Every finding on record at Treemont Health Care Center

Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 12 (Resident #7) residents reviewed for pharmacy services.- The facility failed to administer Resident #7's Vancomycin HCl Intravenous Solution (antibiotic) 500 MG/100ML and Ampicillin-Sulbactam Sodium (antibiotic) Intravenous Solution Reconstituted 3g (2g-1g) GM on 5/6/26.These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.Findings included: Record review of Resident #7's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of RLQ open wound of abdominal wall (wound to right lower stomach), surgical aftercare following surgery on the genitourinary system (needing help after surgery on the urinary system), peripheral vascular angioplasty with implant and graft (bad circulation to the lower extremities requiring an implant to open the vessels), stage 3 kidney disease (kidneys do not filter), hepatitis C (viral infection that causes liver inflammation), respiratory failure with hypoxia (not enough oxygen in the blood), aneurysm of other specified arteries (abnormal dilation of artery), congestive heart failure (heart not pumping effectively).Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, which indicated severely impaired cognition. The resident was partial/moderate assistance (helper does less than half the effort) for all ADLs. According to the MDS, Resident #7 had recent surgery involving the heart or major blood vessels and surgery involving tendons, ligaments, or muscles. He was admitted with surgical wounds, was receiving wound care and antibiotics.Record review of Resident #7's Care Plan dated 3/18/26 revealed a Focus: IV Therapy: Resident #7 required IV therapy AEB IV antibiotic therapy and a PICC (tube in vein in upper arm ending near the heart) line to RUE. Interventions included giving therapy as ordered, changing IV site and tubing per facility policy, and observing the IV site for edema, redness, and drainage. Focus: Antibiotics: Resident #7 was on antibiotics and was at risk for adverse reactions/side effects AEB Vancomycin, Ampicillin-Sulbactam, and Dx of wound infection. Interventions included giving medications per order.Record review of Resident #7's hospital records revealed a Pharmacy Progress note from 5/4/26 at 2:04pm from RPh K that said the resident was to maintain on vancomycin 1000mg IV Q24hr for right groin infection.Record review of Resident #7's admission Note dated 5/5/26 at 7:25pm from LVN J revealed he was admitted back to the facility at 7:25pm on 5/5/26.Record review of Resident #7's Progress Note dated 5/5/26 at 10:01pm from LVN J revealed the resident had arrived back to the facility from the hospital. He had an open wound to his R groin and had a PICC line to his RUA. The nurse said all medications were reconciled with the NP.Record review of Resident #7's from 5/6/26 revealed the following Physician Orders from MD D:- CBC,CMP (labs) AND VANCO TROUGH (measure of vancomycin) BEFORE FOURTH DOSE. Ordered 4/15/26.- Change dressing to PICC line every day shift every 7 day(s) for IV Management/infection control. Ordered 4/17/26.- Vancomycin HCI Intravenous Solution 500 MG/100ML (Vancomycin HCl) Use 500 mg intravenously two times a day for Wound infection until 05/17/2026 07:59 Sodium chloride 0.9% solution 250ml with Vancomycin 500mg reconstituted solution 500mg. Ordered 4/30/26 to start 5/1/26.- Ampicillin-Sulbactam Sodium Intravenous Solution Reconstituted 3g (2g-1g) GM (Ampicillin &Sulbactam Sodium) Use 200 ml intravenously every 8 hours for Wound infection, Every 8 hours for doses. Ordered 5/5/26 to start 5/6/26.- Cleanse Right groin wound with normal saline, apply collagen powder (for wound care), and calcium alginate (for wound care) and cover with dressing daily, every day shift. Ordered 5/6/26.Record review of Resident #7's May 2026 MAR-TAR revealed for Vancomycin and Ampicillin-Sulbactam on 5/6/26 at 8am, a 5 was marked. The number 5 meant hold/see progress notes according to the chart codes in the MAR-TAR.In an observation on 5/6/26 at 10:54am, Resident #7 was asleep in bed. There was an IV pole next to his bed but there was not any IV tubing, IV bag, or IV pump on it.In an observation and interview on 5/6/26 at 3:06pm, Resident #7 was sitting on the edge of his bed. He had a PICC line to his RUA. There was an IV pole next to his bed with no IV tubing, IV bag, or IV pump on it. Resident #7 said staff were always late giving him his IV antibiotics. He said he had been back at the facility since the night before (5/5/26) and still had not received any IV antibiotics.In an interview on 5/6/26 at 3:10pm, the Wound Care Nurse said if a resident was admitted at night, the IV antibiotic would be at the facility by 10am the next day. She looked in the facility's medication storage room and could not find Resident #7's IV antibiotics.In an interview on 5/6/26 at 3:18pm, LVN J said the pharmacy could take 2-3 days to deliver medication. She said sometimes the pharmacy did not have the medication and they would have to call the MD for something different. She said the previous nurse, who left at 2pm, did not tell her anything about the IV antibiotic in report. LVN J did not know they did not have Resident #7's IV antibiotic. LVN J said LVN N should have told her they did not have Resident #7's IV antibiotic so she could have called the pharmacy and requested it.In an interview on 5/6/26 at 3:55pm, NP M said that sometimes it was hard to get the IV antibiotic on time with the logistics of the pharmacy being off site. He said he did not want the resident to go more than 24hr without the antibiotic.In an interview on 5/6/26 at 5:30pm, the ADM said the nurse's should have known about Resident #7's antibiotics because the resident was known by all the staff and he had already been on IV antibiotics. She said it was an unusual circumstance because they were not expecting the resident to come back and then at the last minute he came back, and that was why they did not have his antibiotics. The ADM said if State was not there she would have seen the missed dose in morning report and would have followed up on it, but when State was in the building they do not do anything else but focus on them.In an interview on 5/6/26 at 5:30pm, the DON said he expected the staff to give the antibiotic when it was scheduled. He said if the resident came at night, the pharmacy would deliver the medication by 10am the next day. The DON said the nurse should have noticed the antibiotic was not there and followed up on it with the pharmacy. He said he would have followed up on it because he would have seen it was not given, but ultimately the nurse's should have caught it.Record review of the facility's policy and procedure on Administering Medications (no date) read in part: Medications shall be administered in a safe and timely manner, and as prescribed.The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).Medications in the shall be administered according to established schedules: q8h (every eight hours) 12:00 a.m./8:00 a.m./4:00 p.m./1:00 a.m./9:00 a.m./5:00 p.m., bid (two times daily) 8:00 a.m./4:00 p.m., 9:00 a.m./5:00 p.m., 9:00a.m./9:00p.m.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #55) residents reviewed for intravenous fluids.-The facility failed to ensure Resident #55 's subclavian central line's dry dressing was changed every 5 to 7 days per facility policies and procedures, including orders for monitoring the site. The nurse did not maintain sterile technique while changing subclavian central line dressing on 12/3/25,This deficient practice could place residents at risk of serious harm, injury or death by exposing residents to infections in the blood stream and serious illness.Record review of Resident #55's face sheet dated 12/03/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included hyperlipidemia( high fat blood), lobar pneumonia (a serious lung infection where one or more entire sections of the lung get inflamed and fill with fluid, pus and dead cells), acute kidney failure, unspecified, essential (primary) hypertension (high blood), septic pulmonary embolism without acute coronary pulmonale (a sudden failure or severe strain on the right side of the heart because of a rapid, major blockage or increased pressure in the lungs, most commonly from a blood clot), and rhabdomyolysis (a condition where damaged muscle tissue breaks down, releasing harmful substances into the bloodstream).Record review of Resident #55's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care.Record review of Resident #55's hospital discharge records dated 11/25/25 revealed Resident #55's midline placement (a catheter placed in a vein used to deliver medications and other treatments quickly to the body) with the last dressing change date of 11/20/25. Further review revealed Resident #55 was ordered meropenem (an antibiotic) 500 mg intravenously every 12 hours for 21 days with a start date of 11/25/2025 and a stop date of 12/16/2025. He had a transfer diagnosis of sepsis ((is a life-threatening medical emergency where the body's over-the -top response to an infection starts damaging its own tissues and organs, leading to potential organ failure and death).Record review of Resident #55's physician's progress notes dated 11/25/25 revealed, change IV dressing on admission, Q(every) week, and PRN one time a day every 7 days with a start date 11/26/25. Record review of Resident #55's December/2025 MAR revealed he was receiving Meropenem - Sodium Chloride Intravenous Sodium Reconstituted 500mg/50ml (Meropenem and Sodium Chloride) Use 33.3 ml/hr intravenously every 12 hours for Sepsis for 21 days 100ml. 0.9% Sodium chloride. Record review of Resident #55's care plan dated 11/28/2025 revealed no instructions for maintenance of the right midline subclavian (type of peripheral venous catheter that is inserted in the upper arm, preferred for residents requiring frequent procedures) double lumen (a catheter which splits into two tubes, with each tube being used to take or give blood products and the other used for medication or IV fluids) to be changed every Sunday and as needed.Observation on 12/3/25 at 10:03 a.m., revealed Resident #55 lying in bed and he had a central line in his right upper chest with a double lumen with the dressings cover dated as 11/20/25. Both dressings and tape were brownish in color. Resident #55 was interview-able, and he said the dressing had not changed since his admission to the facility. The ADON was called to Resident #55's bedside to check the central line in his right upper chest dressing. The ADON said the dressing should be changed every Sunday and as needed and she was going to let the nurse know. Further observation on 12/3/25 at 10:09 a.m., revealed LVN C came in Resident #55's room, don clean gloves from her uniform pocket, picked up a central line dressing and opened the sterile dressing package and placed it on the air condition vent by Resident #55's bedside. LVN C doff her gloves, and without washing hands got gloves from her uniform pocket, donned the gloves and tried to remove the old dressing with difficulty. LVN C then pulled scissors from her uniform pocket and cut off the dressing, then picked up the alcohol pad and cleaned around the IV site.Interview with LVN C on 12/3/25 at 2:20 pm regarding the subclavian procedure, LVN C said she should have done the IV change with sterile procedure. She had IV training, but it had been over a year, and the training was somewhere else. LVN C said it her first time working with Resident #55. If she didn't follow the right technique dislodgement, introducing infection could happen. Her gloves and scissors were in her pocket. For the subclavian line, she should have taken the old dressing off with her sterile gloves, then should have cleaned it with the scrubber, made sure it was dry, and made sure the line was secure. She saw the order for dressing change weekly and PRN. Dressing changes were to decrease risk for infection at the site. She said, You could get an embolism and infection. That would not be considered following physician orders. Interview with the DON on 12/3/2025 at 2:54pm, regarding subclavian procedure, she said it was a sterile procedure. The DON said she did checkoffs and did not monitor everyone. The DON said she did PICC and midline training. The DON said the dressing should be done once a week, every seven days. Nurses should ensure residents with a PICC line had physician's orders for it. The PICC line dressings should be changed every 5 to 7 days and that nurses should observe the PICC line site every shift to ensure no redness, drainage, or that the site was not hot to the touch. Record review of the undated facility's Central Venous Catheter Dressing Changes Line policy, revealed in part, .Purpose.The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Follow these guidelines unless otherwise stated in manufacturers' guidelines. Preparation1. Check the State's Nurse Practice Act for LVN/LPNs regarding scope of practice for changing a central venous catheter dressing.2. A physician's order is not needed for this procedure.General GuidelinesApply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet.Change dressings if any suspicion of contamination is suspected.Catheter site care shall allow for the observation and evaluation of the catheter-skin junction and surrounding tissue.After original insertion of CVAD ( central line, is a thin, flexible tube inserted into a large vein that leads near the heart), the dressing will consist of gauze and TSM ( medication naltrexone to reduce alcohol cravings and consumption). This must be changed within 24 hours.1. Replace with sterile transparent dressing.2. Use gauze under the TSM if there is drainage from the catheter insertion site.Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact).If gauze is used, it must be changed every 2 days.Approved antiseptic solutions for cleaning insertion site area include alcohol, povidone-iodine, chlorhexidine gluconate, and tincture of iodine as single agents or in combination. A formula containing alcohol and >0.5% (less than) chlorhexidine gluconate is preferred.Allow the insertion site to air dry before placing dressing. Do not blow or wave over the site.Removal of old dressing is an aseptic, non-sterile procedure.With a well-healed tunneled central venous access device, consideration may be given to no dressing.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 35% based on 11 errors out of 31 opportunities, which involved 4 of 9 residents (Residents #5, #23, #53 and #55) and 2 of 4 staff (MA A, MA B and LVN C) reviewed for medication errors.1. The facility failed to ensure MA A administered Magnesium Oxide (used as a dietary supplement to address magnesium deficiency and as an antacid to relieve heart burn and indigestion). It was initialed as given on 12/1/2025 to Resident #53.2. The facility failed to ensure MA A administered Arginald Powder (used to support wound healing, particularly for chronic and slow-to-heal wounds). It was initialed as given on 12/1/2025 to Resident #5.3. The facility failed to ensure MA B administered Acyclovir (used to treat and prevent infection caused by the herpes virus, cold sores, shingles and chickenpox) with food and extra fluid. It was initialed as given on 12/2/2025 to Resident #23.4. The facility failed to ensure MA B administered the correct dose Baclofen (used as a muscle relaxant and antispasmodic agent to relieve muscle spasms, cramping, tightness and pain caused by specified neurological condition) to Resident #23 on 12/2/25. 5. The facility failed to ensure MA B administered Carvedilol (used to treat high blood pressure, heart failure and to improve outcomes after a heart attack) with food. The Carvedilol was given on 12/2/2025 to Resident #23.6. The facility failed to ensure MA B administered Trazodone (used to treat major depressive disorder (depression) in adults) 50 mg half tablet and taken shortly after meal or light snack to Resident #23 on 12/2/257. The facility failed to ensure MA B administered Gabapentin (used to treat nerve pain and control partial seizures in individuals with epilepsy) at the right time (8:00PM) to Resident #23 on 12/2/258. The facility failed to ensure MA B administered Donepezil (the generic version used to treat dementia) at the right time (8:00PM) to Resident #23 on 12/2/259. The facility failed to ensure MA B administered Lubricating eyedrops ophthalmic drops, on 12/2/25, and initialed as given to Resident #2310. The facility failed to ensure MA B administered Acetaminophen 325 mg (used to treat pain) on 12/2/25, and initialed as given to Resident #23.11. The facility failed to ensure LVN C administered the correct dose of Pantoprazole (used to treat conditions caused by excess stomach acid) to Resident #55 on 12/3/25.These failures could place residents at risk of inadequate therapeutic outcomes.Record review of Resident #55's face sheet, dated 11/25/25, reflected an [AGE] year-old male. His diagnoses included esophageal reflux disease without esophagitis (Gastric reflux), hyperlipidemia (high fat blood), lobar pneumonia (a serious lung infection where one or more (lobes) of the lungs get inflamed and fill with fluid, pus and dead cells often from bacteria like streptococcus pneumoniae) unspecified organism, acute kidney failure, and essential (primary) hypertension (high blood).Record review of Resident #55's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. Record review of Resident #55's Physician's Orders for December 2025, reflected an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 mg (Pantoprazole Sodium). Give 1 by mouth one time a day for GERD order date 11/25/25.Record review of Resident #55's new Physician's Orders for December 2025, reflected an order for Pantoprazole Sodium Intravenous Solution reconstituted/mixed 40 mg (Pantoprazole Sodium). Use 40 mg intravenously two times a day for 10 days in 100ML with a start date of 12/4/25.In an observation on 12/3/25 at 9:59 a.m. revealed LVN C had hung IVSS Pantoprazole Sodium 40 mg vial attached to 100ML of normal saline. Pantoprazole Sodium 40 mg vial was diluted with the normal saline but was not reconstituted back in normal saline. Resident #55 was getting normal saline in the IV without Pantoprazole Sodium 40 mg. Resident #55 was given Pantoprazole Sodium 40 mg tablet by mouth at 6:00 a.m. Pantoprazole Sodium 40 mg IVSS was to started on 12/4/25.Record review MAR dated 12/3/25 reflected Pantoprazole Sodium Oral Tablet Delayed Release 40 mg was given on 12/3/25 at 6:00 a.m. by night nurse.In an interview and observation on 12/03/25 at 9:59 a.m. LVN C was shown the Pantoprazole Sodium 40 mg vial was diluted with the normal saline but was not reconstituted back in normal saline. She said Resident #55 was not getting the medication., She then went and reconstituted another Pantoprazole Sodium 40 mg vial IVSS. In an interview on 12/03/25 at 11:09 a.m., with LVN C, she said the first time she administered the Pantoprazole Sodium 40 mg vial, she didn't mix the contents of Pantoprazole Sodium 40 mg in the vial in normal saline back into the bag and Resident #55 was getting only normal saline. If Resident #55 was not receiving the Pantoprazole he could have acid reflux, and the medication was used to treat the resident's GERD. LVN C did not know Resident #55's Pantoprazole Sodium 40 mg vial was to start on 12/4/25 and she was not aware that Resident #55 was administered Pantoprazole Sodium 40 mg on 12/03/2025 at 6:00 a.m.In an interview on 12/3/25 at 1:49 p.m., the DON said for Resident #55 she did not know the justification for Pantoprazole orally and IVSS but it was in his hospital records, and it was changed to IVSS on 12/3/25. Record review of Resident #53's face sheet, dated 12/1/25, reflected a 73 -years-old female who admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia(low magnesium in the blood) obstructive sleep apnea (occurs when the tongue and other throat muscles relax during sleep, causing your airway to temporarily close) nicotine dependence, cigarettes, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, chronic diastolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia (high sugar levels in the blood), and hypotension (low blood pressure). Record review of Resident #53's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. Record review of Resident #53's Physician's Orders for 11/26/ 2025 reflected an order for Magnesium Oxide 420 mg. Give 1 tablet by mouth one time a day for hypomagnesemia. In an observation on 12/1/24 at 7:04 a.m. revealed MA A prepared Resident #53's medications. MA A did not administer Magnesium Oxide 420 mg with other medications as ordered by the doctor.Record review of Resident #53's MAR dated 12/1/25 reflected Magnesium Oxide 420 mg was initial as given on 12/1/2025. Record review of Resident #5's face sheet, dated 12/1/25, reflected a 74 -years -old male who admitted to the facility on [DATE]. His diagnoses included neuropathy, unspecified, spinal stenosis (narrowing of the curvature of the spine), other retention of urine, constipation, insomnia, anemia, hyperlipidemia (high fat in the blood), unspecified, generalized anxiety disorder, urinary tract infection, unspecified injury of urethra, type 2 diabetes mellitus with hyperglycemia, muscle wasting and atrophy, not elsewhere classified, right shoulder, muscle wasting and atrophy, not elsewhere classified, left shoulder, other lack of coordination, muscle wasting and atrophy, not elsewhere classified, multiple sites.Record review of Resident #5's admission MDS assessment, dated 11/3/25, reflected a BIMS score of 15 out of 15, which indicated intact cognition. Record review of Resident #5's Physician's Orders for 11/26/ 2025 reflected an order for Arginald packet two times a day for nutrient repletion/assist with/wound healing for 60 days. Give 1 packet mixed with water or fruit juice order date was 11/10/25 by mouth one time a day for hypomagnesemia. In an observation on 12/1/24 at 7:40 a.m. revealed MA A prepared Resident #5's medications. MA A did not administer Arginald 1 packet with other medications during medication pass.Record review of Resident #5's MAR dated 12/1/25 reflected Arginald 1 packet was initial as given on 12/1/2025.Attempted interview on 12/3/25 at 11:35 a.m., but MA A did not respond to the telephone call. Record review of Resident #23's face sheet, dated 12/1/25, reflected a 72 -years -old female who admitted to the facility on [DATE] readmitted on [DATE]. His diagnoses included long term (current) drug therapy, muscle wasting and atrophy in right and left thigh, muscle weakness (generalized), insomnia, muscle wasting and atrophy, major depressive disorder, constipation, unspecified, dry eye syndrome of unspecified lacrimal gland duct, other muscle spasm, gastro-esophageal reflux disease without esophagitis Gastric reflux), vitamin deficiency, difficulty in walking, other lack of coordination, personal history of other infectious and parasitic diseases, displaced comminuted fracture of shaft of left tibia (fracture of the lower leg bone), displaced comminuted fracture of shaft of left fibula (fracture of the outer leg bone), other specified disorders of bone density and structure, dysphagia (difficulty swallowing), oropharyngeal phase, other abnormalities of gait and mobility, mild protein-calorie malnutrition, acute respiratory distress syndrome, multiple sclerosis (a chronic disease of the and spinal cord where the immune system mistakenly attacks and damages myelin the protective coating of nerve fibers disrupting signals between the brain and body), unspecified dementia (declining brain function( memory , thinking, judgement) severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), and anxiety (a feeling of worry, unease or fear about an upcoming event).Record review of Resident #23's quarterly MDS assessment, dated 11/3/25, reflected a BIMS score of 14 out of 15, which indicated intact cognition. Record review of Resident #23's Physician's Orders for 2/11/2025 reflected orders for: -Acyclovir oral tablet 400mg. Give 1 tablet by mouth two times a day with food and extra fluid. -Baclofen oral tablet 10 mg. Given 3 tablets (30mg) by mouth three times a day for muscle spasm. - Carvedilol oral tablet 3.125mg, give 1 tablet by mouth three times a day for high blood hold if SBP > 110 or DBP>60, give with food. - Trazodone HCL oral tablet 50 mg. Give 0.5mg tablet by mouth two times a day for anxiety and depression, .50 mg half tablet, to take shortly after meal or light snack. - Gabapentin oral Capsule 300 mg. Give 1 Capsule by mouth at bedtime for pain. - Donepezil HCL oral 5 mg. Give 1 tablet by mouth in the evening for unspecified dementia. Give one tablet every evening at the right time. - Lubricating plus eye drops ophthalmic solution 0.5% (Carboxymethyl/cellulose (Ophth) Instill 1 drop in both eyes two times a day for dry eyes. Acetaminophen oral tablet 325 mg. Give 2 tablet by mouth three times a day for pain.In an observation on 12/2/25 at 4:51 p.m. MA B opened the medication cart and picked up Resident #23's medications blister packets and punched the following in the medication cup without reviewing the resident's chart:- Acyclovir oral tablet 400mg with food - Baclofen oral tablet 10 mg was administered to Resident #23, instead of giving Baclofen oral 30mg tablets - Carvedilol oral tablet 3.125mg was given without food - Trazodone HCL oral tablet 50 mg. Resident #23 was not given before a meal or snack. - MA B did not administer Acetaminophen 325mg 2 tablets as ordered by the doctor, initialed as given to Resident #23 on 12/2/25.- MA B did not administer Lubricating plus eye drops ophthalmic solution 0.5% and initialed the med as given to Resident #23 on 12/2/25. - MA B administered Donepezil HCL oral 5 mg not as ordered by the doctor for 8:00 p.m. MA B gave Donepezil oral 5 mg at 4:00 p.m. on 12/2/25.- MA B administered Gabapentin oral Capsule 300 mg not as ordered by the doctor for 8:00 p.m. MA B gave Gabapentin oral Capsule 300 mg at 4:00 p.m. instead of 8:00 p.m. on 12/2/25 Record review of Resident #23's MAR dated 12/2/25 reflected:- Acetaminophen oral tablet 325 mg. Give 2 tablet by mouth three times a day for pain. MA B did not administer Acetaminophen as ordered by the doctor, initialed given at 4:00 p.m. On 12/2/25.- Lubricating plus eye drops ophthalmic solution 0.5% (Carboxymethyl/cellulose (Ophth) Instill 1 drop in both eyes two times a day for dry eyes. MA B did not administer Lubricating plus eye drops ophthalmic solution 0.5% as ordered by the doctor, initialed given at 4:00 p.m. on 12/2/25.-Baclofen oral tablet 10 mg given instead of 3 tablets (30mg) by mouth three times a day for muscle spasm- Donepezil HCL oral 5 mg. Give 1 tablet by mouth in the evening for unspecified dementia. Give one tablet every evening, MA B administered Donepezil HCL oral 5 mg not as ordered by the doctor for 8:00 p.m. MA B gave Donepezil oral 5 mg at 4:00 p.m. on 12/2/25.-Gabapentin oral Capsule 300 mg. Give 1 Capsule by mouth at bedtime for pain. MA B administer Gabapentin oral Capsule 300 mg not as ordered by the doctor for 8:00 p.m. MA B gave Gabapentin oral Capsule 300 mg at 4:00 p.m. on 12/2/25.Interview with MA B on 12/3/25 at 4:07p.m. revealed when asked about Resident #23's medications not being given as ordered by the physician's orders which included, Baclofen 10 mg given instead of 30 mg, Acetaminophen, Lubricating plus eye drops. Trazodone HCL. For Gabapentin, Donepezil not giving at the right time, MA B said it depended on the individual. She said some want it all at once. She said it also depended on the MAR. The individuals might say they're more comfortable taking it at that time. Resident #23 preferred her medication before or during dinner and the other meds at night. The parameters of giving the right time with medications .He said he would tell the charge nurse when the resident wants their given. He brought it to the charge nurse's attention regarding Donepezil (Aricept). He could not remember when or who he told regarding the timing. MA B said he did not give Resident23 at the right time. When asked why the medications were not administered and why he punched the blister packets without looking at Resident #23's chart, MA B said if residents didn't get their medications as ordered, it could have a negative effect like imbalance and adverse or toxic effect for the resident. When asked if it could slow down their process of healing, he did not answer the question. In an interview on 12/4/25 at 11:12 a.m., the DON said prior to administering the medication the aide should get clarification from the charge nurse if the order did not appear correct or amount administered did not match the order. The DON said staff had a checkoff for med pass this year.DON said she pop up on their cart from time to time to check med pass. Her expectation was for staff to look at MAR to administer medications. MA can't change time at their convenience but follow physician's orders. If there were any issues with the medication, MA B should have told the charge nurse and they could have followed up with the resident's physician.In an interview on 12/4/25 at 11:12 a.m. the Administrator said she expected nursing staff to give medications timely, correctly, and according to the physician orders.Record review of the facility's Administering Medications policy, undated revealed in part Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.3. Medications must be administered in accordance with the orders, including any required time frame.4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification band;b. Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.The individual administering the medication must check the label carefully to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen and 5 of 12 residents reviewed for food procurement.-The facility failed to ensure leftover foods were not stored past used by date.-The facility provided food trays containing a hamburger that was at 68 Fahrenheit and spaghetti with meat sauce at 63.2 Fahrenheit and the chef salad was at 63 Fahrenheit.These failures have the potential to place all residents who ate food prepared by the kitchen at risk of food borne illness and disease. Observation of the facility 's kitchen on 12/05/25 between 7:00 am and 8:30 am with the dietary manager revealed the following:-Observed a pan of leftover gravy with used by date 11-26-25.-Observed a pan of leftover Italian gravy with used by date 11-26-25.-Observed a pan of leftover potato casserole with a used by date 11-30-25.Observation on 12/02/2025 at 1:21pm of the three food sample trays brought in conference room, the following temperatures were taken:-Chef Salad temperature 63 degrees Fahrenheit-Hamburger temperature 68 degrees Fahrenheit-Spaghetti with meat sauce 63.2 degrees Fahrenheit The heated bases used to keep food hot under each plate were cold to touch.Interview on 12/01/2025 at 9:00 a.m., with Resident #34, they stated their food was served cold and they ate in their room.Interview on 12/01/2025 at 9:05 a.m., Resident #29 stated their food was served cold and taste unpalatable and they ate in their room.Interview on 12/01/2025 at 9:15 a.m., Resident #38 stated their food was served cold and lack variety and they ate in their room. Interview on 12/01/2025 at 9:30 a.m., Resident #5 stated that food was served cold and they ate in their room. Interview on 12/01/2025 at 12:01pm, Resident #42 and their RP stated food was sometimes 30 to 45 minutes late and was cold sometimes. She said she ate in her room.Confidential group interview conducted on 12/02/2025 at 10:30a.m., residents stated that food was often cold. Interview with the dietary manager on 12/05/25 at 8:40 a.m., revealed that leftover food saved for later had a used by date and to be stored in the refrigerator for 5 days then discarded. Interview on 12/05/25 at 9:40 a.m., the dietary manager stated that he was responsible for training staff regarding labeling and storage requirements ensuring dietary requirements are met.During an interview on 12/02/25 at 2:30p.m., the dietary manager stated his expectation was food should be cooked according to the recipe and be appealing to the residents. The dietary manager stated the cook was responsible for ensuring recipes were followed and the food was served hot and appealing. The dietary manager stated that he was responsible for monitoring the kitchen staff. The dietary manager stated that he monitored by doing spot checks. The dietary manager stated that the effect on residents might not eat food if it did not look appetizing. The dietary manager stated what led to failure was that staff did not check to see if the heated bases were plugged in. He stated that his expectation was for staff to follow policy.Record review of the facility's grievance logs, residents complained about food being cold on 2/18/2025, 8/19/2025 and 11/5/2025. The facility monitored for temperature and range after delivery.Record review of facility policy not dated reflected that food was to be cooked and served according to the recipe that recipe had to be followed and read in part, Hold hot food at 140 F or above. Hold cold food at 41 F or below.Record review of facility's Policy and Procedure Foods dated October 2017 read in part, .Perishable foods must be stored in the refrigerator will be labeled with the use by date. The food service staff will discard any foods past due expiration dates.

Based on observation, interview, and record review, the facility failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #55) reviewed for incontinent care. -The facility failed to ensure CNA A put on a gown and changed gloves and cleaned Resident #55's scrotum and buttocks before putting on a clean brief during Foley catheter and incontinent care on 12/2/25. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #55's face sheet dated 12/03/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included esophageal reflux disease without esophagitis( Gastric reflux), hyperlipidemia( high fat blood), unspecified, acute embolism and thrombosis ( when a blood clot (thrombus) forms and stays put in a blood vessel, blocking flow, while Embolism is when part of that clot breaks off, travels through the bloodstream, and gets struck somewhere else causing a blockage (embolus) of unspecified deep veins of right lower extremity, lobar pneumonia (a serious lung infection where one or more entire sections( lobes) of the lung get inflamed and fill with fluid, pus and dead cells often from bacteria like streptococcus pneumoniae) unspecified organism, acute kidney failure, unspecified, essential (primary) hypertension ( high blood), benign prostatic hyperplasia ( a common, non-cancerous enlargement of the prostate gland in aging men leading to urinary issues like weak stream, frequent urination urgency, and difficulty emptying the bladder) with lower urinary tract symptoms, septic pulmonary embolism without acute coronary pulmonale ( a sudden failure or severe strain on the right side of the heart because of a rapid, major blockage or increased pressure in the lungs, most commonly from a blood clot), rhabdomyolysis (a condition where damaged muscle tissue breaks down, releasing harmful substances into the bloodstream), other lack of coordination, muscle wasting and atrophy in the right and left shoulder, muscle weakness (generalized), unspecified abnormalities of gait and mobility, and unspecified lack of coordination.Record review of Resident #55's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #55 's care plan, dated 11/27/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #55 was also care-planned for a Foley catheter (a sterile tube that is inserted into your bladder to drain urine) and incontinent care, with interventions including following physician orders for catheter insertion, changes and maintenance.Review of Resident #55's Physician's orders from 11/25/2025 through 12/1/2025 reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 11/25/2025. Observation on 12/02/25 at 5:04 a.m., during Foley Catheter and incontinent care with Resident #55, revealed CNA A did not [NAME] PPE (gown ) and change gloves while cleaning Resident #55's Foley catheter tubing and his penis. CNA A did not clean his scrotum and buttocks and placed a cleaned brief under the resident. In an interview with CNA A on 12/02/25 at 5:41 a.m., she said she did not clean the buttocks because she did not want the dressing on that site to come off and she knew not cleaning the buttocks could cause more skin break and odors. In an interview with CNA A on 12/02/24 at 5:41 p.m., she said she only wears PPE while assisting the nurses with dressing change.Review of the facility's policy titled Subject: Incontinent Care- With or Without Catheter not dated: POLICYIt is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination.MALE1. Follow steps below: . Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone Turn the resident over and repeat on the back side.2. Take off gloves, put them into the trash bag with the soiled brief and wipes.Findings included: Record review of Resident #55's face sheet dated 12/03/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included esophageal reflux disease without esophagitis( Gastric reflux), acute kidney failure, unspecified, essential (primary) hypertension ( high blood), benign prostatic hyperplasia ( a common, non-cancerous enlargement of the prostate gland in aging men leading to urinary issues like weak stream, frequent urination urgency, and difficulty emptying the bladder) with lower urinary tract symptoms, muscle wasting and atrophy in the right and left shoulder, muscle weakness (generalized), unspecified abnormalities of gait and mobility, and unspecified lack of coordination.Record review of Resident #55's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #55 's care plan, dated 11/27/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #55 was also care-planned for a Foley catheter (a sterile tube that is inserted into your bladder to drain urine) and incontinent care, with interventions including following physician orders for catheter insertion, changes and maintenance.Review of Resident #55's Physician's orders from 11/25/2025 through 12/1/2025 reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 11/25/2025. Observation on 12/02/25 at 5:04 a.m., during Foley Catheter and incontinent care with Resident #55, revealed CNA A did not [NAME] PPE (gown ) and change gloves while cleaning Resident #55's Foley catheter tubing and his penis. CNA A did not clean his scrotum and buttocks and placed a cleaned brief under the resident. In an interview with CNA A on 12/02/25 at 5:41 a.m., she said she did not clean the buttocks because she did not want the dressing on that site to come off and she knew not cleaning the buttocks could cause more skin break and odors. In an interview with CNA A on 12/02/24 at 5:41 p.m., she said she only wears PPE while assisting the nurses with dressing change.Review of the facility's policy titled Subject: Incontinent Care- With or Without Catheter not dated: POLICYIt is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination.MALE1. Follow steps below: . Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone Turn the resident over and repeat on the back side.2. Take off gloves, put them into the trash bag with the soiled brief and wipes.Remove gloves and WASH your hands.

Based on observation, interview, and record review, the facility failed to ensure that residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #32). -The facility failed to ensure LVN B used sterile technique during tracheotomy care and suctioning, did not clean around trach site, and did not remove inner canula to clean for Resident #32. - This failure could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Record review of Resident #32's face sheet dated 12/2/2025 revealed a [AGE] year-old male resident was admitted to the facility on [DATE]. His medical diagnoses included malignant neoplasm of prostate (Prostate cancer), essential (primary) hypertension (high blood pressure), essential tremor age-related physical debility, dysphagia (difficulty swallowing), other seizures, constipation, unspecified, gastro-esophageal reflux disease without esophagitis (gastric reflux) , tracheostomy status (a surgical procedure where a small hole in the neck directly into the windpipe (trachea) is made to insert a tube to help with breathing or clearing lung mucus), acute respiratory failure with hypoxia (low oxygen), and muscle weakness. Record review of Resident #32's admission MDS assessment dated [DATE] revealed the BIMS assessment was 15 and mental status assessment found he had no short-term and long-term memory/recall ability problems and was cognitively intact. Record review of Resident #32's Care Plan reflected he had ADL self-care deficits and was at risk for further decline in ADL functioning and injury. It also reflected Resident #32 had a tracheostomy and was care-planned for routine equipment maintenance and changes as indicated, following physician orders related to oxygen administration, medication administration, labs, and encouraging residents to keep head of bed elevated. Record review of Resident #32's Physician's Orders reviewed 10/06/2025 revealed the following: -Order date: 10/6/2025 - Tracheostomy Care cuffed flex#6 Cannula daily and as needed for SOB/Prophylaxis.(shortness of breath) every shift, trach Care: Suctioning, every shift Suction tracheostomy tube as needed to clear airway. Document # (number) of Suctions Performed During Assigned Shift. Notify MD( medical doctor) of any abnormalities. Observation on 12/2/2025 at 4:19 p.m. revealed Resident #32 was in bed with audible moist breath sounds and his tracheostomy was covered with a cap. LVN B don clean gloves, and she did not set up a clean field on top of the bedside dresser. She picked up a Tri-flo suction (a type of suction for gentle removal of phlegm) catheter kit packet and placed it on the bed side dresser. LVN B removed her dirty gloves without washing hands, opened the sterile Trach Care Kit, then picked up opened gloves inside the bedside dresser. LVN B grabbed the sterile suction catheter kit tray with the inner canula, and using the same hand she picked up the connecting tubing from the suction machine, connected the suction tubing to the sterile suction catheter, then opened the trach cap. LVN B picked up a drinking cup and poured normal saline in the cup. LVN B suctioned Resident #32's tracheotomy twice and replaced the suction catheter in a packet and placed it the resident's bedside dresser. LVN B did not remove Resident #32's inner cannula to clean or replace it. LVN B did not clean the surrounding trach site. Resident #32's was coughing up a significant amount of phlegm while suctioning, and his oxygen saturation was not checked. In an interview on 12/02/2025 at 4:32 PM, LVN B stated she did not wash her hands during trach care or during suctioning. She stated she should have used sterile technique throughout, and she was recently in-serviced on tracheostomy care but could not recall the date of the in-service. LVN B did not disclose why she failed to use sterile technique. She stated she was working with Resident #32 for the first time during the observed trach care. LVN B stated that not using the sterile technique placed the resident at risk for a respiratory infection. In an interview on 12/04/2025 at 5:00 PM, the DON stated that LVN B had been in-serviced on tracheostomy care. The DON stated that LVN B should have used sterile technique during tracheostomy care. The DON stated that not using sterile technique could place the resident at risk for an infection. The DON stated that the facility had their nurses trained by the respiratory therapist. The DON said she would be conducting in-services on tracheostomy care and monitoring the nurses during tracheostomy care. Review of the facility's policy titled Tracheostomy Care revised 3/4/2025, revealed in part, It is the policy of this center to provide Tracheostomy care in accordance with current standards of practice to ensure airway patency, maintain skin integrity and prevent infection. Dry area with additional sterile gauze pads and apply new sterile Tracheostomy dressing27. Change trach ties or Velcro collar if soiled or wet (when possible have another staff available to secure trach during this process to prevent accidental dislodgement)28. Mouth care to maintain moist oral membranes and lips and decrease risk of infection 29. Replace any humidification devices.Miscellaneous1. Aseptic technique must be used / sterile gloves must be worn:a. During dressing changes until the Tracheostomy wound is healed (has granulated)b. During Tracheostomy tube changes (non-disposable and disposable)c. During cleaning and sterilization of non-disposable Tracheostomy tubesd. During endotracheal suctioning2. Gloves must be used on both hands during any manipulation of the Tracheostomy and sterile gloves if aseptic procedure3. Mask and eyewear must be worn if splashes, splattering or spraying of body fluids or blood is likely to occur during procedure4. Tracheostomy tubes should be changed per order of the physician or a minimum of q 30 days.5. Non disposable Tracheostomy tubes will be cleaned and sterilized according to manufacturer's recommendations6. Tracheostomy care will be provided as ordered by the physician and as needed (if new Tracheostomy or infection is present required minimum of every 8 hours)7. Replacement Tracheostomy tube of the appropriate type and size must be available at the bedside or an obturator and curved hemostat in the event of accidental dislodgement or other emergencies.8. Suction machine (in working order) connecting tubing, a supply of size appropriate sterile catheters, flushing solution (sterile water / normal saline) and sterile and non-sterile gloves at the bedside at all times9. Protective masks and eyewear are indicated if resident is coughing, producing aerosolization during suctioning or exposure of mucous membranes of the mouth and nose are likely.10. Supplemental oxygen and Ambu bag with trach adapter must be at the bedside for emergency situations.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #42) of 7 residents reviewed for pharmacy services. -Resident #42's Tylenol was delivered on 12/02/2025 at 9:45a.m. when the physician's order said to administer it at 8:00a.m. The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.Record review of Resident #42's face sheet dated 12/02/2025, she was an [AGE] year-old female originally admitted on [DATE] with medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), generalized anxiety disorder (excessive fear and worry), muscle wasting and atrophy of the left and right shoulders, depression (prolonged periods of sadness and hopelessness) and muscle weakness. Record review of Resident #42's MDS dated [DATE], Resident #42 had a BIMS score of 13, indicating high cognitive intactness. Record review of Resident #42's care plan dated 12/02/2025, she was care-planned for ADL self-care performance deficit and is at risk for further decline and injury related to dementia and impaired cognition with interventions including physical therapy and occupation therapy and treatment as per MD orders. Record review of Resident #42's Order Summary report dated 12/02/2025, revealed she had acetaminophen oral tablet to be given 500 milligrams by mouth three times a day for arthritis with an order date of 07/28/2025. Record review of Resident #42's individual order for acetaminophen, it had an order date of 07/28/2025 with scheduled times for 8:00a.m., 1:00p.m., and 5:00p.m. daily.Record review of Resident #42's MAR for December 2025 captured 12/02/2025 at 9:05a.m. revealed Resident #42 was documented as not having been administered Acetaminophen oral tablet 500 milligrams by mouth three times a day for arthritis for 12/02/2025. The MAR listed that Resident #42 was scheduled for pain medications at 8:00a.m., 1:00p.m., and 5:00p.m.Record review of Resident #42's pain assessment effective 12/02/2025 at 8:49p.m., revealed she was coded as hurts a whole lot related to pain or hurting in the last 5 days. Resident #42 was coded as having pain almost constantly and it had made it hard for her to sleep at night over the last 5 days. Resident #42 had chronic pain in the left shoulder. Her pain treatment was a lidocaine patch.Interview with Resident #42 on 12/01/2025 at 12:01pm, she said she did not get her pain medication on time on 12/01/2025 in the morning until 11:00a when she checked her clock and her medication was supposed to be given at 9:00am. Resident #42 said she had pain in her left shoulder and that it had felt better after the medication was administered, but she could not give a pain scale rating. Resident #42 said medication was sometimes delivered late. Interview on 12/02/2025 at 9:23am, Resident #42 said she did not think she got her medications that day.Interview on 12/02/2025 at 9:45am with MA A, she said that medication could be given one hour before and one hour after the order time. MA A said she was still administering medication in the other hall and was almost done, and she was going immediately to Resident #42's hallway. MA A said she had not administered Resident #42's medications on 12/02/2025. When asked if there could be any harm to residents if medication was not administered on time, she said she did not know. In a later attempted interview by phone on 12/04/2025 at 12:30pm, MA A did not return the call.Interview on 12/02/2025 at 5:00pm with the DON, she said she would ensure Resident #42 got her medications on time. On 12/03/2025, the DON said MA A told her that she spent a little long getting other residents' blood pressures which caused a delay in medication administration for Resident #42. The DON said if medications were due at 8:00 a.m ., then they would be able to take them as early as 7:00 a.m. and as late as 9:00 a.m. If the medications were given beyond the time range, residents could be at risk of increased pain. Resident #42 never reported to the DON or staff that she had pain. In a later interview on 12/04/2025 at 1:49pm, the DON said that staff should follow physician orders for administering medications. Record review of the facility's policy on Administering Medications, undated, revealed in part, Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on record review and interviews, the facility failed to send to the attending physician and the facility's medical director and director of nursing medication irregularity the pharmacist identified during review for 1 of 2 resident (Resident #23) reviewed for medication review.-The facility failed to act on Pharmacist's recommendation for Resident #23 's Baclofen. This failure could place residents at risk of adverse reaction related to taking medications.Record review of Resident #23's face sheet, dated 12/1/25, reflected a 72 -years -old female who admitted to the facility on [DATE] readmitted on [DATE]. His diagnoses included long term (current) drug therapy, muscle wasting and atrophy in right and left thigh, muscle weakness, insomnia, muscle wasting and atrophy, major depressive disorder, constipation, vitamin d deficiency, difficulty in walking, displaced comminuted fracture of shaft of left tibia (fracture of the lower leg bone), displaced comminuted fracture of shaft of left fibula (fracture of the outer leg bone), other specified disorders of bone density and structure, multiple sclerosis (a chronic disease of the and spinal cord where the immune system mistakenly attacks and damages myelin the protective coating of nerve fibers disrupting signals between the brain and body), unspecified dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), and anxiety (a feeling of worry, unease or fear about an upcoming event).Record review of Resident #23's quarterly MDS assessment, dated 11/3/25, reflected a BIMS score of 14 out of 15, which indicated intact cognition. Record review of Resident #23's Physician's Orders for 2/11/2025 reflected an order for Baclofen oral tablet 10 mg to be given 3 tablets (30mg) by mouth three times a day for muscle spasm.Record review of Resident #23's MAR dated 12/1/25 reflected that Baclofen oral tablet 10 mg. Give 3 tablets (30mg) by mouth three times a day for muscle spasm.Record review of the pharmacist's review dated 2/16/25 revealed According to Long-term Care Drug Monitoring Regulations, our review of the above Patient's Chart identifies the following as requiring your attention: Baclofen 30mg TID (three times daily). Please evaluate and verify the desire to utilize a muscle relaxer. According to CMS(Center Medicare and Medicaid Service) this medication is considered inappropriate for use. The rational is '.For the most part, these are poorly tolerated by older individuals, leading to anticholingergic (any substance that blocks a key neurotransmitter that works for a functioning central and peripheral nervous system) side effects, sedation, increased risk of fractures and weakness'.Record review of Resident #23's progress notes, (2/16/25 ) revealed there was no documentation that the doctor and DON were aware of the pharmacist's review.Interview with the DON on 12/3/25 at 12:30p.m., she said she was not aware of it, she was seeing the pharmacist's recommendation the first time. DON said the ADON who no longer worked for the facility was responsible for notifying the doctor about the recommendation. The DON said not following the recommendation could cause drug over dose and falls.Record review of the facility policy of the undated Medication Regimen Review, revealed, Policy StatementThe Consultant Pharmacist shall review the medication regimen of each resident at least monthly.Policy Interpretation and Implementation.1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility.2. Routine reviews will be done monthly.3. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility.4. Routine reviews will be done monthly.5. Reviews for short-stay individuals (those who are expected to stay for 30 days or less) will be done as needed to identify individuals with high-risk medications and those who may be experiencing adverse consequences from their medications.6. Additional reviews for long-stay individuals will be done as indicated or as requested by the Physician and staff to help manage drug regimens and identify and address suspected or confirmed adverse consequences.7. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.8. As part of the MRR, the Consultant Pharmacist will:3. Evaluate whether any medications in a drug regimen present potentially significant drug-drug or drug-food interactions;4. Determine if the resident is receiving the correct medications as ordered.5. Determine if medications are administered at the prescribed times;6. Determine if medications are administered in the correct dosage and form.7. Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences; and8. Identify medication errors, including those related to documentation.7. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report.8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. If the Physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or-if the Medical Director is the Physician of Record-the Administrator.9. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions.10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #23) of 9 residents reviewed for pharmacy services.-MA A did not administer Carvedilol (medication used to help your heart by lowering blood pressure) with meals to Resident #23 as ordered by the physician on 12/2/25.This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings included:Record review of Resident #23's face sheet, dated 12/1/25, reflected a 72 -years -old female who admitted to the facility on [DATE] readmitted on [DATE]. His diagnoses included long term (current) drug therapy and unspecified dementia ( declining brain function( memory , thinking ,judgement) severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance.Record review of Resident #23's quarterly MDS assessment, dated 11/3/25, reflected a BIMS score of 14 out of 15, which indicated intact cognition. She required assistance from staff with ADL care. She needed extensive assistance of 1-2 staff for ADLs.Record review of Resident #23's Physician Order Report for 02/11/2025 revealed an order for Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth three times a day for blood pressure with meals HOLD FOR SBP>10, HR>60.In an observation on 12/2/25 at 4:51 p.m., MA B prepared and administered Carvedilol 3.125 mg tablet 1 tablet from the blister packet which had instructions for the medication as, Take with meal. In interview on 12/2/25 at 4:56p.m., MA B was asked if Resident #23 has had eaten, MA B said, not yet, the diner tray comes at 5:30 p.m. and he did not give Med Pass shake because Resident #23 would gain too much weight. MA B was shown the blister packets of Carvedilol 3.125 mg tablet (that indicated to be given with meals), MA B said, I did not read that, I am very sorry.In an interview on 12/4/25 at 11:12 a.m., the DON said prior to administering the medication aide should get clarification from the nurse if the order did not appear correct. She said the amount administered did not match the order and the order was not clear. DON said staff had a checkoff for med pass this year. We pop up on their cart from time to time to check med pass. Her expectation was for staff to look at MAR to administer medication. The DON said MA B should not change medication times at his or the resident's convenience but to follow physician orders. If there were any issues he should have told the charge nurse and they could have followed up with the physician.In an interview on 12/4/25 at 11:12 a.m. the Administrator said she expected nursing staff to give medications timely, correctly, and according to the physician orders.Record review of the facility's Administering Medications policy, undated read in part Policy Statement.Medications shall be administered in a safe and timely manner, and as prescribed.The individual administering the medication must check the label carefully to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation and interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services.-The facility dumpster lids and doors were not secured.This failure could place residents at risk of infection and a decreased home-like environment from pests and rodents. Observation on 12/05/2025 at 8:45 a.m., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the door was wide open.In an interview with the dietary food manager on 12/05/2025 at 9:20 a.m., with the dietary food manager, he stated that the dumpster doors must be closed to keep vermin, pests, and insects out of the dumpster from entering the facility. He also stated that he will in service dietary staff, nursing, housekeeping and maintenance that the dumpster door was to be closed for proper sanitation and residents' safety. In an interview with the DON and the Administrator on 12/02/2025 at 5:00p.m., the Administrator said the dumpster should not have been open. The [NAME] said waste could come out of the dumpster and animals could come in and spread the trash and infection around. The Administrator said a risk could be residents going into the dumpster and possibly climbing in there.Record review of facility policy and procedures on waste disposal undated revealed that .food related garbage and rubbish is disposed of in accordance with current laws and regulations. The outside dumpster provided by garbage pickup service will be kept closed and free of surrounding liter.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident #55) and 1 of 3 staffs (CNA A) reviewed for infection control. -The facility failed to ensure CNA A performed hand hygiene including washing hands before wearing gloves before incontinent care and washing hands between glove change during incontinent care on Resident #55.This failure could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Record review of Resident #55's face sheet dated 12/03/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included acute kidney failure, benign prostatic hyperplasia ( a common, non-cancerous enlargement of the prostate gland in aging men leading to urinary issues like weak stream, frequent urination urgency, and difficulty emptying the bladder) with lower urinary tract symptoms.Record review of Resident #55's admission MDS assessment, dated 11/30/25, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. The MDS revealed in section H0300: Urinary continence was coded as always continent. Section H0400: Bowel Incontinence was coded as always incontinent. Record review of Resident #55 's care plan, dated 11/27/25, reflected, . The resident had an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent . Resident #55 was also care-planned for a foley catheter/incontinent care, with interventions including following physician orders for catheter insertion, changes and maintenance.Review of Resident #55's Physician orders from 11/25/2025 through 12/1/2025 reflected orders for the following:-Foley Catheter cleansing and perineal hygiene daily and as needed soiled, using a catheter securing device with a start date of 11/25/2025. During observation rounds on 12/1/25 at 6:45 AM, Resident #55 had an Enhanced Barrier Precaution sign posted on the entered door. Observation on 12/02/25 at 5:04 PM of Resident #55's Foley Catheter and incontinent care with CNA A, CNA A did not don PPE before she picked a cleaned brief and wet wipes and placed the items on Resident #55's bed. She donned clean gloves without washing hands, unfastened the residents soiled brief, and used wet wipes to clean Resident #55's penis, Foley catheter tubing and his groin. She did not cleaned his scrotum and buttocks. CNA A placed a cleaned brief under the resident changed gloves without washing hands and don clean gloves. In an interview with CNA A on 12/02/24 at 5:41 p.m., she said she only wears PPE while assisting the nurses with dressing change. She said she did have in-service about using PPE usage to prevent infection to her and the resident. C.NA A said she forgot to wash her hands. Review of the facility's policy titled Enhanced barrier precautions not dated: .Policy.It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).Policy Explanation and Compliance Guidelines. 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. B. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. C. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.Record review of the facility's Hand Hygiene policy (Revised 6/2019) revealed read in part: .It is the policy of this facility that proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicated. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Procedure: After: After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident inn bed .Record review of the Infection Control Program (Revised 2/2022) revealed read in part: .Policy: Evidence-based policies and procedures are the foundation of a facility's infection control and prevention program. Goals: A Decrease in the risk of infections and communicable diseases to residents, employees, volunteers, and visitors .

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (main kitchen) reviewed for sanitary kitchen. The facility failed to ensure the thermometer on the low temperature dishwashing machine was in working condition. This failure could place residents at risk for foodborne illness. The findings include: In an observation and interview on 9/19/24 at 12:50 p.m. of the dishwashing machine located in the kitchen area, Dishwasher A demonstrated how to use the machine by turning it on and running dishware through it. Observation of the two thermometers on the screen revealed they did not move. Dishwasher A said the thermometers did not work. In an interview on 9/19/24 at 1:00 p.m., Dishwasher A said (via Spanish interpretation from the Chef) the thermometers on the dishwashing machine had not been working for one week but when he touched the sides of the machine the doors burned him. In an interview on 9/19/24 at 1:12 p.m., the Dining Supervisor said the dishwashing company came to the facility 2 weeks ago and the dishwashing machine was not working at that time. She said the company did not say anything about the machine and was unsure if they left paperwork regarding the visit. In an interview on 9/19/24 at 1:15 p.m., the Chef said the dishwashing machine temperatures should be between 170-180 F to ensure the dishes were sanitized. He said kitchen staff would not know the temperature of the water without a functioning thermometer. He said the dishwashing machine was used for silverware and glassware and said there was no risk to the residents. In an interview on 9/19/24 at 2:25 p.m., the Administrator said she thought the dishwashing machine was already fixed. She said the kitchen staff informed her the dishwashing machine was a low temperature machine. Record review of the Dishwasher Temperature Log for September 2024 reflected there was no wash or rinse temperature recorded for breakfast, lunch, or dinner from 9/1/24 - 9/18/24. There was no wash or rinse temperature recorded for breakfast or lunch for 9/19/24. The PPM was 50 from 9/1/24 - 9/19/24. Record review of the facility's Dishwashing Machine Use policy, dated March 2010, read in part, .Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation . Policy Interpretation and Implementation . 2. Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: a. 150 F for stationary rack, dual temperature machines or multi-tank, conveyor, multi-temperature machines. B. 160 F for single tank, conveyor, dual temperature machines. C. 165 F for stationary rack, single temperature machines. 3. Dishwashing machine hot water sanitation rinse temperatures may not be more than 194F, or less than: a. 165 F for stationary rack, single temperature machines. B. 180 F for all other machines . 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. 8. The supervisor will check the calibration of the gauge weekly by: a. Running a secondary thermometer through the machine to compare temperatures; or b. using commercial temperature test strips following manufacturer's instructions. 9. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted Record review of the U.S. Food and Drug Administration Food Code dated 2022 read in part, .4-501;110 Mechanical Warewashing Equipment, Wash Solution Temperature . B. The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120F .

Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 12 residents (Resident #34) reviewed for ADL care. - The facility staff failed to provide timely incontinence care to Resident #34. This failure could place residents at risk of skin breakdown, pain, and infection. Findings include: Record review of Resident #34's undated face sheet, revealed an [AGE] year-old female admitted on [DATE], with an original admitted [DATE]. She had diagnoses of muscle weakness, muscle wasting and atrophy (wasting away of a part of the body), difficulty in walking, muscle spasms, osteoporosis (bone mineral density and bone mass decreases), need for assistance with personal care, lack of coordination, repeated falls, and Parkinson's Disease (unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of Resident 34's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. She was substantial/max assist with toileting, personal hygiene, and upper body dressing. She was dependent with shower/baths, lower body dressing, and putting on/taking off footwear. She required substantial/max assist when rolling in bed, going from sit to lying, to go from lying to sitting, and for chair/bed to chair transfers. She was dependent with sitting to standing, toilet transfers, and tub/shower transfers. The resident was always incontinent of bowel and bladder. Record review of Resident #34's care plan, dated 1/30/24, revealed a Focus: Resident has an ADL selfcare performance deficit r/t impaired mobility, osteoporosis (bone mineral density and bone mass decreases), and muscle weakness. Goals: Resident will maintain current level of function in ADL performance through the review date. Interventions: Encourage resident to use call bell for assistance. Focus: The resident has bowel/bladder incontinence r/t impaired mobility and cognition. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Brief Use: The resident uses disposable briefs. Female Care Attendants to clean peri-area with each incontinence episode. Record review of Resident #34's progress notes revealed no notes which indicated the resident refused to be changed. In an interview on 9/17/24 at 10:43am, Resident #34 said the last time she was changed was at 3:00am that morning. She said she put her call light on, and it would stay on for a couple hours at a time and never got answered. She said the CNA only came in one time around 10:15am, when she had visitors. The CNA opened the door and the dog that was in the room barked and the CNA got scared and closed the door. The resident said the CNA had not been back since then. Resident #34 said she would often have to wait for extended periods of time to be changed. She said she would not tell anyone because it did not do any good. In an interview with CNA A on 9/17/24 at 10:53am, she said she had not had time to change Resident #34 because she was getting all the residents up out of bed, picking up breakfast trays, and helping get the residents into the shower beds for their showers. She said she told the nurse that she was unable to change the resident and the nurse went and informed the resident she could not be changed at that time because the CNA was picking up trays. In an interview with LVN B on 9/17/24 at 10:56am, she said CNA A had not told her anything about Resident #34 that morning. She said she did not know anything about the resident needing to be changed. She said the CNAs round every 2 hours and PRN and change the residents at that time. The nurse said if the CNA was unable to change the resident, she could tell the nurse and she would do it. She said if residents sat in soiled briefs for extended amounts of time, it could cause skin break down. She said she would go check on the resident and change her. In an interview with the DON on 9/17/24 at 2:40pm, she said her expectations were for the CNAs to check residents every 2-3 hours and PRN. She said if the CNA was busy at that moment, they should tell the resident they would be back shortly, and it should not take more than 30min for them to go back to the resident. She said if they were really busy, they could inform the nurse or the DON and they could change the resident. The DON said if a resident was sitting in a soiled brief for extended periods of time it could cause UTIs and skin breakdown. Record review of the facility's policy and procedure on Activities of Daily Living (ADLs), Supporting (Revised Qtr 3, 2018) read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). 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: Hygiene .Elimination .

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 12 months (July and August 2024) reviewed for RN coverage. The facility failed to ensure they had an RN on duty for the weekends during July and August 2024. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: In an interview with the Administrator on 9/19/24 at 2:03pm, she said she did not have enough RN coverage on the weekends for July and August 2024. She said there was no point in printing the schedules and bringing it to the Surveyors because she knew she did not have an RN on the weekend. She said they had trouble keeping RNs, but she had just hired an RN Supervisor and an RN floor nurse at the end of August. She said having an RN provided a higher scope of practice for the facility and without one they were not able to perform certain procedures that only an RN could perform. In an interview with the DON on 9/19/24 at 2:16pm, she said she worked Monday through Friday from 8am to 5pm. She said she had the RNs round, review admissions, and do anything she would do if she were there. She said it was important to have RNs at the facility because they could do things LVNs could not like, remove PICC (long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) lines, place a suprapubic catheter (hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen), and perform dressing changes for PICC (long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) lines. She said not having an RN could put residents at risk because they were like a second pair of eyes with their assessment skills. The DON said when she was hired, she was told there were RNs, but she never saw them once she started, so she hired 2 and they stared at the end of August 2024. Record review of the facility's policy and procedure on Staffing (No revision date) read in part: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .Direct care staffing information per day .is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 11% based on 3 errors out of 26 opportunities, which involved 3 of 6 residents (Residents #22, #29 and #148) and 2 of 4 staff (MA A and LVN B) reviewed for medication errors. 1. The facility failed to ensure MA A administered the correct dose of Nicotine gum to Resident #29. 2. The facility failed to ensure MA A administered the correct dose of Acetaminophen to Resident #22. 3. The facility failed to ensure LVN B administered Cefepime 2 gram IV to Resident #148 at the rate indicated on the pharmacy label. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: 1. Record review of Resident #29's face sheet, dated 9/19/24, reflected a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included acute respiratory failure (a condition in which your lungs have trouble loading your blood with oxygen or removing carbon dioxide), delusional disorders (a mental health condition that causes unshakable beliefs in somthing thats untrue), major depressive disorder and anxiety. Record review of Resident #29's MDS assessment, dated 8/14/24, reflected a BIMS score of 15 out of 15, which indicated intact cognition. She required assistance from staff with ADL care. Record review of Resident #29's Physician Orders for September 2024, reflected an order for Nicotine gum 4 mg give 1 gum by mouth every 4 hours for nicotine craving, order date 7/3/24. In an observation on 9/18/24 at 9:39 a.m. with MA A revealed she prepared and administered one Nicotine 2 mg gum to Resident #29 during the morning medication pass. In an interview on 9/18/24 at 1:06 p.m. LVN B said Resident #29 was on Nicotine 4 mg gum scheduled. In an interview on 9/18/24 at 1:07 p.m., MA A said it was a lot going on during the medication pass this morning and she did not concentrate on the dose. She said she normally verified the dosage, resident, time and medication. In an interview on 9/18/24 at 11:14 a.m., the DON said Resident #29 normally supplied the 4 mg dose. She said the facility had the 2 mg on hand and the medication aide should have clarified if she could have given two of the 2 mg gums. She said there was no risk to the patient. 2. Record review of Resident #22's face sheet, dated 9/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of shaft of humerus, acute pain due to trauma, fracture of sternum, fracture of sacrum, and fracture of shaft of right tibia. Record review of Resident #22's admission MDS assessment, dated 6/26/24, reflected a BIMS score of 13 out of 15, which indicated intact cognition. She required assistance from staff with ADL care. Record review of Resident #22's care plan, revised on 7/16/24, reflected she had acute pain related to multiple fractures. Interventions were to administer analgesia as per orders. Record review of Resident #22's Physician Orders for September 2024 reflected an order for Acetaminophen 650 mg give 2 tablets by mouth every 8 hours for pain, order date 6/20/24. In an observation and interview on 9/18/24 at 9:20 a.m. revealed MA A prepared and administered two tablets of Acetaminophen 325 mg to Resident #22. Observation of the MAR revealed the directive Acetaminophen 650 mg give 2 tablets. MA A said she knew how much of the medication to give by reviewing the MAR. She said she thought the MAR said to give two tablets of Acetaminophen 325 mg to equal 650 mg. She said she asked an unknown nurse previously and was informed to give two of the 325 mg tablets. In an interview on 9/18/24 at 9:35 a.m. the Regional Nurse said if anything on the MAR was different from what was available on the cart the medication aide should not give anything and notify the nurse. In an interview on 9/18/24 at 11:12 a.m., the DON said prior to administering the medication the medication aide should get clarification from the nurse if the order did not appear correct. She said the amount administered did not match the order and the order was not clear. 3. Record review of Resident #148's face sheet, dated 9/19/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute osteomyelitis (infection in the bone), type 2 diabetes, atherosclerotic heart disease (involves plaque buildup in artery walls), heart failure, and acute respiratory failure (a life threatening condition that occurs when your lungs cannot exchange oxygen and carbon dioxide properly). Record review of Resident #148's care plan, dated 9/19/24, reflected he required IV therapy and was at risk for adverse reactions, altered skin integrity and injury related to PICC line in place, receiving IV antibiotic, diagnosis osteomyelitis (infection of bone) and cellulitis (bacterial infection of the skin and the tissue beneath the skin) right foot/heel. Interventions were to give therapy as ordered. Record review of Resident #148's Physician Orders for September 2024 reflected an order for Cefepime IV 2 gm/100 mL use 2 gram intravenously every 12 hours for cellulitis of bilateral extremities until 10/11/24, order date 9/13/24. Observation and interview on 9/18/24 at 8:27 a.m. revealed LVN B prepared and connected Cefepime 2 gm/100 mL IV to Resident #148. She set the rate to flow at 100 mL per hour. Observation of the pharmacy label on the Cefepime read in part, Activate and mix 1 bag (2 gm) give intravenously every 12 hours until 10/12/24. Infuse over 30 minutes LVN B said the bag was 50 mL and she set the flow rate to 100 mL per hour so it could run over 30 minutes. LVN B said the bag was a 100 mL bag and she thought it was a 50 mL bag because it was small. She calculated the new flow rate and changed it to 200 mL per hour so the bag could run over 30 minutes. She said she normally verified the size of the bag prior to administering but she did not check this time, she said she only verified the strength. She said if the flow rate was not set properly, she would not be following the orders. She said if the flow rate was not specified in the Physician order, she would follow the directive on the pharmacy label. In an interview on 9/19/24 at 11:22 a.m., the DON said the physicians order should give the flow rate and it was normally on the pharmacy label. She said the nurse should also get clarification. She said she was unsure how the pharmacy came up with how long the IV should run. In an interview on 9/19/24 at 1:33 p.m. the Administrator said she expected nursing staff to give medications timely, correctly, and according to the physician orders. Record review of the facility's Administering Medications policy, dated December 2018, read in part .Medications shall be administered in a safe and timely manner, and as prescribed . 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication

Based on interviews and record review, the facility failed to develop and implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 10 staff (LVN C, LVN D, and LVN E) reviewed for developing and implementing abuse and neglect policies. - The facility failed to develop and implement abuse policies for review of an employee EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property. The findings included: Record review of the facility's policy and procedure on Background Screening Investigations (Revised March 2019) read in part: Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents . Record review of the facility's policy and procedure on Abuse Prevention Program (Revised August 2006) read in part: Our residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility conducts employee background checks and will not knowingly employ and individual who has been convicted of abusing, neglecting, or mistreating individuals. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Protocols for conducting employment background checks . Record review of LVN C's personnel file revealed a hire date of 7/23/21. Her EMR was ran on 7/16/21 and her criminal history was performed on 7/30/21. On 4/26/22, her EMR was ran again, and a background check was performed on 5/15/22, along with a sex offender check. Nothing was checked again until the State Surveyors asked for her chart on 9/18/24. On 9/18/24, LVN C's criminal history and EMR were checked. Her EMR was over 28 months due, and the criminal history was over 27 months due. Record review of LVN D's personnel file revealed a hire date of 9/27/22. Her criminal history was run on 9/12/22 as well as her EMR. Nothing was checked until the State Surveyors asked for her file on 9/18/24. On 9/18/24, her criminal history was run, as well as her EMR. Her EMR and criminal history checks were over 24 months due. Record review of LVN E's personnel file revealed a hire date of 9/2/22. Her EMR was checked on 8/26/22 and her criminal history was checked on 8/31/22. Nothing was checked until the State Surveyors asked for her file on 9/18/24. On 9/18/24, her criminal history was run, as well as her EMR. Her EMR and criminal history checks were over 24 months due. In an interview with the Human Resources Director on 9/19/24 at 10:30am, she said she started at the facility on 6/26/24. She said she would perform a criminal history check, license verification, EMR check, and sex offender check on everyone when they were first hired and then yearly thereafter. She said she noticed when she was pulling the files the State Surveyors requested, that some of the checks had not been done so she ran them. She said she did not know why they were not done because it was before she started. She planned on running everyone's at the beginning of the year so she could keep track of everyone. She said by not running the checks it could put residents at risk because an employee could have gotten in trouble and the facility would not know. In an interview with the Administrator on 9/19/24 at 11:15am, she said the previous Human Resources Director checked the staffing files near the annual hire date for each person. She said she was unaware the checks were not done and did not know why they were not done since the person no longer worked at the facility.

Based on observation, interview and record review, the facility failed to ensure grievances were resolved for 3 of 3 (confidential group) residents reviewed (Resident #1) for grievances. The facility did not document or follow-up on Resident's grievances from group who expressed concerns during resident council meetings for April, May, June, and July of 2023. This deficient practice could affect 1 resident who attended resident council meetings during April, May, June and 3 residents who attended resident council meeting during July 2023 and could contribute to grievances not being resolved. The findings were: Interview on 07/26/23 at 02:00 p.m. during the confidential resident council meeting 1 of 3 residents stated she was not satisfied with the way the facility addressed the concerns. The facility has no Ombudsman at present, it has been a couple of months since the last one came to visit. Residents are waiting 30, 45, and up to 1 hour for call lights to be answered. The facility changed bingo time from 2:15 -2:00 PM. She stated she does not get changed in time after lunch to attend bingo. The carpet in the halls was dirty and has an odor. The wheelchairs' role over the carpet and leave dark marks on the floor. The warming plate was not hot, and food was cold, grits are always cold, and tea was so dark it looks like coffee. The facility serves too much pork, fruit cocktail and was given orange juice on her tray despite her meal ticket indicating no orange juice/allergic. She stated no matter what she marks on her meal ticket she will get something different on the tray. Sometimes there was no utensils on the tray. A resident on her hall had his television playing loudly and it was disturbing. It was loud enough that staff cannot hear the alarm to an oxygen machine/IV pumps of another residents. She stated the AD and Administrator are aware of her concerns but do nothing about them. She stated she knows how to file a complaint and has in the past. She stated that the facility did not follow-up with her then either. Record review of Resident Council Minutes for 04/18/2023 revealed the following concerns: Administrator - Resident waited for her pictures and books to be returned to her room when she moved 5 months ago and has not heard a response on the whereabouts of the items. Nursing - On 03/31/2023, staff grumbled/complained while she provided the resident patient care at 1:30 PM, 4:00 PM, 7:00 PM and again at 9:00 PM. Dietary: Resident marked out tuna and wrote in chicken for the salad plate for dinner on 4/8/2023 and received tuna fish. On 4/10/2023 the breakfast warming plate and food were cold: oatmeal, sausage, and waffle. Lunch 04/14/2023, resident ordered a grilled ham and cheese sandwich, but received a roll and tartar sauce on her plate. Requested sugar free syrup and received regular syrup. Laundry: Resident shirt returned from laundry torn, marked and with holes. Clothes retuned with strings hanging, need scissors to cut threads. Maintenance - Resident mentioned (several times) that the bathroom sink was too high - it needs to be lowered. Needs air filter changed in room. Further review of the April 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 05/16/2023 revealed the following concerns: Administrator - Resident waited for her pictures and books to be returned to her room when she moved 6 months ago and has not heard a response on the whereabouts of the items. Nursing - Resident down the hall's television was loud at night. Staff talked on their cellphones will providing patient care. Resident does not want to be weighed right after a meal. Dietary - Resident requested/circled apple juice on menu and served orange juice. Resident was allergic to orange juice. Marked out ice cream and requested fresh fruit. Received fresh fruit and ice cream. Activities - Resident cellphones needed to be silenced during bingo. Laundry: Resident's bra and shirts returned damaged. Clothes retuned with strings hanging, need scissors to cut threads. Maintenance - Needs air filter changed in room. Carpet needed cleaning in halls. Further review of the May 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 06/20/2023 revealed the following concerns: Nursing - Resident down the hall's television was loud at night. On 06/07/2023 staff cellphone alarm went off during patient care. Staffing short. Activities: Bingo money should be paid out at time of win. Dietary - Resident continued to circle other juices on menu and was served orange juice. Resident was allergic to orange juice. On 06/17/2023 served cold grits and warming plate barely hot. Requested sugar free syrup and received regular syrup. Menu stated beef enchiladas, resident received bean and cheese enchiladas. Resident requested/circled apple juice on menu and served orange juice. Resident was allergic to orange juice. Requested fresh fruit, received canned fruit cocktail. Laundry: Resident new shirts returned from laundry marked with holes. Shirt with lace torn. Clothes retuned with strings hanging, need scissors to cut threads. Further review of the June 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 07/18/2023 revealed the following concerns: Nursing - Resident down the hall's television loud passed midnight with door closed. Staff talked on their cellphones will providing patient care. 07/02/23 call light pressed at 01:30 Pm, answered at 2:45 PM. Resident's roommate moved into her room in the middle of the night. Requested fresh fruit, received canned fruit cocktail. Resident requested/circled apple juice on menu and served orange juice. Resident allergic to orange juice. Activities: Bingo money should be paid out at time of win.Dietary: Resident circled fresh tomato salsa on menu, was not received. Laundry: Resident's shirts have marks, new shirts with holes and lace shirt torn. Further review of the July 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of the July 2023 Grievance Log revealed no logged grievances. Record review of the June 2023 Grievance Log revealed no logged grievances. June 2023; 6/19/23 Laundry over flowed. May 2023 reported books missing: Resolved: Yes 6/5/23. April 2023 none reported. Interview on 07/25/23 at 02:04 a.m. AD stated that only the resident council president attends the council meetings. She stated that she has been working with the facility for about 2 years. One year as the AD and the previous year as the AD assistant. She stated only the resident council president attends the group meetings. She stated that the other residents do not want to attend. She stated she tries to stress the importance of their attendance, but residents are not interested in participating. Two other residents were coming but one moved to independent living and the other has passed away. Interview on 07/25/23 at 03:33 p.m. DON stated that the current resident council president, has been the same president for many years. The other residents do not like to attend the meetings because the meetings are only always about the president. The other residents do not get a chance to voice or weigh in on their concerns and therefore stopped attending meetings months ago. Interview on 07/25/23 at 03:33 p.m. Administrator asked what they could do to encourage more residents to attend. She asked what the facility could do to replace the current president. The president brings with her a notebook full of complaints. The other residents do not get a change to voice their concerns or make comments. Interview on 07/26/2023 at 11:55 a.m. AD stated that she was responsible for reminding residents of the date and time of the resident council meetings and encouraging residents to attend. At the resident council minutes, she writes the minute notes and/or all the resident's concerns. She stated for the last few months only one resident has attended the resident council meetings. That resident usually brings written concerns to the meetings and the AD summarizes the notes in the group minutes for each month. Those minutes are distributed to the facility's department heads the following morning during the morning meeting. She stated that the minutes are also discussed during the Quality Assurance and Performance Improvement (QAPI) committee meeting held every 4th Friday of each month. Interview on 07-27-23 at 10:00 a.m. AD stated that she reminds residents of the group meeting the day before the meeting. She stated she then tells the CNAs of those residents who want to attend so the CNAs can get those residents ready for the day first. She stated when she completes the minutes her and the group members go over all the departments and address concerns. After the meetings, she meets with the Administrator to discuss each concern addressed. She stated July's group meetings were the first given to the present administrator. She stated she gave the previous group minutes to the previous administrator who resigned. She stated that she does not go over any resident rights. She is not responsible for ensuring the concerns are resolved or grievances logs, or forms are completed. It is the administrator's responsibility to ensure the group's concerns are resolved. Interview on 07-26-23 at 03:06 p.m. Administrator stated she had only been in the administrator role for the last 5 weeks. She stated that she received the copies of the resident council minutes for the last 4 months today. She was aware that one of the residents from group had a dislike for the fruit cups. She stated she is not aware of what the outcomes were from the previous group complaints but would find out and share that information thereafter. She stated she was not aware of the dirty carpet, but the facility had a working carpet cleaner. She stated that one of the resident council members did not like roommates and was resistant to roommates. She stated that new admissions and room changes typically take place in the afternoon. She stated if a resident is admitted late at night from a hospital discharge, it would be possible for a resident to be moved into a shared room late at night. She stated the resident with the loud television was hard of hearing and she would see if the resident had or needed a hearing aid. She stated she would ask laundry if the resident had complained of damaged clothes and whether they were repaired. She stated the bingo time was changed to give the residents more time to play. She stated after resident council meetings the AD should create grievances and log them after every group meeting. She stated that she does not know why the AD had not created grievances or if that was a responsibility in the AD's job description. Each grievance related to the department it pertains to would be responsible for addressing, resolving, and following up with the resident or family member who made the complaint with the outcome. She stated thereafter it would be check off the grievance log as completed. She stated that she had only held one QAPI meeting since she became administrator and fruit cocktails and the loud television were the only group complaints brought up and discussed. She stated she provided follow ups to all the group grievances on 07/26/23 over the last 4 months. She stated that the SW will be responsible to ensure that the grievances are resolved and followed up on. Interview on 07-27-23 at 03:00 p.m. DON stated that she addressed grievances and in-serviced staff as needed. She was not aware of any outstanding grievances. She stated staff are in-serviced on resident rights monthly. She stated it is all the department heads responsibility to respond to the grievances. Grievances are also discussed during the monthly QAPI meetings. She stated that she addressed all the concerns that are addressed in the group meetings, but the resolve was not documented. She stated that her and the Administrator will come up with a tracking and resolve system to ensure grievances are addressed, resolved, and followed up on in a timely manner. She stated that moving forward the SW and AD will be responsible for ensured the grievances are resolved and residents informed of the resolve. Record Review of Resident Council Policy Statement's revised April 2017 date revealed 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 items(s) of concern. 6. The QAPI Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.) Records received: [NAME] Health Care Center Concern Forms Nursing dated 07/26/23.

Based on observation, interview, and record review, the facility failed to develop and implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #22) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #22's comprehensive care plan included the resident's repeated refusal of Dronabinol (A medication used to treat nausea and vomiting). This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #22's face sheet undated revealed an [AGE] year-old female who admitted into the facility on [DATE]. The resident was diagnosed with fracture of the left Tibia (shin bone), dementia (mental decline not anormal part of aging), vitamin B deficiency, hypertension (elevated blood pressure), cardiac arrhythmia (irregular heartbeat), falls, and muscle weakness. Record review of Resident #22's admission MDS dated [DATE], revealed Resident #86's BIMS was scored as 11 which indicated her cognition was moderately impaired. Record review of Resident #22's Order Summary Report dated 07/26/2023 revealed Dronabinol Oral Capsule 2.5MG (Dronabinol) Give one capsule by mouth two times a day for nausea and vomiting. Order start dated 04/07/2023. Record review of Resident #22's Nurse MAR dated 07/01/2023-07/31/2023 revealed Resident #22 refused her Dronabinol on the following dates: July 2023 at 7:30AM: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 20, 22,23, 24, 25. July 2023 at 4:00 PM:1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24. Record review of Resident #22's Nurse Progress Notes revealed Resident refused her Dronabinol on July 2023: 1, 2, 3, 5, 6, 7, 16, 17, 18 and 24 by LVN A Record review of Resident #22's Nurse Progress Notes revealed Resident refused her Dronabinol on July 2023: 10 and 11 by LVN B Record review of Resident #22's care plans revision dated 07/18/2023 revealed no care plan for the resident's repeated refusal of Dronabinol. Observation on 07/26/2023 at 11:05 AM, revealed Resident #22 was in bed on her back with her head slightly elevated. Resident #22 had a wedge under her right shoulder. The resident refused to be interviewed. In a phone interview on 07/26/2023 at 12:45 PM, the facility pharmacist stated Resident #22's Dronabinol was a routine order to be given twice daily. The pharmacist stated the order was not an as needed for nausea medication. In an interview on 07/26/2023 at 2:07 PM, LVN B stated she did document the attempts to administer the Dronabinol to Resident #22. LVN B stated Resident #22 often refused the medication. LVN B stated she explained the purpose of the medication to the resident. LVN B stated the resident still refused it. LVN B stated the resident's refusal could interfere with her treatment plan. In an interview on 07/26/2023 at 2:13 PM, LVN A stated she did attempt to give Resident #22 the Dronabinol. LVN A stated Resident #22 often refused the medication. In a phone interview on 07/27/2023 at 8:37 AM, Resident #22's physician stated he was aware that Resident #22 refused her Dronabinol. The physician stated Resident #22 had no negative affects from the refusal. As the interview continued, he stated he would not change her treatment plan because of her medication refusal. In an interview on 07/27/2023 at 12:00 PM, MDS LVN stated the purpose of the care plan was to direct the resident care. The MDS LVN stated the completion of the care plan was a team effort from all departments. The MDS LVN stated nursing participated by presenting resident problems that needed to be care planned as they presented. The MDS LVN stated the care plans were reviewed quarterly and in the daily morning meetings. As the interview continued, she stated the daily morning meeting was where the DON would present issues that needed to be care planned. The MDS LVN stated the facility also had weekly standard of care meetings where resident care concerns were addressed. The MDS LVN stated Resident # 22's repeated refusal of the medication should have been care planned. She stated the refusal could have been presented in the daily morning meeting or stand of care meeting by the DON. The MDS LVN stated she did not know why it was not addressed. The MDS LVN stated the risk to the resident of an inaccurate care plan was not providing guidance for the resident's care. In an interview on 07/27/2023 at 12:51 PM, the DON stated the purpose of the care plan was to ensure the resident care was based on the individualized need of the resident. The DON stated the MDS nurse was responsible for completion of the care plan. The DON stated the care plans were reviewed quarterly and as needed for any resident changes. The DON stated Resident #22's medication refusal should have been care planned. The DON stated she was not sure how the resident's medication refusal was missed. The DON stated she did not review the care plans to follow up for accuracy. The DON stated the risk of an inaccurate care plan was it could lead to a decrease in the resident functioning with poor health outcomes. The DON stated to prevent this in the future she would be more involved in reviewing the care plans for accuracy at least monthly. In an interview on 07/27/2023 at 1:28 PM, the Administrator stated the purpose of the care plan was to provide the plan for the resident's care. The Administrator stated the completion of the care plan was a team effort from different departments. The Administrator stated the MDS was responsible for the care plan accuracy. The Administrator stated monitoring the care plan for accuracy should be on a continuous basis. The Administrator stated the risk of an inaccurate care plan was failure to provide proper care to the resident. The Administrator stated the medication refusal should be care planned especially if it was continual. The Administrator stated to prevent this again we will develop a system for addressing issues in our daily morning meetings and every Friday's standard of care meeting. The Administrator stated she was not sure why they had not already been presented and addressed. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Revised dated December 2016, reflected in part Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems .

Based on observation, interview and record review the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen as frozen foods were improperly stored, and freezers and refrigerators were unsanitary. These failures could place residents who ate from the kitchen at risk for cross-contamination and food-borne illness. Findings included: Observation on 06/14/22 at 10:20 a.m. revealed in the outside walk-in freezer there were uncovered and exposed hamburger patties. There was also beer battered onion rings that were soft to the touch and not completely frozen. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the expectation was the hamburger patties be in a closed bag and the onion rings thrown out. She stated an employee had accessed the hamburger patties and did not close the bag. She also stated the onion rings were close to the door of the freezer which was why they had thawed out. The Dining Room Manager stated there was no risk to the residents as neither the hamburger patties nor the onion rings would had been used but thrown away. Review of the facility's undated Food Storage Guidelines policy revealed Opened ingredients should be stored in sealed, airtight containers, and Doors to all cold storage facilities should be kept closed when not in use. Review of the U.S. Public Health Service, Food Code (2017) section § 3-302.11 (A)(6) revealed, FOOD shall be protected from cross contamination by: Protecting FOOD containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. Review of the U.S. Public Health Service, Food Code (2017) section § 3-501.11 revealed, Stored frozen FOODS shall be maintained frozen. Observation on 06/14/22 at 10:20 a.m. revealed the outside walk-in freezer floor had debris, spillage, and food crumbs. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the expectation was the freezer was to be cleaned every night and that the evening supervisors survey the kitchen to ensure proper cleaning. She thought the outside freezer got missed the previous evening. She stated there was no risk to the residents as that day she had the freezer cleaned. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section § 4-601.11(C), NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Interview on 06/16/22 at 9:15 a.m. the surveyor requested a cleaning schedule, the Dining Room Manager stated they did not have one. Observation on 06/14/22 at 10:20 a.m. revealed the ice cream freezer had a thick layer of ice at the bottom. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the ice cream freezer needed to be defrosted and cleaned out. She stated this was completed once a month. She also stated the reason there was a layer of ice was someone may have halfway cracked the freezer door and caused the water to defrost and freeze on the bottom. The Dining Room Manager stated there was not a risk to the residents as she checked the temperature and if it was incorrect everything was thrown out. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section §4-602.13 revealed, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Observation on 06/14/22 at 10:20 a.m. revealed the meat walk-in refrigerator and the produce walk-in refrigerator fans had dark gray debris and dust build-up. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated a company comes out once a month and services their freezers; she stated the company had not yet been out to clean this month. She also stated the risk to the residents was dust could get on the produce, but it was washed prior to preparing. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section § 4-601.11(C), NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program to prevent the development and transmission of communicable diseases for 2 (MA B, and MA C) of 2 staff and for (Resident #19, and #21) of observed for infection control. 1. MA B failed to perform hand hygiene for Resident's #21 during eye drop administration. 2. MA C failed to perform hand hygiene for Resident #19 during eye drop administration. 3. LVN E failed to change a contaminated nasal cannula tubing prior to placing it back into Resident #1's nose after it was observed on the floor. These failures could place residents at risk for spread of infection. Findings included: 1. Review of Resident #21's Face Sheet dated 08/06/2021 reflected she was a [AGE] year-old female admitted to the facility on [DATE].Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 06/14/22 at 1:18 p.m. revealed MA C pulled the medication cart to Resident #21's room. She opened the medication top drawer, obtained a bottle of [MEDICATION(S)]-[MEDICATION(S)], then closed the drawer and pulled one Kleenex for a box. She entered Resident#21's room without washing her hands. She explained to the resident it was time for her eye drops. She proceeded to the bedside, removed the cap from the bottle of [MEDICATION(S)]-[MEDICATION(S)] then pulled down the lower eye lid with her left hand without performing hand hygiene and applied one drop of [MEDICATION(S)]-[MEDICATION(S)] solution into the sac of the left eye and handed the resident the Kleenex, then exited the room without washing her hands. An interview with MA C on 06/14/22 at 12:50 p.m. revealed she should have performed hand hygiene and used gloves for eye drop administration. She said she should have washed her hands before she put on her gloves and after she removed her gloves. She stated she was just not thinking. 2. Review of Resident #19's Face sheet, dated 10/28/2021 reflected he was a [AGE] year-old male with an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 06/14/22 at 3:07 p.m. revealed MA D pushed the medication cart to Resident #19's room. He opened the medication top drawer obtained a bottle of [MEDICATION(S)] Ophthalmic solution, then closed the drawer. He entered Resident#19's room without washing his hands. He explained to the resident it was time for his eye drops. He proceeded to the bedside, removed the cap from the bottle of [MEDICATION(S)], reached over on the bedside table, pulled a tissue from the box without washing his hands he pulled down the lower right eye lid with his right index finger, applied one drop of [MEDICATION(S)] solution into the sac of the right eye, then he pulled down the left lower eye lid with his right index finger applied one drop of [MEDICATION(S)] solution into the sac of the left eye without performing hand hygiene. Then he handed the resident the tissue paper and exited the room without washing his hands. In an interview with MA D on 06/14/22 at 3:55 p.m. revealed he was supposed to wash his hands between each resident and before applying eye drops to the resident's eyes. He stated he realized he should have washed his hands and used gloves before applying eye drops. He stated he was a little nervous. An interview with the ADON on 06/15/22 at 10:35AM she revealed that hand washing was expected for eye drop administration. She stated staff was to perform hand hygiene and glove changes before and after eye drop administration. Review of the facility's dated August 2019 policy titled Handwashing, reflected, . All personnel shall follow the handwashing/hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors soap and water for the following situations before and after contact with residents .after contact with resident's intact skin. 3. Record Review of Resident #1's face sheet dated 06/16/22 reflected the resident was a [AGE] year-old female, initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #1 on 06/15/22 at 11:02 revealed resident's nasal cannula was on the floor under the bed. Observation and interview of LVN E on 06/15/22 at 11:06 revealed she picked up Resident #1's nasal cannula tubing from the resident's bedroom floor and placed it in Resident #1's nose. Interview with LVN E directly following the observation reflected she should not have placed the nasal cannula into the resident's nose, because it was contaminated with possible bacteria from being on the floor, which could lead to infection. LVN E apologized and stated she should have gone to her medication cart and retrieved new tubing.