she provided a bed bath to Resident #102 every day and during the bed bath she provided oral care, brief change, and a linen change. S6 CNA revealed she worn only gloves when she provided all of the above care to Resident #102 this morning. S6 CNA accompanied the surveyor to the doorway of Resident #102’s room and observed the EBP signage posted. S6 CNA stated, “Oh yeah, I should have worn a gown and gloves when I gave her a bath this morning, but I didn’t.” After further interview, S6 CNA revealed she did not wear the correct PPE (gown and gloves) for all of the EBP residents on her assigned hall (Hall Y) because the PPE was not stored outside of their room door and she did not know where to obtain the PPE supplies. There was a total of 14 residents on the S6 CNA’s assigned hall (Hall Y) who required EBP with direct care. In an interview on 09/03/2025 at 1:58 p.m., S3 IP Nurse revealed that all staff had been educated on the policy and procedures for the use of EBP. S3 IP Nurse stated she expected all staff to wear gown and gloves when direct/physical care is provided to these residents such as bathing, incontinent care, etc. S3 IP Nurse revealed the PPE is stored in the clean linen closet or the rounding cart, which all staff have access to and are aware of. S3 IP Nurse confirmed the CNA should have worn both gown and gloves when providing a bath to Resident #102 and all other residents who had EBP requirement signage posted at their doorway, but did not. In an interview and record review on 09/03/2025 at 3:17 p.m., S3 IP Nurse confirmed there were a total of 14 residents on Hall Y which required EBP PPE during direct/physical care. In an interview on 09/04/2025 at 1:20 p.m., S2 DON confirmed that the CNAs are aware of where to find the PPE for all residents who require EBP and the staff should wear both gown and gloves when providing direct/physical care to those residents. 2. Dining observation on 09/02/2025 at 12:03 p.m. in Hall Z revealed the following in part . S7 CNA observed serving and preparing resident meals with gloves on. Observed S7 CNA, with gloved hands, touch the upper shelves and doors x2 (located behind her), then gather multiple clean plates, gather clean utensils, touch the countertops, touch four lids on each item of food, touch multiple meal tickets, touch her apron, touch her mask, and rinse dishes in the sink .S7 CNA grabbed a bread roll directly and placed it on a resident’s plate. During this observation, S7 CNA had the same gloved hands and no hand hygiene or glove change was observed throughout the process. S7 CNA was observed eight times touching the bread rolls directly with the same contaminated gloves and serving the bread rolls to the residents. Continued observation revealed the following part .S7 CNA removed her gloves and disposed of them. No hand hygiene observed after disposal of the gloves. S7 CNA took her unwashed bare hands and got clean utensils for the remaining residents to use for meal time. S7 CNA obtained gloves out of her co-workers pocket, applied these contaminated gloves, and finished serving and plating resident meals. S7 CNA was observed touching the bread rolls directly with her contaminated gloves three more times and served the residents their meals. No hand hygiene observed throughout dining procedures observed. In an interview on 09/02/2025 at 1:15 p.m., S7 CNA confirmed all the above findings. S7 CNA confirmed she did not wash her hands, change her gloves, or wash her hands in between touching different surfaces, before touching the bread rolls directly and served the rolls to the residents. S7 CNA confirmed she should have washed her hands after she disposed of her gloves, but did not. S7 CNA confirmed she should not use gloves that came out of her co-worker’s pocket and use them for meal services, but did. S7 CNA confirmed she served 11 total residents without using proper hand hygiene and gloving practices during meal services, but should have. In an interview on 09/03/2025 at 1:39 p.m., S8 DM revealed the following in part .CNAs are educated on proper serving, plating, gloving, and hand hygiene during meal services prepared on the hallways. S8 DM stated the CNAs are to follow the same practices as the dietary staff. S8 DM stated that during meal service, the server is to stay in a front facing field .if the server has to turn around at any point, they are to remove their gloves, wash their hands, and apply new clean gloves before continuing the serving process. S8 DM stated that the CNA who served the meal should use tongs to serve the bread rolls and not touch the bread rolls directly with contaminated gloves. S8 DM stated that if the server touches their face, mask, apron, the counter tops, or cabinets .the server should stop, dispose of their gloves, provide hand hygiene, and reapply clean gloves (not from a co-worker’s pocket) before beginning meal service again. In an interview on 09/04/2025 at 1:20 p.m., S2 DON confirmed the above dining observations and procedures. S2 DON confirmed the CNA serving the meal should have practiced good hand hygiene and gloving by: properly disposing of her gloves, wash her hands, and reapply clean gloves during meal service and before touching the resident’s bread rolls directly, but did not. S2 DON confirmed the CNA serving the meal should not have used gloves that came out of their co-worker’s pocket due to unsanitary issues, but did not. Resident #2 Review of Resident #2’s medical record revealed an admission date of 06/02/2023 with diagnoses including, in part…Alzheimer’s Disease, Dementia, Chronic Kidney Disease, Muscle Wasting and Atrophy, and Malnutrition. Review of Resident #2’s Significant Change MDS with an ARD of 07/14/2025 revealed a BIMS Score of 3, indicating severe cognitive impairment. Resident #2 had a functional limitation in range of motion and was at risk for development of pressure ulcers. Review of Resident #2’s active Physician’s Orders revealed the following, in part… 08/19/2025 Pressure Ulcer of Sacral Region, Unspecified Stage: cleanse with wound cleanser, apply Santyl ointment, calcium alginate, and cover with composite dressing every day; and 08/20/2025 Left upper arm blisters: cleanse with wound cleanser, pat dry, apply triple antibiotic ointment and composite dressing every day. Observation of wound care for Resident #2 with S5 Tx Nurse on 09/04/2025 at 10:45 a.m. revealed she used her gloved hands to move the bedside table, then picked up calcium aginate and placed it onto Resident #2’s pressure ulcer of the sacral region, without changing her gloves. S5 Tx Nurse changed her gloves, then used her gloved hands to move the bedside table, lift her gown, and reach into the pockets of her clothing. S5 Tx Nurse proceeded with wound care of Resident #2’s left upper arm blisters without performing hand hygiene or changing her gloves. Interview with S5 Tx Nurse on 09/04/2025 at 11:00 a.m. confirmed she used her gloved hands to touch the resident’s bedside table, her gown, and her clothing, then performed Resident #2’s wound care without performing hand hygiene or changing her gloves, but should not have.

Based on observation, interview and record review the facility failed to ensure all care and services were provided according to accepted professional standards of clinical practice. The facility failed to:1. Ensure proper physician orders were obtained for oxygen therapy requirements for 1 (Resident #100) of 2 (Resident #73 and Resident #100) residents reviewed for respiratory care; and 2. Ensure a wound dressing was properly labeled with the date/time of the treatment and initials of who performed the wound care for 1 (Resident #100) of 2 (Resident #63 and Resident #100) residents review for skin conditions. Findings: Review of a facility policy on 09/03/2025 at 3:17 p.m. titled, Oxygen Administration with a revision date of 02/2025 revealed the following in part .The purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention associated with respiratory therapy goals. Preparation; 1. Verify that there is a physician's order for this procedure. Equipment and Supplies: 2. Nasal cannula, nasal catheter, mask (as ordered). Review of an undated facility policy on 09/03/2025 at 3:30 p.m. titled, Wound Care revealed the following in part . The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 12. Dress wound. Pick up sponge and apply directly to the area. [NAME] tape with initials, time, and date and apply to the dressing. Review of Resident #100's medical record revealed an admission date of 07/03/2025, which included diagnoses in part . Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Unspecified Protein-Calorie Malnutrition, Personal History of other Malignant Neoplasm of Skin, Hypoxemia, and Chronic Diastolic (Congestive) Heart Failure. Review of Resident #100's Annual MDS with an ARD of 07/10/2025 revealed a BIMS of 13, which indicated intact cognition. Resident #100 required partial/moderate assistance with eating and oral hygiene and substantial/maximal assistance with toileting hygiene, personal hygiene, and shower/bathing. Resident #100 was at risk for developing pressure ulcers and had skin tears present at the time of this assessment. Review of Resident #100's current physician's orders (as of 09/03/2025) revealed the following active orders .(Start date: 07/15/2025) Respiratory: oxygen at 2 liters per nasal cannula as needed for shortness of breath (SOB)/hypoxia as needed related to Chronic Diastolic Congestive Heart Failure. No other current/active oxygen physician orders viewed at this time. (Start date: 09/05/2025) Laceration to posterior left lower extremity/calf, steri-strips in place: cleanse wound cleanser, pat dry, apply triple antibiotic ointment, cover with non-adherent dressing and wrap with kerlix every day shift every 3 day(s). Review of Resident #100's plan of care revealed the following in part . (Initial date: 07/03/2025) Focus: The resident has a cerebral vascular accident affecting the left side. Interventions: Oxygen as ordered. (Initial date: 07/03/2025) Focus: The resident has shortness of breath related to hypoxia and Congestive Heart Failure. Interventions: 07/15/2025- Resident noted with shortness of breath and decreased oxygen saturation. New order received for oxygen at 2 liters per nasal cannula PRN (as needed) for shortness of breath/hypoxia. (Initial date: 07/03/2025) Focus: The resident is at risk for impaired skin integrity related to fragile skin. Interventions: 09/02/2025- skin tear to left lateral lower leg- treatment as ordered. Review of Resident #100's medical record revealed nursing progress notes in part .08/22/2025: A nurse wrote: Resident continues on oxygen continuously. The resident received oxygen therapies on the following dates: 08/20/2025, 08/21/2025, 08/22/2025, 8/23/2025, 8/24/2025, 08/25/2025, 08/26/2025, 08/27/2025, 08/28/2025, 08/29/2025, 08/31/2025, 09/01/2025, and 09/02/2025. In an interview on 09/02/2025 at 10:00 a.m., Resident #100 revealed he used oxygen continuously. Observed oxygen in progress and oxygen concentrator set at 3 liters via nasal cannula. Resident #100's daughter was at the bedside and showed the surveyor Resident #100's wound dressing to the left lower leg. Observed the left lower leg (shin area) wound dressing wrapped loosely with gauze, undated, unlabeled, and soaked with red blood. Observed wet red blood on the bed linens where Resident #100's left leg was placed in the bed. In an interview on 09/03/2025 at 12:30 p.m., Resident #100 revealed the staff did not change his wound dressing to his left lower leg today (09/03/2025). Observed the left lower leg and viewed an undated/unlabeled, loose fitting gauze dressing with a moderate amount of dried bright red blood. Observed resident with oxygen in progress and the oxygen concentrator set at 3 liters running continuously. Resident #100 stated he wore oxygen throughout the evening and all day long. Resident #100 stated he was blind and bedbound and unable to adjust the oxygen settings himself. In an interview on 09/03/2025 at 12:45 p.m., S4 LPN accompanied the surveyor to Resident #100's room. S4 LPN confirmed Resident #100's left lower wound dressing was loose and saturated with dried red blood. S4 LPN assessed the dressing further and confirmed it was unlabeled/undated and had no initials of the nurse who performed the treatment. S4 LPN stated all wound dressings should be labeled and dated at the time of treatment and initialed by the nurse who performed the treatment, but Resident #100's wound dressing was not. S4 LPN confirmed Resident #100's oxygen concentrator was set at 3 liters via nasal cannula and had oxygen applied to him all day today (09/03/2025). In a interview and record review on 09/03/2025 at 12:57 p.m., S4 LPN confirmed Resident #100 had oxygen orders for 2 liters oxygen for shortness of breath PRN (as needed). S4 LPN confirmed there were no other oxygen orders at this time and Resident #100 should not have had the oxygen set to continuously run at 3 liters, per current physician orders. S4 LPN stated she needed to re-assess the resident's oxygen needs and obtain new orders in this situation. S4 LPN confirmed the laceration to the left lower limb was ordered to be treated every 3 days; however, she could not determine when the dressing was completed due to it being saturated, and unlabeled/undated. S4 LPN confirmed Resident #100's left lower leg wound treatment should be performed again and properly labeled and dated, but was not. In an interview on 09/03/2025 at 1:13 p.m., S5 TX Nurse revealed that she and the floor nurses are both responsible for the treatment of resident wounds. S5 TX Nurse stated that all wound dressings should be dated at the time of treatment and initialed with the name of the nurse who completed the treatment. S5 TX Nurse stated if a wound dressing became dislodged or soil, or was undated/unlabeled, she expected the floor nurses to perform this treatment again or notify her to treat the resident wound. In an interview on 09/04/2025 at 1:20 p.m., S2 DON revealed all nurses are aware to properly label and date treatment dressings. S2 DON confirmed she expected all resident treatment dressings to be labeled and dated at the time of the treatment. S2 DON revealed oxygen orders are obtained by the physician prior to placement on the resident and should be followed as stated in the medical record. S2 DON confirmed that if an oxygen order needed to be revised to meet the needs of a residents, she expected the nurse to obtain the correct oxygen orders prior to application of oxygen.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #9) of 39 sampled residents. Review of Resident #9's medical record revealed an admission date of 11/16/2023 with diagnoses including Dysphagia, Cerebral Infarction, and Unspecified Convulsions.Review of Resident #9's Significant Change MDS with an ARD of 08/13/2025 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #9 experienced coughing or choking during meals or when taking medications. Review of Resident #9's Physician's Orders revealed the following, in part. 08/08/2025 May perform oral suctioning.Review of Resident #9's Care Plan revealed Resident #9 was not care planned for suctioning.Interview with S2DON on 09/04/2025 at 2:00 p.m. confirmed Resident #9 should have been care planned for suctioning, but was not.

Based on observation and interview the facility failed to maintain a medication error rate below 5%. A total of 29 medication administration opportunities were observed. This practice had the potential to affect all 145 residents that receive medications in the facility. Observation of medication administration with S9LPN on 09/03/2025 at 7:50 a.m. revealed the following: Pantoprazole DR 40mg tablet was crushed and provided po; Tolterodine ER 4mg capsule was opened and the contents were provided po; and Potassium Chloride ER 10meQ tablet was crushed and provided po.Interview with S9 LPN on 09/03/2025 at 12:40 p.m. confirmed she had crushed a Pantoprazole DR 40mg tablet and a Potassium Chloride ER 10meQ tablet and provided the crushed tablets to a resident. S9 LPN confirmed she had opened a Tolterodine ER 4mg capsule and provided the contents to a resident.Interview with the facility's contract pharmacist on 09/04/2025 at 2:39 p.m. revealed ER and DR medications should not have been crushed or opened and he had not provided any documentation stating that crushing the medication would not adversely affect a resident. The contract pharmacist confirmed the Pantoprazole DR 40mg tablet, Tolterodine ER 4mg capsule, and Potassium Chloride 10meQ tablet should not have been crushed or opened and provided to a resident.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to store all drugs and biologicals in locked compartment, and failed to permit only authorized personnel to have access to the keys. The facility failed to ensure an unattended medication cart (Cart A) was locked appropriately and failed to ensure medication keys were inaccessible to unauthorized personnel. This deficient practice has the potential to effect 137 residents currently residing in the facility. Findings: Review of the facility's policy titled Storage of Medications with a revised date of April 2019 revealed the following in part . Policy Statement: The facility stores all drugs and biologicals in a safe and secure manner . 1. Drugs and biologicals used in the facility are stored in locked compartments . 9. Unlocked medication carts are not left unattended . Review of the facility's policy titled Administering Medications with a revised date of April 2019 revealed the following in part . 15. The medication cart is kept closed and locked when out of sight of the medication nurse . On 01/27/2025 at 2:45 p.m., an observation was made of Cart A on the entrance of a high-traffic area on X Hall. Observation revealed residents commuted throughout X Hall in front of Cart A. Observation revealed Cart A was unlocked and unattended with the medication keys rested on top of Cart A. On 01/27/2025 at 2:50 p.m., an observation and interview made with S3 LPN revealed Cart A was located on entrance of X Hall. S3 LPN confirmed that Cart A was unlocked, unattended, and the medication keys were placed on top of the medication cart. S3 LPN stated that she was not sure who the cart belonged to but they should not have left their medication cart unlocked and unattended. S3 LPN revealed that the nurse should have kept her medication keys with her. On 01/27/2025 at 2:58 p.m., an interview made with S2 RN revealed that she was responsible for Cart A. S2 RN stated she went into a nursing room on X Hall and left Cart A outside the closed door unattended. S2 RN confirmed that she left Cart A unattended, out of site, and unlocked with her medication keys on top of the cart and should not have. On 01/29/2025 at 10:37 a.m., an interview made with S1 DON confirmed that a medication cart should always be locked while unattended. S1 DON confirmed that medication keys should not be left unattended on top of a medication cart accessible to others.

Based on observation, record review, and interview, 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 of communicable diseases and infections for 1 of 1 resident reviewed for pressure ulcers (#292), and 1 (#292) of 43 residents reviewed for Enhanced Barrier Precautions. The facility failed to: 1. Perform proper hand hygiene during wound care for Resident #292; and 2. Ensure signage was used to communicate to staff those residents who required the use of Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) before high contact care activities were provided for Resident #292. Findings: 1. Review of the facility's policy on 06/25/2024 titled Wound Care, with a revision date 11/2017, read in part . 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. 6. Put on Gloves . Review of Resident #292's medical record revealed Resident #292 was admitted to the facility on [DATE], and had diagnoses that included in part .Lack of Coordination, Age Related Debility, and Generalized Muscle Weakness. Review of Resident #292's Admission MDS with an ARD of 05/24/2024, revealed Resident #292 had a BIMS of 13 (Cognition intact). Review of Resident #292's Comprehensive Person Centered Care Plan revealed the following in part . Pressure ulcers to right heel and right lateral malleolus. Interventions included in part . EBP care should be maintained for resident's entire stay, or until wounds have healed. Post clear signage on the door or wall outside of room indicating the type of precautions and required PPE. Review of Resident #292's 06/2024 physician orders revealed the following: Right heel pressure wound: cleanse with wound cleanser, apply Santyl ointment then calcium alginate to wound bed, apply Xeroform gauze to peri wound skin, then wrap with kerlix and secure with paper tape daily. Observation on 06/25/2024 at 9:41 a.m. revealed S1 Treatment Nurse performed wound care to Resident #292's right heel. S1 Treatment Nurse put on gloves and removed Resident #292's old dressing to her right heel. S1 Treatment Nurse held Resident # 292's right foot off the bed with her left hand and discarded the soiled dressing with her right hand. S1 Treatment Nurse continued to hold Resident #292's right foot with her left hand, then reached into the clean field with her right hand to grab supplies, and proceeded to clean Resident #292's wound. S1 Treatment Nurse did not remove gloves or sanitize her hands after removing the soiled dressing, before cleaning the wound. Interview on 06/25/2024 at 9:53 a.m. with S1 Treatment Nurse, revealed she should remove gloves and sanitize hands after removing the old dressing, and before cleaning the wound. Interview on 06/25/2024 at 10:30 a.m. with S2 DON, confirmed gloves should be changed and hands sanitized after removing a dressing, and before cleaning the wound. 2. Review of the facility's policy on 06/25/2024 titled Implementation of Standard and Transmission-Based Precautions, dated 03/2024 read in part . 3. Enhanced Barrier Precautions (EBP) . I. Examples of Enhanced-Barrier Precaution Residents: Wounds-Include chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous stasis ulcers; . Signage will be used to communicate to staff which residents require the use of EBP and PPE before high contact care activities are provided. Observation on 06/24/2024 at 10:52 a.m. revealed Resident #292 with a dressing on her right foot. Interview with Resident #292 at that time revealed she had a wound on her right foot for a while (unable to determine how long). Observation revealed no Enhanced Barrier Precaution signage in or outside of Resident # 292's room. Observation on 06/25/2024 at 9:35 a.m. revealed no EBP signage in or outside of Resident # 292's room. Interview on 06/25/2024 at 10:14 a.m. with S3 Infection Preventionist, revealed she was responsible to ensure staff was aware of residents who require EBP. S3 Infection Preventionist stated that residents with Peg tubes, Foley Catheters, and wounds should be on Enhanced Barrier Precautions. S3 Infection Preventionist stated she puts EBP signage next to the resident's door to indicate to staff that Enhanced Barrier Precautions was required, so that direct care staff would be aware and take the necessary precautions before high contact care activities are provided to residents. Observation of Resident #292's room on 06/25/2024 at 10:20 a.m., with S3 Infection Preventionist, revealed no EBP signage. S3 Infection Preventionist confirmed there was no signage to alert direct care staff that Resident #292 was on Enhanced Barrier Precautions. S3 Infection Preventionist confirmed Resident #292 should have signage alerting staff to use Enhanced Barrier Precautions.

Based on observation, interview, and record review the facility failed to maintain a medication error rate below 5% by failing to give two medications as ordered, and administering a discontinued medication for 1 (#37) of 3 (#37, #96, and #101) residents observed during medication administration. A total of 30 opportunities were observed which included 3 medication errors for a medication error rate of 10%. Findings: Review of the facility's policy on 06/25/2024 titled, Administering Medications with revision date April 2019 revealed the following, in part: . 3. Medications are administered in accordance with prescriber orders, including any required time frame. 9. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication Observation on 06/24/2024 at 8:31 a.m. revealed S4 LPN prepared and administered the following medications for Resident #37: Aspirin 81mg 1 tablet by mouth Zyrtec 10mg 1 tablet by mouth Docusate Sodium 100mg 1 tablet by mouth Ferrous Sulfate 325mg 1 tablet by mouth Potassium 10meq 1 tablet by mouth Lasix 10mg 1/2 tablet by mouth Lasix 20mg 1 tablet by mouth Coreg 3.125mg 1 tablet by mouth Oxycodone 10mg 1 tablet by mouth 8.5 tablets were administered to Resident #37 by S4 LPN. Record review of the current physician orders for Resident #37 revealed the following medication orders: Lasix (Diuretic) Oral Tablet 20 mg. Give 1 tablet by mouth one time a day. Order date 06/09/2024 Lasix Oral Tablet 10 mg. Give 1/2 tablet by mouth one time a day. Discontinue date 06/08/2024 Ticagrelor (Antiplatelet) Oral Tablet 90 mg. Give 1 tablet by mouth two times a day. Order date 05/29/2024. Lansoprazole (Antacid) Oral Capsule Delayed Release 30 mg. Give 1 capsule by mouth one time a day. Order date 05/29/2024. Record review of Resident #37's 06/2024 EMAR revealed the following medications were documented as administered on 06/24/2024 during surveyor observation: Ticagrelor 90 mg Lansoprazole 30 mg Lasix 10mg was not documented as administered on the EMAR. Observation on 06/24/2024 at 8:31 a.m. of medicine administered to Resident #37 by S4 LPN revealed Ticagrelor and Lansoprazole were not administered as ordered, and Lasix 30 mg (1.5 tablets) was administered. Interview on 06/24/2024 at 9:30 a.m. with S4 LPN confirmed that she did not administer to Resident #37, Ticagrelor 90 mg and Lansoprazole 30 mg as ordered, but should have. S4 LPN confirmed she administered Lasix 20 mg, and Lasix 10 mg to Resident #37. S4 LPN stated she was unaware Lasix 10 mg was discontinued on 06/08/2024, and confirmed Lasix 10 mg should not have been administered to Resident #37.

Based on observation and interview the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to ensure expired food was not available for resident consumption and failed to appropriately date and label food that was opened and available for use. This failed practice had the potential to affect all residents who receive meals prepared by the facility's kitchen. Findings: Review of the facility policy titled, Food Storage, revealed in part .To ensure that all food served by the facility is off good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Observation of the facility cooler on [DATE] at 11:10 a.m. accompanied by S8 Cook Help, revealed the following items on shelves for use: 1 (24ct) box of cucumbers which were noted to be soft to touch, with areas of mold and mildew, 1 opened (24ct) box of 118ml Thick and Clear ice teas with an expiration date of [DATE], 1 crate containing (25) 118ml apple juices with mildew noted outside of all cartons in the crate, and 1 clear container of broccoli soup covered with plastic wrap and dated [DATE]. Findings confirmed with S8 Cook Help at the time of observations. Observation of the facility dry storage area on [DATE] at 11:20 a.m. accompanied by S8 Cook Help, revealed the following items on the shelf for use: (3) dented 7lb cans of baked beans and 1 opened, undated packet of commercial size tea bags. Findings confirmed with S8 Cook Help at the time of observations. Observation of the facility freezer on [DATE] at 11:25 a.m. accompanied by S8 Cook Help, revealed an opened, undated pack of pressed flour tortillas with a large block of ice attached, on the shelf for use. Findings confirmed with S8 Cook Help at the time of observation.

Based on record review, observation, and interview, the facility failed to ensure food served to residents was palatable and at an appetizing temperature for 1 (Resident #6) of 5 (Resident #1, Resident #2, Resident #3, Resident #5, and Resident #6) residents reviewed for dietary services. Findings: Review of the facility's policy titled Food Holding and Service revealed in part . Policy: To ensure that all food served by the facility is of good quality and safe for consumption. Procedure: Serve all hot foods at a temperature of 135 degrees Fahrenheit or greater. If hot foods drop below 135 degrees Fahrenheit, reheat to 165 degrees. Review of Resident #6's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE], admitting diagnoses included COPD (Chronic Obstructive Pulmonary Disease), Quadriplegia, Essential (primary) Hypertension, and Major Depressive Disorder. Review of Resident #6's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/20/2023 revealed a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact). Observation of Resident #6 on 10/24/2023 at 11:35 a.m. revealed Resident #6 at Hall A's serving station with a plate of food in front of him. Observation of the untouched plate revealed a chicken drumstick separated from the bone, macaroni & cheese stirred around, mixed vegetables and apple crisp. Interview on 10/24/2023 at 11:40 a.m. with Resident #6 stated he couldn't eat the food because it was too cold. Resident #6 stated most of the hot foods were often served cold. Review of the daily temperature log binder for Hall A revealed temperature monitoring for 10/23/2023 and 10/24/2023 revealed in part . 10/23/2023- breakfast eggs (scramble & boiled) -130 degrees, lunch entree (sausage) -125 degrees starch (rice) -125 degrees, vegetable (field peas & snaps)-100 degrees and dinner starch- potato soup- 125 degrees and vegetable sticks- 100 degrees. 10/24/2023- breakfast entree meat (sausage)-100 degrees, starch (eggs)-125 degrees, lunch entree (chicken) -125 degrees, starch (macaroni & cheese)-120 degrees, and vegetable(mix) -120 degrees. Review of additional food temperature monitoring for Hall A provided on 10/24//2023 at 3:15 p.m. by S3 Dietary Manager revealed in part . 10/12/2023- lunch starch (rice) - 30 degrees. 10/14/2023- dinner entree (meatballs)-30 degrees, starch (rice)-70 degrees and vegetable (mix)-35 degrees. 10/16/2023- dinner entree vegetable (hash brown)-37 degrees. 10/20/2023- dinner entree vegetable (broccoli) -37 degrees. Interview on 10/24/2023 at 12:05 p.m. with S11 CNA revealed she had checked the breakfast and lunch food temperatures on 10/24/2023. S11 CNA stated all hot foods were to be served at 120 degrees or above. Interview on 10/24/2023 at 2:25 p.m. with S9 RN after reviewing the food temperature log, confirmed on 10/23/2023 and 10/24/2023, hot foods served on Hall A serving station were below 135 degrees Fahrenheit. S9 RN confirmed the food items should have been returned to the kitchen to be reheated and they were not. Interview on 10/25/2023 at 1:30 p.m. with S1 Administrator stated the Infection Preventionist Nurse and the CNA Supervisor were responsible for monitoring the food temperature logs on the hall's serving station. S1 Administrator stated an in-service training was conducted on 07/05/2023 and only the CNAs who worked on that day attended the in-service. S1 Administrator confirmed all CNAs should have been in-serviced on food temperature monitoring and they were not. S1 Administrator confirmed the temperatures recorded by the CNAs on the dates of 10/12/2023, 10/14/203, 10/16/2023, 10/20/2023, 10/23/2023, and 10/24/2023 were below 135 degrees. S1 Administrator confirmed the food should have been returned to the kitchen to be re-heated and not served to the residents.

Based on interview and review, the Facility failed to ensure that a response and rationale for grievances reported during the Resident Council Meetings were addressed for 1 (06/28/2023) of 4 (06/28/2023, 07/26/2023, 08/31/2023, and 09/27/2023) Resident Council Meeting minutes reviewed. Findings: Review of the Facility's Policy and Procedure titled Resident Council read in parts . 5. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 6. The Quality of Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. Review of the Facility's Resident Council meeting minutes dated 06/28/2023 revealed residents voiced concerns of cold food being served from the hall's serving station. Interview on 10/24/2023 at 3:05 p.m. with R#1 revealed at a previous Resident Council meeting, Resident's voiced concerns to S10 Activity Director about the cold temperature of food served on the hall's serving stations. R#1 stated S3 Dietary Manager nor Administration addressed the cold food concerns voiced by the Resident Council. Interview on 10/25/2023 at 11:00 a.m. with S10 Activity Director revealed during the 06/28/2023 Resident Council meeting, resident's complained of food being served cold on Hall B, Hall C and Hall D. S10 Activity Director stated the meeting minutes were emailed to S1 Administrator for follow up to the concerns. Interview on 10/25/2023 at 11:50 a.m. with S3 Dietary Manager revealed she had not addressed the cold food concerns received from the Resident Council. Interview on 10/25/2023 at 1:30 p.m. with S1 Administrator revealed she was aware of the Resident Council's complaint of cold food being served from the hall's serving stations. S1 Administrator confirmed there was no response or rationale concerning the complaint of cold food, but there should have been.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (Resident #108 and Resident #136) of 4 (Resident #72, Resident #108, Resident #121, and Resident #136) residents investigated for respiratory care out of a total sample of 47 residents. Findings: Review of the facility's policy titled Oxygen Administration revealed in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. 5. Date and initial humidified water bottle and oxygen tubing. 12. Change oxygen tubing and humidified water bottle weekly and prn. Review of the facility's policy titled Administering Medications through a Small Volume (Handheld) Nebulizer revealed in part The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. 26. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 27. Change equipment and tubing every seven days. Resident #108 Review of Resident #108's Medical Record revealed an admitted [DATE] with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Sleep Apnea, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of Resident #108's Admission MDS with an ARD of 03/22/2023 revealed a BIMS score of 14, indicating intact cognition. Resident #108 was total dependence with 2+ persons physical assistance with transfer and bathing. Resident #108 required extensive 2+ persons physical assistance with bed mobility. Review of Resident #108's Care Plan with a Target Date of 07/05/2023 revealed a problem of potential for alteration in cardiac output related to obesity, Diabetes Mellitus, and sleep apnea with interventions that included: observe for signs and symptoms of altered cardiac output (chest pain, shortness of breath, dyspnea) and administer oxygen PRN as ordered. Resident #108 had a problem of shortness of breath upon exertion/activity and lying flat with interventions that included: administer oxygen therapy as ordered, obtain and record oxygen saturation levels as ordered, and assess respiratory status. Resident #108 requires oxygen therapy and C-PAP while sleeping per MD order with interventions that included: administer oxygen as ordered, change tubing per protocol, provide humidification, observe for changes in symptoms that may indicate worsening respiratory status and report to physician. Review of Resident #108's Physician orders for 06/2023 revealed no order for oxygen therapy. Observation on 06/11/2023 at 10:02 a.m. revealed Resident #108 lying in bed with 3 liters per minute of oxygen via nasal cannula in progress by oxygen concentrator. The humidified water bottle was not attached to the concentrator and held onto the oxygen concentrator by being pushed into the back of her nightstand. There was no date on the humidified water bottle or the nasal cannula. Observation on 06/12/2023 at 8:49 a.m. revealed Resident #108 sitting on the side of her bed with 3.5 liters per minute of oxygen via nasal cannula in progress by oxygen concentrator. The humidified water bottle was not attached to the oxygen concentrator and held onto the concentrator by being pushed into the back of her nightstand. There was no date on the humidified water bottle or the nasal cannula in use. A nasal cannula dated 05/11/2023 was draped over the back of Resident #108's wheelchair open to air and uncovered. Interview at that time with Resident #108 revealed she got in her wheelchair every day and she used that nasal cannula. Resident #108 reported her oxygen was ordered for 2 liters per minute. Interview on 06/12/2023 at 9:13 a.m. with S2 LPN confirmed the humidified water bottle was being held to the concentrator by being pushed against the resident's nightstand, but should have been attached to the concentrator. S2 LPN confirmed there was no date on the nasal cannula or the humidified water, but there should have been. S2 LPN reported the nasal cannula and the humidified water were supposed to be changed every Thursday. S2 LPN reported the resident had an order for 2 liters per minute of oxygen via nasal cannula. S2 LPN confirmed the oxygen was set at 3.5 liters, but should not have been. S2 LPN reported nasal cannulas over the wheelchairs were never covered and were to be wrapped around one handle when not in use. S2 LPN confirmed the nasal cannula that was draped over the wheelchair was dated 05/11/2023, and should have been changed every Thursday but was not. Interview on 06/13/2023 at 2:13 p.m. with S1 DON revealed Resident #108's physician had provided a standing order for oxygen at 2 liters per minute as needed. S1 DON stated staff did not contact Resident #108's physician for oxygen orders and therefore oxygen was not included on the MAR to sign off. S1 DON confirmed staff should have contacted Resident #108's physician, obtained orders for oxygen, and signed off oxygen as administered on the MAR. Interview on 06/13/2023 at 2:48 p.m. with S1 DON confirmed nasal cannulas should be bagged when not in use. S1 DON confirmed nasal cannulas and humidified water bottles were to be changed and dated every week on Thursday night. Resident #136 Review of Resident #136's Medical Record revealed an admitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, other Nonspecific Abnormal Finding of Lung Field, and Dysphagia. Review of Resident #136's Admission MDS with an ARD of 05/01/2023 revealed a BIMS score of 99, indicating Resident #136 was unable to complete interview. Resident #136 had problems with short-term and long-term memory, and had moderately impaired cognitive skills for daily decision making. Resident #136 required extensive 2+ persons physical assistance with bed mobility, transfer, and toilet use. Review of Resident #136's Care Plan with a Target Date of 08/01/2023 revealed a problem of potential for alteration in cardiac output with interventions that included: administer medications as ordered, and observe for signs and symptoms of altered cardiac output (chest pain, shortness of breath, etc.) Review of Resident #136's 06/2023 Physician orders revealed the following order: Nebulizer: tubing and mask change night shift every Thursday Observation on 06/11/2023 at 11:58 a.m. revealed a nebulizer machine with a mask on Resident #136's nightstand. The mask was open to air, uncovered, and dated 06/01/2023. Observation on 06/12/2023 at 8:37 a.m. revealed a nebulizer machine with a mask on Resident #136's nightstand. The mask was open to air, uncovered, and dated 06/01/2023. Interview on 06/12/2023 at 9:08 a.m. with S2 LPN confirmed the nebulizer mask was open to air and uncovered, but should not have been. S2 LPN stated they were to be placed in zip lock bags when not in use. S2 LPN confirmed the mask was dated 06/01/2023, but it should have been changed on 06/08/2023. S2 LPN stated they were to be changed every Thursday.

Based on observation, interview and record review the facility failed to ensure services were provided to meet professional standards of quality by failing to obtain a physician's order to administer a nebulizer treatment for 1 (#121) of 4 (#108, #136, #76 and #121) residents reviewed for respiratory care out of a total sample of 47. Findings: Review of the policy titled Medication and Treatment Orders revealed in part . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Observation on 06/13/2023 at 11:41 a.m. revealed Resident #121 seated in a wheelchair in her room. A nebulizer treatment was in progress at that time. Review of the Medical Record revealed Resident #121 was admitted to the facility on [DATE]. Resident #121 had diagnoses that included COPD, Congestive Heart Failure, Cardiomyopathy and Essential Hypertension. Review of Resident #121's Physicians Orders revealed no order for nebulizer treatments. Review of Resident #121's Quarterly MDS with an ARD of 02/22/2023 revealed a BIMS of 15 indicating Resident #121 was cognitively intact and required oxygen therapy. Interview on 06/13/2023 at 2:17 p.m. with S2 DON revealed Resident #121 did not currently have an order for nebulizer treatments. S2 DON stated the order for nebulizer treatments was discontinued in April 2023. S2 DON stated the nurses gave Resident #121 the medication to put in the nebulizer and shouldn't have without an order for nebulizer treatments in place. Observation on 06/13/2023 at 2:30 p.m. of the medication cart for the 100 hallway revealed a box with 15 ampules of Duo-neb nebulizer treatments labeled for Resident #121. Interview at that time with S3 LPN revealed she was the nurse for Resident #121. S3 LPN stated Resident #121's nebulizer treatments were ordered as needed. S3 LPN stated Resident #121 does not request the nebulizer treatments often. S3 LPN stated she thought the order for the nebulizer treatment was still in effect.

Based on record review, interview and observation, the facility failed to ensure that the nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of three residents (#1, #47 and #104) as determined by resident assessments and individual plans of care and in consideration of the number, acuity and [DIAGNOSES REDACTED]. This deficient practice resulted in an actual harm for resident #1, who did not have any urinary output from 7/7/209 at 7:00 a.m. through 7/8/2019 at 7:00 a.m. Both of the nurses who cared for the resident, S2 LPN and S3 LPN, were aware that the resident did not have any urine output during that period of time, however there was no evidence of any assessments and/or that resident's physician was notified. On 7/9/2019 at 11:46 a.m., the resident was observed to be pale, weak and unresponsive. The resident's physician was notified and the resident was transferred to a local hospital where she was admitted for Acute Kidney Injury, Altered Mental Status, UTI and Recent [MEDICAL CONDITION] status [REDACTED]. Findings: Review of the policy titled: Change in a Resident's Condition or Status in part revealed: 1. The nurse will notify the resident's Attending physician or physician on call when there has been a (an) d. significant change in the residents physical/emotional/mental condition Review of the resident's face sheet revealed an admitted [DATE] with the following Diagnoses: [REDACTED].'s, Vitamin Deficiency [MEDICAL CONDITION], Muscle Weakness, Unspecified Lack of Coordination, Vitamin B Deficiency, Anxiety Disorder, and [MEDICAL CONDITION] with Behavioral Disturbance. Review of the Quarterly MDS Assessment with an ARD of 6/22/19 revealed that the resident had a BIMS of 12 indicating mild cognitive impairment, required two person assist for transfers and toileting, and was incontinent of bowels and bladder. Review of the resident's care plan dated 6/21/19 revealed the following problems: I am at risk for infection r/t history of UTI, URI, Disease of Respiratory System, [MEDICAL CONDITION], Skin Infection, Urethral Disorder, Allergies and Fever/Cough. 1/31/19 - I am receiving antibiotics for a UTI per MD orders. 2/26/19 - Antibiotics for UTI Target date 9/28/19 Approaches: My physician will be notified and informed of any complications/decline. Review of an Intake and Output record dated 7/7/19 revealed an entry at 6:03 p.m. by S7 CNA that stated, Did not void this shift - nurse notified. Further review of the resident's Intake and Output records revealed that the resident had an oral intake of 1000cc on 7/6/19, 1960cc on 7/7/19, and 1020cc on 7/8/19. Review of the nurse's notes from 7:00 a.m. on 7/7/19 through 7:00 a.m. on 7/8/19 revealed that there was no documentation that an assessment had been performed on the resident, or that the physician had been notified of the resident's lack of urine output. Interview on 7/11/19 at 10:40 a.m. with S7 CNA revealed that she was the CNA on duty on 7/7/19 from 7:00 a.m. to 7:00 p.m. S7 CNA revealed that the resident did not void at all on the 7:00 a.m.-7:00 p.m. shift on 7/7/19, and that she had reported it to S2 LPN. Further interview with S7 CNA revealed that rounds are made every 2 hours to assist residents with ADLs and to provide incontinent care. Telephone interview on 7/11/19 at 10:46 a.m. with S2 LPN confirmed that he was the nurse assigned to the resident on 7/7/19 from 7:00 a.m. to 7:00 p.m. S2 LPN revealed that the resident did not void on his shift, he did not notify the doctor, and stated that he probably should have. S2 LPN further stated that he told the staff to encourage fluids and passed it on to the night nurse, S3 LPN, and told her to keep an eye on the resident. Telephone interview on 7/11/19 at 11:21 a.m. with S3 LPN confirmed that she was assigned to the resident on 7/7/19 from 7:00 p.m. to 7:00 a.m., and was told in report that the resident had not voided on the previous shift. Further interview with S3 LPN revealed that the 7:00 p.m. to 7:00 a.m. CNA reported to her at 6:30 a.m. on the morning of 7/8/19 that the resident had not voided during the shift. S3 LPN confirmed that this was not normal for the resident because she liked to drink and stated that she had not notified the MD. Review of a nurse's note dated 7/8/19 at 9:25 a.m. documented by S8 LPN revealed that the resident was found unresponsive and was receiving a sternal rub at that time by S9 LPN. Further review of the nurse's note revealed that at that time the MD was notified by S8 LPN. Further review of the nurse's note revealed that orders were received for a Foley catheter for 24 hours, to monitor urine output, and to obtain a urinalysis and culture. It was noted that 800 ml dark, foul smelling urine had drained from the resident's bladder after the Foley catheter was inserted. Review of a nurse's note dated 7/8/19 at 3:59 p.m. revealed that the resident's urinalysis results had been received and noted as 4+ bacteria and 30-49 rbc's. Further review of the note revealed that the MD was notified of the results, and no new orders were given at that time. Review of a nurse's note dated 7/8/19 at 5:50 p.m. documented by S8 LPN revealed that the resident was on the meal report due to poor intake, and that the resident complained of not feeling good. Further review revealed that the MD was aware. Observation of the resident on 07/09/19 at 11:46 a.m. by the surveyor and S8 LPN revealed that the resident was pale. Further observation revealed that the resident was not responding to verbal or tactile stimulation when S8 LPN attempted to arouse her. Interview on 7/9/19 at 12:00 p.m. with S8 LPN revealed that she notified the doctor of the resident's decreased responsiveness and was sending the resident to the emergency room for evaluation. Further interview with S8 LPN revealed that the resident was normally awake and alert, and only required assistance for transfers and toileting because she had a history of [REDACTED]. Review of SBAR dated 7/9/19 at 12:55 p.m. revealed in part the following documentation: 1. Situation: Symptom, sign, change prompting call: Lethargy Status is worse, better, same since it started: Gotten worse Other things that have occurred: [MEDICAL CONDITION] 2. Background: Pertinent history:[MEDICAL CONDITION] right side Vital signs: BP - 135/85, P - 69, T - 97.5, R - 18, BS - 96 Change in function or mobility: Decreased Mental Status Changes: Lethargy GI/GU Changes - [MEDICAL CONDITION] Pain level/location: Denies Pertinent Labs: UA 4+ Bacteria/Blood Other data: Foley Inserted 07/08/19 for Retention 3. Assessment: LPN's: The resident appears lethargic and weak 4. Request: Action taken or suggested next step: Lab work, x-rays, EKG, other diagnostic tests Staff name completing SBAR/Credential: S8 LPN Reported to: Medical Doctor Date/Time reported: 7/8/19 at 9:30 a.m., 7/9/19 at 12:15 p.m. Communication method: Telephone Interview on 7/11/19 at 1:00 p.m. with S1 DON revealed that the resident's physician should have been notified before she went (2) 12 hours shifts without voiding. Further interview with S1 DON revealed that it was basic nursing knowledge to report when a resident has not voided. S1 DON further stated that the nurses chart by exception (abnormal findings only), and confirmed that there was no nursing documentation done on 7/7/19 for the 7:00 a.m. to 7:00 p.m., or 7:00 p.m. to 7:00 a.m. shifts that addressed the resident's lack of urinary output. Review of the Hospitalist History and Physical (H&P) dated 7/9/19 revealed resident #1 was admitted to the hospital on [DATE]. The H&P revealed the following: On presentation to the ER: T = 98.1, P = 75, B/P = 100/53, and sats not reported yet. General: Not in acute distress, awake, alert and trying to talk, but confused. Neuro: Awake, alert, confused Laboratory Data: Blood cultures pending, Urine cultures pending, Urine analysis showed Leukocyte [MEDICATION NAME] of 250, White blood cells 20, Red blood cells 48. Assessment and Plan: UTI and Altered Mental Status, Recent [MEDICAL CONDITION] status [REDACTED]. Plan: Continue Antibiotics, continue IV fluids 75cc/hour, continue the rest of her home medications.

Based on observation, interview and record review the facility failed to ensure a resident's environment remains as free from accident hazards as is possible for 2 (#5 & #6) of 4 (#6, #7, #8 & #9) residents observed smoking out of total 9 residents identified as smokers. The facility further failed to: 1. Provide supervision resident #6 who was assessed to be cognitively impaired with a BIMS of 9 (moderately impaired), and who was observed to be an unsafe smoker and to have cigarette burn holes in his clothing on himself and in his closet; 2. Ensure Resident #5 was assessed for the safe use of bed rails. This failed practice resulted in an Immediate Jeopardy situation for resident #6. The Immediate Jeopardy began on 1/10/17 when the resident was observed outside on the smoke patio located at the back of the facility with a lit cigarette noted in his left hand. The resident was leaning to his right side and he had a pillow stuffed on the right side of the wheelchair. The resident dropped his lit cigarette which landed on his lap, rolled down his right leg, and landed on the ground next to his foot. The resident had no shoe on his right foot, only a dressing that was covered by a sock. S1 Administrator and the surveyor observed several burn holes in the resident's fleece pajama bottoms. Observation with S4 Nurse Auditor/LPN confirmed there were 18 cigarette burn holes in the resident's pajama bottoms. The S1 Administrator was informed of the Immediate Jeopardy on 1/10/17 at 5:15 p.m. The Immediate Jeopardy ended for resident #6 when he was sent to the emergency roiagnom on [DATE] at 4:10 p.m. The Immediate Jeopardy was removed on 1/11/17 at 11:25 a.m. when the S1 Administrator presented the surveyors with an acceptable plan of removal, and evidenced that the facility had began implementation of the plan at the time. Observation on 1/11/17 at 11:25 a.m. revealed staff was assigned to the smoking patio to monitor residents smoking. The plan of removal included the following: 1. The resident who was identified has been assessed and a current smoking assessment was completed by clinical staff and the Care Plan was updated to reflect current needs. 2. Identified residents determined to be smokers have been assessed for safe smoking abilities, and those identified as non-safe have been care planned accordingly and supervision is in place, in-services have been performed on smoking safety of residents. 3. Quality Assurance measures put in place to ensure that deficient practice does not recur are: a. Continuous supervision has been initiated for residents identified as non-safe smokers. b. Smoking assessments have been completed for smokers to determine whether safe or unsafe. c. Care plans have been reviewed and revised as needed. d. In-services are completed with staff to educate on safe smoking measures, and smoking supervision requirements. e. In-services will be held on 1/11/17 for all residents who are identified as smokers to discuss smoking requirements and supervision during smoking sessions. f. Resident's representative will be notified of smoking policy requirements. g. Weekly High Risk meetings by nursing administration to discuss residents who smoke and any revisions to the POC. 4. Plans put into place to ensure POC remains compliant will be that any concerns identified during the High Risk meeting will be reported to the Quality Assurance Committee for continued tracking, trending and compliance. Revision of POC will be determined and revised as needed. 5. Date Certain: 1/11/17 The deficiency remains at a potential for more than minimum harm for the other 8 residents who smoked at the facility. Findings: Resident #6 Review of resident #6's record revealed his [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 9 (moderately impaired). Review of the Smoking Policies and Regulations with a revision date of 11/08 revealed residents are not permitted to smoke in their rooms. Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses' station. The facility will provide matches and will light cigarettes upon request in designated areas for resident's assessed with [REDACTED]. Review of the facility ' s Resident Smoking Log revealed there were 9 residents that smoked and all 9 residents were labeled as safe smokers. Review of the January, 2017 Physician order [REDACTED]. Also in order for resident to smoke each day, resident must attempt to eat and drink at each meal before going to smoke. Review of the resident's Safe Smoking assessment dated [DATE] revealed the resident was identified as a safe smoker. The section of the assessment of a random inspection of the resident's clothing and bed linens revealed, the area for no burn holes were noted was checked yes. Review of the resident's care plan with a goal date of 4/10/17 revealed on 7/12/11, the resident was identified to have a problem with being at risk for injury R/T smoking and at risk for burns. Hand written documentation revealed the resident was a safe smoker at this time. Approaches included that the resident refused to wear smoker's apron, and staff to continue to encourage him to wear it to prevent burning holes in clothing and injuring self with cigarettes ashes and lighted cigarettes. There was no approach to supervise the resident while smoking as a result of his refusal to wear the smoker's apron. Observation of resident #6 on 1/10/17 at 1:10 p.m. revealed the resident was outside on the smoke patio located at the back of the facility with a lit cigarette noted in his left hand. The resident was leaning to his right side and he had a pillow stuffed on the right side of the wheelchair. The resident dropped his lit cigarette which landed on his lap, and rolled down his right leg and landed on the ground next to his foot. The resident had no shoe on his right foot, only a dressing that was covered by a sock. The resident never attempted to pick the cigarette up, so the surveyor motioned for S1 Administrator to come assist with obtaining the lit cigarette. Further observation at that time revealed S1 Administrator picked up the lit cigarette and disposed of it. S1 Administrator and the surveyor observed several burn holes in the residents fleece pajama bottoms. The Administrator began to take the resident back into the facility, stating that he was going to get him changed. The surveyor requested the pajama bottoms be brought to observe the number of holes. Interview with S1 Administrator on 1/10/17 at 1:20 p.m. revealed the resident had been encouraged to wear a smoking apron but he refused. The surveyor asked S1 Administrator what other measures had been put in place to ensure the resident smoked safely. He stated he would have to ask his team before answering the question. S1 Administrator confirmed he did not have anyone designated to monitor residents smoking. S1 Administrator revealed that the door to the back was motion censored, to allow the residents that were assessed as safe to smoke alone, to go outside and smoke when they wanted. Observation on 1/10/17 at 1:45 p.m. of the resident's fleece pajama bottoms revealed there were 18 cigarette burn holes in the bottoms. S4 Nurse Auditor/LPN counted and confirmed there were 18 cigarette burn holes in the resident's pajama bottoms. Interview with S4 Nurse Auditor/LPN on 1/10/17 at 1:50 p.m. confirmed there were 18 cigarette burn holes in the resident's pajama bottoms. She stated they had tried a smoking apron, but the resident refused to wear it. She stated they encouraged the resident to wear the apron as additional measures. Observation on 1/10/17 at 2:35 p.m. of the resident's clothing in his closet revealed another pair of fleece pajama bottoms to have 5 cigarette burn holes, and a pair of flannel pajama bottoms with 2 cigarette burn holes. The resident was also present and the flannel shirt that he was wearing had 3 cigarette burn holes, and an outer jacket had 2 burn holes. The resident's jacket that he was wearing at that time had cigarettes and a lighter in his left pocket. Interview on 1/10/17 at 2:35 p.m. with resident #6 revealed he lifted his head up to give permission to look through his clothing. The resident stated he was paralyzed and then put his head back down. Interview and observation on 1/10/17 at 2:35 p.m. with S6 CNA confirmed the clothing he was pulling from the resident's closet were the clothes the resident wore on a normal basis. He confirmed that some of the clothes were Christmas gifts. S6 CNA also stated the resident was acting groggy today. Interview on 1/10/17 at 2:45 p.m. with S5 LPN confirmed she was the resident's nurse and she had been working with him for approximately 4 months. S5 LPN revealed that the resident had difficulty using his right side due to paralysis. She stated that the resident had seemed groggy today. She confirmed she had noticed the burn holes in his jacket and had talked to him for a while about not smoking to prevent him burning his clothing. She confirmed she had not reported to anyone of her observations of the burn holes in his clothing. She stated it was on the eMARs that the resident was a safe smoker and he was allowed one pack of cigarette per day. She confirmed he kept his cigarettes and lighter on himself. Interview on 1/10/17 at 2:47 p.m. with S6 CNA revealed he had been working with the resident for approximately 7 months and had seen the holes in the resident's clothing since he had started working. He stated he had not reported the burn holes in the resident's clothing to anyone. Interview with S8 RN/Assessment Nurse on 1/10/17 at 4:40 p.m. revealed when she performed a resident's smoking assessment she only looked at the clothing the resident was currently wearing. She confirmed she did not go and look at the residents' clothes in their closets, only the one set of clothes the residents were wearing at the time the assessment was done. Interview with S4 Nurse Auditor/LPN on 1/10/17 at 4:40 p.m. revealed if there was a concern with a resident dropping lit cigarettes or ashes on their clothing, or if the resident had a posture problem then they would try putting the smoking apron on the resident. She confirmed that they had tried putting an apron on him about a year ago, but the resident refused to wear it. She stated the only way they could monitor resident #6 while smoking was to have someone monitoring him 24 hours/day, because he smoked all the time. S4 Nurse Auditor/LPN confirmed there was no staff that monitored the residents who smoked outside. Further interview with S4 Nurse Auditor/LPN revealed resident #6 had been sent to theER on [DATE] at 4:10 p.m., due to him being so groggy and he had a temp of 100.4 ancillary. Resident #5 Review of #5's January, 2017 Physician order [REDACTED]. The orders also included may use side rails X 1 or 2 as indicated to define parameters of the bed, promote self bed positioning and to assist with placement of positioning devices. Observation on 1/9/17 at 2:55 p.m. revealed the resident was lying flat in bed on his right side, and there was a three quarter length bed rail elevated centrally on the right side of the bed. The left side of the bed was against the wall. Further observation revealed the resident appeared restless, moved his legs back and forth, and extended his right foot partially through the bars of the bed rail several times. Interview on 1/9/17 at 3:00 p.m. with S9 LPN revealed she was the nurse assigned to care for the resident, and stated the resident was being treated for [REDACTED]. Further interview with S9 LPN confirmed the resident appeared restless and was moving his legs back and forth and had extended his foot partially into the bars of the bed rail. Review of the Quarterly MDS assessment dated [DATE] (ARD date) revealed that bed rails were not used for the resident.

Based on observation, interview and record review the facility failed to ensure staff notified the physician when an antibiotic was not available to administer to a resident for a [DIAGNOSES REDACTED].#5) for 1 of 9 sampled residents (#1, 2, 3, 4, 5, 6, 7, 8, and 9). According to the Resident Census and Condition of Residents Report the facility census was 101. This failed practice resulted in actual harm for resident #5. The resident was ordered [MEDICATION NAME]-sulb 875 mg 1 po X 10 days for UTI on 1/7/17. According to the facility, the medication was not available in po form in their emergency kit. The pharmacy was contacted and the medication was to be delivered. However, the medication was never delivered to the facility and administered to the resident. The facility was unable to contact the MD to clarify the order, and the Medical Director was not consulted when the facility did not receive a response from the resident's physician. Resident #5 never received the [MEDICATION NAME]-sulb 875, experienced a change in his mental status, and was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Findings: Review of resident #5's January, 2017 Physician order [REDACTED]. Review of the Accumulative [DIAGNOSES REDACTED]. Observation on 1/9/17 at 2:55 p.m. revealed the resident was lying flat in bed on his right side, and there was a three quarter length side rail elevated centrally on the right side of the bed. The left side of the bed was against the wall. Further observation revealed the resident was restless, moved his legs back and forth, and reached and gripped his sheet with a tight fist. Interview on 1/9/17 at 3:00 p.m. with S9 LPN revealed she was the nurse assigned to care for the resident, and stated the resident was being treated for [REDACTED]. She stated the resident was more confused and more restless than his usual, and she confirmed he was gripping the sheet with a fist. Review of a physician's orders [REDACTED]. Interview on 1/11/17 at 11:56 a.m. with S15 LPN revealed she was the resident's nurse on the day shift 1/7/17 and had received a new order to start an antibiotic ([MEDICATION NAME]-sulb) for the resident when it arrived from the pharmacy due to a [DIAGNOSES REDACTED]. S15 LPN stated she called the pharmacy concerning the new order for the medicine on 1/7/17, and the medicine was supposed to be delivered to the facility, and that she reported off to the oncoming shift that it was to be started when it arrived. Further interview with S15 LPN revealed the resident was up in his wheelchair on 1/7/17, propelled himself in the hallway, and sat and talked to her in the hallway like he usually did. S15 LPN stated he did not complain of pain during her shift on 1/7/17, had a good appetite and drank his fluids well. She stated his side rail was usually down and he sat at the side of the bed. Interview on 1/11/17 at 12:15 p.m. with S19 LPN revealed she was the resident's nurse on the day shift on 1/8/17 and she stated she did not have the antibiotic to give the resident on her shift. Further interview with S19 LPN revealed she was told during the morning report that they had called the pharmacy on Saturday (1/7/17), and were waiting on the medication to be delivered, and stated that she did not report to the RN Supervisor or to the resident's physician that the resident had missed receiving the antibiotic. S19 LPN stated the resident did not eat much breakfast and had to be fed lunch and supper on 1/8/17, which was not normal for the resident, and she said he seemed aggravated. Review of the January, 2017 EMAR entry for [MEDICATION NAME]-Sulb (order date 1/7/17) revealed the medication had not been administered on Saturday 1/7/17 and Sunday 1/8/17; however, was signed off as given on 1/9/17. Interview on 1/11/17 at 12:28 p.m. with S4 LPN Nurse Auditor revealed she had worked a partial day on Sunday 1/8/17 as a representative of the Department Heads, and was informed the antibiotic had not arrived from the pharmacy. Further interview revealed S4 LPN stated she attempted to call the physician because the pharmacist informed them the medication was not available in oral form and they needed to clarify the order with the physician. However, she stated they were unable to reach the physician on the phone, and did not get a response back from the physician after they left a message. S4 LPN confirmed that the January 2017 EMAR entry revealed the antibiotic had been signed off as given on 1/9/17 by another nurse; however, it was an error. She confirmed that it was not given because the medication was never delivered to the facility. Further interview of S4 LPN on 1/11/17 at 12:28 p.m. revealed the physician's NP was notified on Monday 1/9/17 by S9 LPN, and an order was received to administer one dose of [MEDICATION NAME] IM; however, review of the Urine C&S report dated 1/6/17, during interview of S4 LPN on 1/11/17 at 12:28 p.m. with surveyors and S4 LPN, S4 LPN stated that the report read that [MEDICATION NAME] was not an antibiotic found to be effective for the treatment of [REDACTED]. S4 LPN further stated the NP instructed them to continue to try to reach the physician to clarify the order for [MEDICATION NAME]-sulb po. S4 LPN stated they were unable to reach the resident's physician to clarify the order for [MEDICATION NAME]-sulb and the antibitotic was never started for the UTI prior to the resident's admission to the hospital on [DATE], and confirmed the resident missed 5 doses of antibiotic. S4 LPN Nurse Auditor stated the resident was transferred to the emergency roiagnom on [DATE] and was admitted to the hospital. Review of the hospital medical record document Encounter Summary dated 1/10/17 revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Medical Director Guidelines in a Long Term Care Facility Directive (Administrative Manuel) provided by S4 LPN revealed the Medical Director agreed to be on call for 24 hour coverage for emergency services when the facility was unable to reach the resident's own physician or designated alternate. Interview on 1/11/17 at 12:58 p.m. with S4 LPN Nurse Auditor revealed the nurses should have called the facility's Medical Director concerning the changes in the resident's condition, and to clarify the order for the antibiotic when they were unable to get in touch with the resident's physician.