Every finding on record at Twin Pines North Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 7 residents (Residents #5, #10, #63 and, #92) reviewed for infection control, in that: 1. The facility failed to ensure Resident #5 who had a wound was placed on enhanced barrier precaution. 2.The facility failed to ensure LVN C changed her gloves to prevent cross contamination while providing wound care for Resident #10 3. The facility failed to ensure CNA D sanitized or washed her hands between changing gloves while providing incontinent care for Resident #63. 4. The facility failed to ensure LVN B did not touch the medications she was administering to Resident #92 with bare hands, These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1.Record review of Resident #5's face sheet, dated 06/02/2026, revealed the resident was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood) , Vascular dementia (decline in cognitive abilities due abnormal blood flow in the brain), Chronic kidney disease (gradual loss of kidney function), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Cellulitis (spreading skin infection, most commonly of the lower leg) , and Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating no cognitive impairment. Resident #5 required limited assistance and was always incontinent of bowel and bladder. Record review of Resident #5's care plan, dated 03/20/2025, revealed a problem of ulcer development r/t weakness, COPD, heart failure, protein calorie malnutrition, obesity, PVD, DM. Resident with full thickness non-pressure wound to RLE. and, an intervention of Assess/record/monitor wound healing at least weekly. Measure length, width anddepth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Record review of Resident #5's physician orders for June 2026 revealed an order for STAGE 2 NON-PRESSURE ULCER TORIGHT LOWER LEG CLEAN WITH WOUND CLEASER, PAT DRY, APPLY MEDIHONEY, APPLY CALCIUM ALGINATE AND COVER WITH 4X4 BOARDER GAUZE DRESSING EVERY DAY AND PRN UNTIL HEALED. Observation on 06/02/2026 at 1:50 p.m. revealed no enhanced barrier precaution sign and no personal protective equipment seen by Resident#5's room. During an interview with LVN E on 06/02/2026 at 2:13 p.m. LVN E stated Resident #5 had a leg wound and stated he should be on enhanced barrier precaution, but he was not on enhanced barrier precaution at the moment. The wound was recurring from time to time, and it had just reopened a couple days ago. During an interview with the DON on 06/04/2026 at 4:05 PM, she stated any resident with a wound should be on enhanced barrier preauction. Resident #5 should have been placed on enhanced barrier precaution as soon as his wound reopened. Enhance barrier precaution training was provided to the staff within the current year. Record review of the facility's policy titled, Hand Washing, dated 04/01/2024, revealed Enhanced barrier precautions are indicated for residents with any of the following [ .] wound and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 2. Record review of Resident #10's face sheet, dated 06/04/2026, revealed the resident was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses which included: Chronic kidney disease (gradual loss of kidney function) , Dysphagia (Difficulty swallowing), Colostomy status (opening in the colon through the abdominal wall, called a stoma, allowing stool to bypass the rectum and anus and exit into a pouch or bag), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), and Pressure ulcer of right buttocks (Pressure ulcers, also known as bedsores or decubitus ulcers, develop when sustained pressure reduces blood flow to the skin, leading to tissue damage) . Record review of Resident #10's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating no cognitive impairment. Resident #5 required extensive assistance and was coded for having a stage 4 pressure ulcer. Record review of Resident #10's care plan, dated 01/29/2026, revealed a problem of The resident has a pressure ulcer to Left buttock, unstageable to Right & Left heel and Right buttock. Resident is at risk for future ulcers r/t reduced mobility, large body frame with multiple skin folds, DM, incontinent episodes of bowel, foley catheter insertion. and an intervention of Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Observation on 06/04/2026 at 11:19 a.m., while providing wound care for Resident #10, LVN C cleaned the wound and did not change her gloves or wash her hands before applying the treatment and clean dressing. During an interview with LVN C on 06/04/2026 at 11:45 p.m. she stated she forgot to change her gloves after cleaning the resident's wound, but she should have changed her gloves and sanitize her hands. She stated she received infection control training within the current year. During an interview with the DON on 06/04/2026 at 4:05 PM, she stated staff should change their gloves after cleaning a wound to prevent cross contamination and infection for the resident. She stated infection control training was provided for the staff annually. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, undated, revealed Hand hygiene continues to be the primary means of preventing the transmission of infection. Thefollowing is a list of some situations that require hand hygiene: [ .] After contact with a resident's mucous membranes and body fluids or excretions. 3. Record review of Resident #63's face sheet, dated 06/04/2026, revealed the resident was admitted to the facility on [DATE], with diagnoses which included: Parkinson's disease (progressive neurological disorder that primarily affects movement) , Cardiomegaly (enlargement of the heart), Dysphagia (Difficulty swallowing), Hypercholesterolemia (Elevated level of any or all lipids(fat) in the blood) , Dementia (decline in cognitive abilities), Anxiety disorder (A group of mental illnesses that cause constant fear and worry). Record review of Resident #63's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 11, indicating moderate cognitive impairment. Resident #63 required limited to extensive assistance and was coded for having an indwelling catheter. Resident #63 was always incontinent of bowel. Observation on 06/04/2026 at 11:00 a.m., revealed while providing catheter care for Resident #63, CNA D changed her gloves after cleaning the resident and before applying cream and touching the clean briefs, but she did not sanitize her hands prior to putting on new gloves. During an interview with CNA D on 06/04/2026 at 11:11AM, CNA D stated she did not realize she had to use sanitizer between change of gloves during care. She did receive infection control training within the current year. During an interview with the DON on 06/04/2026 at 4:05 PM, she stated staff should sanitize or wash their hands between changing of gloves to prevent cross contamination and infection for the resident. She stated infection control training was provided for the staff annually. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, undated, revealed Hand hygiene continues to be the primary means of preventing the transmission of infection. Thefollowing is a list of some situations that require hand hygiene: [ .] After contact with a resident's mucous membranes and body fluids or excretions. 4. Record review of Resident #92's face sheet, dated 06/04/2026, revealed the resident was admitted to the facility on [DATE], with diagnoses which included: Fracture of sacrum (break in the sacrum, a triangular bone at the base of the spine), Malignant neoplasm of sigmoid colon (Cancer of part of the intestine), Type 2 diabetes mellitus (high level of sugar in the blood), and Hypertension (High blood pressure). Record review of Resident #92's BIMS score assessment, dated 05/27/2026, revealed the resident had a BIMS score of 9, indicating moderate cognitive impairment. Record review of Skilled Section GG assessment, dated 05/29/2026, revealed Resident #92 required limited assistance and had a colostomy. Observation on 06/04/2026 at 9:08 a.m., revealed while preparing medications for Resident #92, LVN B placed a pill in the palm of her bare hand before placing in the medications cup. During an interview with LVN B on 06/04/2026 at 9:25AM, LVN B stated she realized she had touched the pill with her hand and knew she should not have because of the risk of contaminating the pill before giving it to the resident. She received infection control training within the current year. During an interview with the DON on 06/04/2026 at 4:05 PM, she stated staff should not touch medications with bare hands and the medication should go from blister or bottle directly in the cup to prevent contamination and prevent infection for the resident. She stated the staff was provided with infection control training within the current year. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, undated, revealed Staff will wear intact disposable gloves in good condition and change after each use, which helps reduce the spread of microorganisms.

Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen 1) and 2 of 3 Serveries (Servery 2 and Servery 3) reviewed for food safety requirements.1. Three bulk bin lids in the kitchen for flour and cornmeal were cracked with sharp edges and gaps are not easily cleanable and could let contaminants into the bin.2. Food service staff in Servery 2 and Servery 3 stored items in the hand sink and trash cans in front making them inaccessible for use on 6/2/2026. 3. Reach in refrigerator read 51 degrees F on the digital thermometer and milk read 53.7 degrees F in Servery 3 on 6/2/2026.4. Staff personal cell phones observed on a cutting board and stainless table used for food preparation in Servery 2 and Servery 3 respectively.5. Open milk and other open containers of TCS food observed in the reach in refrigerators in Servery 2 and Servery 3 lacked a date mark for discarding food.These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life.The findings included: During an observation on 6/2/2026 at 12:00 PM, the three bulk bin storage system with cornmeal and flour in two of the bins was observed with cracked lids on all three bins. During an observation on 6/2/2026 at 12:18 PM, a resident's personal reuseable food storage container was observed in the hand sink in Servery 2, and a trashcan was observed directly in front of the hand sink making the only hand sink in the food preparation room inaccessible. During an observation on 6/2/2026 at 12:19 PM, a personal cell phone was observed in Servery 2 on a cutting board at the steam table next to a Styrofoam cup of food and exposed dinner rolls. During an observation on 6/2/2026 at 12:21 PM, milk was observed in the Servery 2 reach in refrigerator lacking a discard by date of 7 days or less for time/temperature control for safety foods. During an observation on 6/2/2026 at 12:21 PM, the Dietary Manager instructed the Dietary Aide in Servery 2 to write a 7-day date mark on the milk showing the day it needs to be used or discarded which was 7 days after opening. During an observation on 6/2/2026 at 12:23 PM, a roll of trash bags was observed in the hand sink in Servery 3, and a trashcan was observed directly in front of the hand sink making the only hand sink in the food preparation room inaccessible. During an observation on 6/2/2026 at 12:23 PM, a personal cell phone was observed in Servery 3 on a stainless-steel table next to used foil, plastic food storage bags, a food tray, and other packaged food items. During an observation on 6/2/2026 at 12:30 PM, the reach in refrigerator in Servery 3 was observed with a cold holding temperature of 51 degrees F on the external digital display and 46 degrees F on the internal mechanical thermometer. A glass of milk poured from milk stored in the reach in cooler was observed to be 53.7 degrees F. The temperature log was observed to be blank for the AM and PM shifts on 6/1/2026 and the AM shift of 6/2/2026. During an interview on 6/2/2026 at 11:46 AM, the Dietary Manager stated she had ordered replacement lids for the cracked bulk bins. During an interview on 06/19/2026 at 11:21 AM, the Dietary Manager stated that staff take reach-in cooler temperatures, when they come in and record them on the cooler log. She stated that staff check temperatures by look(ing) at the digital thermometer on the cooler and the backup thermometer in the cooler and will notify me and maintenance if the temperature is above 41 degrees F. She stated, We discard the food if it's determined to be above 41F. The Dietary Manager stated the risk to residents of TCS foods stored above 41 degrees F was They could get sick like food poisoning. There is a greater risk for elderly residents because their immune system is different, older. She revealed that staff cannot have personal items in the food preparation areas and that lockers are provided for this purpose. She stated that staff can have a cell phone in their pocket because some have children and need to be able to receive emergency calls. This conflicts with the policy which states that cell phones are not allowed in the food preparation rooms and must be stored in lockers. She stated that hands must be washed when coming into the preparation area, leaving the preparation area, and anytime a change in task happens. She said that the hand sink must be stocked with soap and paper towels and must be accessible for hand washing at all times. She stated that the risk to residents if the hand sink was not accessible for hand washing was cross-contamination. During an interview on 6/5/2026 at 11:35 PM, the Dietary Aide stated that she would contact the Dietary Manager or Maintenance if the cooler was above 41 degrees F. Record review of the facility's undated policy, Storage Refrigerators with descriptor IC 00-10.0 revealed: All Storage Refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage.1. Storage refrigerators shall be well lighted, ventilated, temperature controlled, and must have an internal thermometer.2. Storage refrigerators shall have thermometers frequently monitored throughout the day and recorded in the am and pm shifts. Temps are recorded on the Refrigerator/Freezer Temperature Log. The refrigerator should be 41 degrees F or less, and the freezer should be maintained at less than O degrees F.3. If the temperature is not within the correct range, contact the Dietary Service Manager. If the food within the unit is still in the correct range, move it to a working unit if available. Record review of the facility's undated policy, Dietary Food Service Personnel Policy and Procedures with descriptor HR 00-2.0 revealed: Work Procedures:9. Telephone Calls: personal calls are permitted only in the case of an emergency.Work Conduct:3. All personal belongings (cigarette packages, sweaters, papers, books, eel phones, and purses) must be kept out of the food preparation area.Sanitation and Food Handling:11. All unused food must be securely covered. All items are to be dated and labeled as to their content.14. All food must be kept at its safest temperature. Room temperature is never acceptable for potentially hazardous foods. If more than 15 minutes holding is necessary, the food must be in a refrigerator at less than 41 degrees or kept hot, above 140 degrees. Record review of the facility's undated policy, Hand Washing with descriptor IC 00-4.0 revealed: Hand WashingWe will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below.Procedure:1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin.Record review of the FDA Food Code 2022, https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 6/9/2026 revealed: 3-305 Preventing contamination from the premises3-305.11 Food Storage.(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:(2) Where it is not exposed to splash, dust, or other contamination; and 3-307 Preventing Contamination from Other Sources3-307.11 Miscellaneous Sources of Contamination.FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-501 Temperature and Time Control3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(2) At 5 C (41 F) or less. P 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. PfCommercially processed foodOpen and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf 4-202 Cleanability4-202.11 Food-Contact Surfaces.(A) Multiuse FOOD-CONTACT SURFACES shall be:(1) Smooth; Pf(2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; Pf(3) Free of sharp internal angles, corners, and crevices; Pf 5-205 Operation and Maintenance5-205.11 Using a Handwashing Sink.(A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf(B) A HANDWASHING SINK may not be used for purposes other than handwashing. Pf 3-501 Temperature and Time Control3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(2) At 5 C (41 F) or less. P

Based on interview and record review the facility failed to have the comprehensive care plan reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 residents (Resident #25) reviewed for comprehensive care plans.The facility failed to revise Resident #25's care plan after the quarterly MDS assessment.This failure does not allow the resident and resident representative to participate in updating care plan goals and interventions which could place the resident at risk of not receiving needed care and treatment.The findings include:Record review of Resident #25's admission sheet dated 6/4/2026 revealed he admitted to the facility on [DATE] and was a [AGE] year-old male with primary diagnoses of acute kidney failure with tubular necrosis (kidney's tubular cells are damaged, often due to reduced blood flow, exposure to toxins, or infections), unspecified dementia (cognitive decline is evident), and unspecified intellectual disabilities (developmental disorder characterized by limitations in intellectual and adaptive functioning). Record review of Resident #25's Quarterly MDS assessment dated [DATE] documented a BIMS score of 15 of 15 indicating the resident is cognitively intact.Record review of Resident #25's care plan history on 6/4/2026 revealed the last update was completed on 12/24/2025 with the next review date listed as 3/24/2026.Record review of Resident #25's Habilitation Service Plan first quarter note dated 1/29/2026 stated, 1Q SPT meeting held at Twin Pines North. PASRR Services and supports were discussed. [Resident #25] is not on Hab therapy. Outcomes discussed and created. CLO discussed and declined. No DME needed.During an interview on 6/5/2026 at 12:02 PM, the Regional Reimbursement Nurse in the MDS office stated that she could answer questions about care plans. The Regional Reimbursement Nurse stated that Resident #25's care plan was not updated after the last quarterly MDS assessment was completed on 12/24/2025. She stated that she can't say why it was not updated but that the EMR clinical dashboard shows overdue care plans and Resident #25's care plan was listed there. She stated that the MDS case managers were responsible for reviewing the dashboard and updating the care plans that are due. She stated, At that time we were missing a case manager and the regionals were completing assessments. We hired a case manager on 3/9/2026. She stated that the impact to residents would be, The care plan would not be accurate, and the team would not be aware of the changes for a resident.During an interview on 6/5/2026 at 2:40 PM, the DON stated, After we do assessments, the assessments items trigger a care plan update, and it feeds directly in. It could be updated daily or weekly. It should be updated after each assessment. She stated, Nurses and MDS nurses are responsible for updating care plans. She stated that the impact to residents would be, We wouldn't be following up on things we could improve on that could affect the resident improvement.Record review on 6/5/2026 of the facility policy Comprehensive Care Planning revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being; andAny specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR and the resident's representative(s)-The residents' goals for admission and desired outcomes.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for 1 of 5 medication carts (Hall 500: Nurse Medication Cart) reviewed for secured medications, in that: The Facility failed to ensure that Hall 500 Medication Cart was kept locked and supervised at all times. That deficient practice could place residents at risk for drug diversion or accidental medication ingestion.The findings included: Observation on 06/04/2026 at 8:57 a.m. revealed LVN B left Hall 500's medication cart unlocked while going in a resident room to take vitals. She lost sight of the cart which was left outside the resident's room with the door partially closed. The medication cart contained medications in solid and liquid form. One resident's family member passed by the cart and one staff member walked by the cart while it was left unlocked but did not lock it. During an interview with LVN B on 06/04/2026 at 8:59 a.m., LVN B stated the medication cart was left unlocked, and she had forgotten to lock it before entering the resident's room. She stated, per policy, the cart had to be locked when she was not supervising it. During an interview with the DON on 06/04/2026 at 4:05 p.m., the DON stated all medication carts were to be kept locked when not supervised by the staff using them. She stated the staff had been trained in drug diversion and storage of medications within the current year. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, revealed: Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #33) reviewed for incontinent care and catheter care, in that: The facility did not ensure that, while providing incontinent care for Resident #33, CNA A separated the resident's labia. That deficient practice could place residents at risk for infection and skin break down due to improper care practices. The findings included: Record review of Resident #33's face sheet, dated 06/04/2026, revealed an admission date of 05/25/2022 and, a readmission date of 05/26/2026, with diagnoses that included: Atrial Fibrillation (irregular heart rhythm), Hypertension (high blood pressure), Hyperlipidemia (elevated levels of cholesterol in the blood, particularly low-density lipoprotein (LDL), often referred to as bad cholesterol.), Essential tremors (rhythmic shaking that can't be controlled), Spondylosis (degenerative changes in the spine). Record review of Resident #33's BIMS assessment, dated 05/27/2026, revealed a score of 14, indicating no cognitive impairment. Record review of Skilled Section GG, dated 05/28/2026, revealed Resident #33 required extensive assistance with her activities of daily leaving and was incontinent of bowel and bladder. Record review of Resident #33's care plan, dated 05/26/2026, revealed a problem of Resident is incontinent of bowel andbladder and requires assistance for toileting tasks / incontinent care. Potential for improved functional independence fortoileting tasks with skilled Occupational Therapy interventions. Potential for UTI (urinary tract infection). Potential for constipation. And an intervention of Ensure cloths and linen are clean, and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Observation on 06/04/2026 at 10:25 a.m. revealed while providing incontinent care for Resident #33, CNA A did not separate the resident's labia and did not clean the resident's urethral area. During an interview with CNA A on 06/04/2026 at 10:35 a.m., CNA A stated she did not separate Resident #33's labia and did not clean the resident's urethral area. She thought she was cleaning the resident by doing a path on top of the resident's labia. During an interview with the DON on 06/04/2026 at 4:04 p.m., the DON stated that during perineal care for female residents, the staff must separate residents' labia and clean the residents' urethral area to ensure appropriate cleaning and prevent infection. Training and annual skills checks for incontinent care was provided every year by the DON and ADON. Record review of Providing Perineal-Genital Care (Peri Care). dated 11/17/2024, https://nurseslabs.com/perineal-care-pericare/ , revealed Gently cleanse the outer folds of the labia majora. Use a gentle, separate motion to spread the labia and access the folds between the labia majora and labia minora, washing this area thoroughly.

Based on observations and interview, the facility failed to post the nurse staffing data on a daily basis for 1 (6/4/26) of 4 days reviewed in that:The daily posted nurse staffing information was not posted in the facility on 6/4/26.This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.Findings include:During observations on 6/4/2026 between the hours of 8:30 AM and 3:40 PM, the posting of the nursing staff information was not available for review by residents and visitors of the facility.During an interview on 6/4/26 at 3:33 PM the Administrator stated of the nurse staffing post, It's moved due to the office changes, but it should be located by the DON office. Observations made with the DON revealed the nurse staffing was not posted by the DON office. The Administrator stated she would let this surveyor know once one was posted. The sheet was located and observed posted by 3:40 PM on 6/4/2026.During an interview on 6/5/2026 at 3:45 PM, the Administrator revealed the facility does not have a policy for posting nurse staffing.

Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 of 4 (Residents #1 and #4) residents reviewed for accuracy of clinical records. There were no Nurse Notes in the EMR documenting that Resident #1's and Resident #4's missed or refused showers/bathing. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings include: 1.Record review of Resident #1's face sheet, dated 12/27/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged home on [DATE]. Resident #1 had diagnoses which included: HTN (hypertension), kidney disease, a UTI (urinary tract infection at admissions), and a history of stroke. The RP was listed as: a family member. Record review of Resident #1's admissions MDS, dated [DATE], reflected a BIMS score of 15, indicative of no impairment in cognition. The ADLs for: B/B were incontinent for some episodes Transfer and Mobility was set up. ROM: was left side impairment. Toileting was assisted by one staff member. Resident's assistive device was walker. Record review of Resident #1's Care Plan, undated, revealed, the goals and interventions included: ADLs: showers X1. G Interventions included-self-determination, participation during care, and staff to give explanation. CP also reflected that residents were resistive to care related to adjustment to NF, anxiety, and refusals of baths. Record review of Resident #1's Customer Service assessment, dated 12/3/25 and authored by corporate staff, revealed: the family (RP) expressed concern that the resident was not showered, and the family member stated the resident refused showers at time. Resident was showered on 12/3/25. Record review of Resident #1's POC for showers/bathing revealed: the scheduled days were Tuesday, Thursday, and Saturday. Further review of the POC revealed, in reference to showers/bathing:-11/18/25-not documented-11/20/25-not documented-11/22/25-not documented-11/25/25-refused-11/27/25-refused-11/29/25-not documented-12/2/25-received-12/4/25-received Record review of Resident #1's Nurse Notes from 11/17/25 to 12/4/25 revealed no nurse documentation of resident refusing or missing showers. During an interview on 12/17/25 at 4:39 PM, the MDS Nurse stated she had no explanation for nurse notes not containing any documentation involving Resident #1 refusing or missing showers. The MDS Nurse stated the DON or Administrator was responsible for the accuracy of the clinical record. During a telephone interview on 12/18/25 at 10:25 AM CNA B stated Resident #1 had refused showers 1 or 2 times and she informed the charge nurse, LVN A. CNA B stated she documented refusals in the POC. During a telephone interview on 12/18/25 at 4:14 PM, the RP stated she visited the resident daily and would inquire about the need for Resident #1 to be showered. The RP stated she complained every day for 15 days and was given excuses or told the resident would be showered. The RP stated the resident was showered only on 12/3 and 12/4/25. During a telephone interview on 12/8/25 at 4:20 PM, Resident #1 stated he did not refuse showers and asked for a shower daily from the CNA [name not given] staff. Resident #1 stated the CNAs [names not given] would state he would be given a shower but did not return to give him a shower. Resident #1 stated the CNAs would make excuses why he missed or was not given a shower. The resident stated it was frustrating to get a shower, but showers were given on 12/3/25 and 12/4/25. 2.Observation and interview on 12/17/25 at 3:21 PM, Resident #4 was in bed watching TV; There were no injuries, skin tears or bruises present. W/C present. Disposition was one of neutrality. The resident was alert and oriented X3. The residents stated her showers day were M, W, and F. The resident stated, I have not had a shower in the past week.missed many days.they say (we will see about a shower) .my family has complained about showering. The Resident stated she was not sure about any skin breakdown due to lack of showers. The resident stated she gets angry when not showered. Record review of Resident #4 's face sheet, dated 12/17/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included inflammation of the intestine, lack of coordination, and gait abnormality. The RP was listed as a family member. Record review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 12, indicative of moderate impairment in cognition. The resident's ADLs for showers/bathing were documented as supervision with one staff assistance. B/B was listed as incontinent X1; transfer and mobility X1. Resident's assistive device was a W/C. Record review of Resident #4's KARDEX (nurse form for listing of ADLs) dated 12/17/25 reflected one person assistance for bathing. Record review of Resident #4's POC reflected her shower days were M, W, and F. Further review of documentation reflected:-12/1/25-refused-12/3/25-refused-12/5/25-refused-12/8/25-refused-12/10/25-received-12/15/25-refused-12/17/25-received Record review of Resident #4's nurse notes reflected no entries made about the resident refusing showers/bathing for 9 days from 12/1/25 to 12/20/25 and for another 7 days from 12/10/25 to 12/17/25. Record review of Resident #4's Negotiated Risk Agreement dated 10/21/25 revealed: refusal of care and ADLs; and alternatives offered were bed bath, education, and showers. During an interview on 12/17/25 at 4:14 PM, the MDS Nurse stated the only place documented about shower refusals for Resident #4 was in the POC. The MDS Nurse stated there were no progress notes documenting shower refusals. The MDS Nurse stated that nursing staff needed to document shower refusals in the nurse notes, and she had no explanation for the missing documentation. During an interview on 12/18/25 at 8:27 AM, CNA C stated she provided services to Resident #4. CNA C stated ADLs included bathing/showering. CNA C stated the resident had refused showers in the past and she documented in the POC (Point of Care Portal). CNA C stated Resident #4 required one assistance with bathing. CNA C stated part of showering was to do skin assessments and report to nursing any negative findings; and she never saw any negative findings. CNA C stated that her expectation was for the charge nurse to follow up and determine why the resident refused bathing/showers. CNA C stated if a Resident #4 went without a shower for 2 weeks her expectation was to report to the charge nurse and the Administrator. During an interview on 12/18/25 at 8:53 AM, LVN D stated she had provided nursing care to Resident #1 and Resident #4. Regarding Resident #4, LVN stated the resident had not refused to receive a shower. LVN D stated that no CNA had told her about Resident #4 or any resident missing or refusing a shower. LVN D stated the expectation for residents missing showers was to explore with the resident the cause of the refusal and if needed to notify the family and physician for guidance. LVN D stated that if a pattern of missed showers was present the nurse was required to document it in the nurse's notes. During an interview on 12/18/25 at 9:18 AM, CNA E stated she had provided showering to Resident #4. CNA E stated Resident #4 had complained to her about two weeks ago that she had not been showered for a long period of time. The CNA E stated she told the charge nurse [name not given] about the comment made by Resident #4 of missing showers. CNA E stated she expected the charge nurse to do something or relay the message of the resident alleging missing showers to nurse management or the Administrator. CNA E stated she was not aware of Resident #4 having any negative outcomes or psychosocial harm from missing showers/bathing. CNA E stated she had no explanation for nursing staff not giving Resident #4 showers on scheduled shower days. During an interview on 12/18/25 at 9:51 AM, the wound nurse, LVN F stated she had provided nursing care to Resident #1. Nursing care included: assessments, skin assessments, vitals, monitoring, and medications. LVN F stated if Resident #4 refused or missed showers for over a week nurse management needed to be informed and the RP. LVN F stated, the charge nurse was responsible for checking the POC to ensure showers were done for residents. LVN F stated she had no explanation for no nursing notes in the EMR for Resident #1 and Resident #4 missing or not given showers. During an interview on 12/18/25 at 10:34 AM, the acting DON (Regional Compliance Nurse) stated she had not worked with Resident #1 or Resident #4 but had been a former DON in the facility. The DON stated that if a resident by nursing practice had a history of refusing showers/ bathing interventions included: documentation as a nurse note in the nurse note section of the EMR. The DON stated for Resident #1 the POC had to be documented for missing showers or showers not given; and she could not explain the missing documentation. The DON stated the POC as well as nurse notes had to reflect ADLs given or refused for an extended period During an interview on 12/18/25 at 11:40 AM, the Administrator stated she had no knowledge of complaints involving ADLs in showers/bathing until the appearance of the surveyor on 12/17/25. The Administrator stated she received communications from corporate on 12/3/25 [16 days from admissions of Resident #1] call that a family member alleged Resident #1 was not getting showers. The Administrator stated she did an internal investigation and the outcome revealed that the resident had a shower on 12/3/25 and the resident was discharged [DATE]. The Administrator stated the communications from the corporate HQs were not treated as a grievance and no further action was taken. The Administrator stated that she was leaving her position effective 12/19/25. The Administrator stated she was not aware of Resident #4 expressing that she missed showers. The Administrator stated she expected nursing management to keep her informed when there was a negative outcome in showers or clinical documentation. The Administrator stated she was not aware of documentation errors or lack of documentation involving Resident #1 or Resident #4, but she was aware as the Administrator for the accuracy of clinical records. Record review of facility's Documentation policy undated revealed .The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #1 and Resident #4), reviewed for the ADL of showers/bathing. 1.Resident #1 did not receive showers/bathing for the period 11/18/25 to 11/29/25 (11 days). 2.Resident #4 did not receive showers/bathing for the period 12/01/25 to 12/15/25 (14 days). This failure could result in residents experiencing infections, skin breakdown, and a diminished quality of life.The findings include: 1.Record review of Resident #1's face sheet, dated 12/27/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged home on [DATE]. Resident #1 had diagnoses which included: HTN (hypertension), kidney disease, a UTI (urinary tract infection at admissions), and a history of stroke. The RP was listed as: a family member. Record review of Resident #1's admissions MDS, dated [DATE], reflected a BIMS score of 15, indicative of no impairment in cognition. The ADLs for: B/B were incontinent for some episodes; and Transfer and Mobility was set up. ROM reflected: left side impairment. Toileting was assisted by one staff member. The resident's assistive device was a walker. Record review of Resident # 1's Care Plan, undated, revealed, the goals and interventions included: ADLs: showers X1. The interventions included self-determination, participation during care, and staff to give explanation. The CP also reflected that resident was resistive to care related to adjustment to NF, anxiety, and refusals of baths. Record review of Resident #1's physician orders, dated December 2025 reflected: no orders for infections at exit. A UTI was treated in the hospital. There were no orders for a rash or itching. Record review of Resident#1's Customer Service assessment, dated 12/3/25 and authored by corporate staff, revealed: the family (RP) expressed concern that the resident was not showered, and the family member stated the resident refused showers at times. Resident #1 was showered on 12/3/25. Record review of Resident #1's Skin Assessments revealed: Admissions (dated 11/17/25) bruise to hand. Last skin assessment, dated 12/1/25, revealed his skin was intact. Record review of Resident #1's daily charting for skin assessment reflected no skin findings for 12/3 and 12/4/2025. Record review of Resident #1's POC for showers/bathing revealed the scheduled days were Tuesday, Thursday, and Saturday. Further review of the PPC revealed, in reference to showers/bathing:-11/18/25-not documented-11/20/25-not documented-11/22/25-not documented-11/25/25-refused-11/27/25-refused-11/29/25-not documented-12/2/25-received-12/4/25-received Record review of Resident #1's Nurse Notes from 11/17/25 to 12/4/25 reflected no nurse documentation of resident refusing showers. During a telephone interview on 12/18/25 at 10:08 AM, LVN A stated he had provided nursing care to Resident #1. LVN A stated Resident #1 refused showers a lot. LVN A stated the resident would accept showers from family members and at times refused the showers from family members. LVN A stated the OT [name not given] attempted to encourage the resident to accept showers and the resident would still refuse. LVN A stated he did not call the MD to get guidance or get new orders to deal with the resident's refusals of showers. LVN A stated there were no negative outcomes from the resident's refusals of showers and the resident did not reveal body odors. LVN A stated the CNAs [names not given] would inform him about the shower refusals. During a telephone interview on 12/18/25 at 10:25 AM CNA B stated Resident #1 had refused showers 1 or 2 times and she informed the charge nurse LVN A. CNA B stated she had been employed in the facility for 2 months. The CNA stated she documented refusals in the POC. CNA B stated she saw no skin breakdown or smelled odors when providing ADL care to the resident. During a telephone interview on 12/18/25 at 4:14 PM, the RP stated she visited the resident daily and would inquire about the need for Resident #1 to be showered. The RP stated she complained every day for 15 days and was given excuses or told the resident would be showered. The RP stated the resident was showered only on 12/3/25 and 12/4/25. During a telephone interview on 12/8/25 at 4:20 PM, Resident #1 stated he did not refuse showers and asked for a shower daily from the CNA [name not given] staff. Resident #1 stated the CNAs [names not given] would state he would be given a shower but did not return to give him a shower. Resident #1 stated the CNAs would make excuses why he missed or was not given a shower. The resident stated it was frustrating to get a shower, but showers were given on 12/3/25 and 12/4/25. 2.Observation and interview on 12/17/25 at 3:21 PM, Resident #4 was in bed watching TV; There were no injuries, skin tears or bruises present. W/C present. Disposition was one of neutrality. The resident was alert and oriented X3. The residents stated her showers day were M, W, and F. The resident stated, I have not had a shower in the past week.missed many days.they say (we will see about a shower) .my family has complained about showering. The Resident stated she was not sure about any skin breakdown due to lack of showers. The resident stated she gets angry when not showered. Record review of Resident #4's face sheet, dated 12/17/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included inflammation of the intestine, lack of coordination, and gait abnormality. The RP was listed as a family member. Record review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 12, indicative of moderate impairment in cognition. The resident's ADLs for showers/bathing were documented as supervision with one staff assistance. B/B were listed as incontinent X1; and transfer and mobility X1. The resident's assistive device was a W/C. Record review of Resident #4's KARDEX (nurse form for listing of ADLs) dated 12/17/25 reflected one person assistance for bathing. Record review of Resident #4's Skin assessment dated [DATE] reflected her skin was intact. Record review of Resident #4's CP, undated, in the Goal of ADLs listed the resident could refuse showers as a personal preference. Record review of Resident #4's POC reflected her shower days were M, W, and F. Further review of documentation reflected:-12/1/25-refused-12/3/25-refused-12/5/25-refused-12/8/25-refused-12/10/25-received-12/15/25-refused-12/17/25-received Record review of Resident #4's nurse notes dated reflected there were no documentation of resident refusing showers from the period 12/1/25 to 12/9/25. Record review of Resident #4's Negotiated Risk Agreement dated 10/21/25 revealed: refusal of care and ADLs; and alternatives offered were bed bath, education, and showers. During an interview on 12/17/25 at 4:14 PM, the MDS Nurse stated the only place documented about shower refusals for Resident #4 was in the POC. The MDS Nurse stated there were no progress notes documenting shower refusals. The MDS Nurse stated that nursing staff needed to document shower refusals in the nurse notes, and she had no explanation for the missing documentation. During an interview on 12/18/25 at 8:27 AM, CNA C stated she provided services to Resident #4. CNA C stated ADLs included bathing/showering. CNA C stated the resident had refused showers in the past and she documented in the POC (Point of Care Portal). CNA C stated Resident #4 required one person assistance with bathing. CNA C stated part of showering was to do skin assessments and report to nursing any negative findings; and she never saw any negative findings. CNA C stated that her expectation was for the charge nurse to follow up and determine why the resident refused bathing/showers. CNA C stated if Resident #4 went without a shower for 2 weeks her expectation was to report to the nurse and the Administrator. During an interview on 12/18/25 at 8:53 AM, LVN D stated she had provided nursing care to Resident #1 and Resident #4. Regarding Resident #4, LVN D stated the resident had not refused to receive a shower. LVN D stated that no CNA had told her about Resident #4 or any resident missing or refusing a shower. LVN D stated the expectation for residents missing showers was to explore with the resident the cause of the refusal and if needed to notify the family and physician for guidance. LVN D stated that if a pattern of missed showers was present the nurse was required to document it in the nurse's notes. During an interview on 12/18/25 at 9:18 AM, CNA E stated she had provided showers to Resident #4. CNA E stated Resident #4 had complained to her about two weeks ago that she had not been showered for an extended period. The CNA E stated she told the charge nurse [name not given] about the comment made by Resident #4 of missing showers. CNA E stated she expected the charge nurse to do something or relay the message of the resident alleging missing showers to nurse management or the Administrator. CNA E stated she was not aware of Resident #4 having any negative outcomes or psychosocial harm from missing showers/bathing. CNA E stated she had no explanation for nursing staff not giving Resident #4 showers on scheduled shower days. During a telephone interview on 12/18/25 at 9:46 AM, Resident #4's MD stated he had not been informed about any resident missing showers. The MD stated bathing/showers were to be given at least every third day. The MD stated showers were important for hygiene and bodily function. The MD stated if a resident went without showers for an extended period he should be notified for him to speak to the resident and issue any new orders. During an interview on 12/18/25 at 9:51 AM, the wound nurse, LVN F stated had provided nursing care to Resident #1. LVN F stated that nursing care included assessments, skin assessments, vitals, monitoring, and medications. LVN F stated skin assessments for the past 90 days to include on 12/10/25 had shown Resident #4'skin was intact. LVN F stated if a resident had missed showers for a week or more, the nursing staff should contact the MD, RP and speak to the resident to ascertain the reason for refusals and missed showers. LVN F stated, the charge nurse was responsible for checking the POC to ensure showers were done for residents. During an interview on 12/18/25 at 10:34 AM, the acting DON (Regional Compliance Nurse) stated she had not worked with Resident #1 or Resident #4 but had been a former DON in the facility. The DON stated that if a resident by nursing practice had a history of refusing showers/ bathing interventions included a CP meeting, notification to family, and re-education of the resident; and ensuring the CP and documentation were current. The DON stated for Resident #1 the POC had to be documented for missing showers or showers not given; and she could not explain the missing documentation. The DON stated the POC had to reflect ADLs given or refused. During an interview on 12/18/25 at 11:40 AM, the Administrator stated she had no knowledge of complaints involving ADLs in showers/bathing until the appearance of the surveyor on 12/17/25. The Administrator stated she received communications from corporate on 12/3/25 [16 days from admissions of Resident #1] call that a family member alleged Resident #1 was not getting showers. The Administrator stated she did an internal investigation and the outcome revealed that the resident had a shower on 12/3/25 and the resident was discharged [DATE]. The Administrator stated the communications from the corporate HQs were not treated as a grievance and no further action was taken. The Administrator stated that she was leaving her position effective 12/19/25. The Administrator stated she was not aware of Resident #4 expressing that she missed showers. The Administrator stated she expected nursing management to keep her informed when there was a negative outcome in showers or clinical documentation. The Administrator stated she was not aware of documentation errors or lack of documentation involving Resident #1 or Resident #4, but she was aware as the Administrator for the accuracy of clinical records. Record review of facility's Bath, Tub/Shower policy undated read: .The resident will experience improved comfort and cleanliness by bathing.

Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. LVN B inaccurately documented on Resident #1's TAR that his BiPAP was removed on 9/16/25 in the morning. This failure could place residents at risk for inaccurately documented interventions, monitoring, and information provided to the interdisciplinary team. The findings were: Record review of Resident #1 's face sheet, dated 9/18/25, reflected the resident was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: acute and chronic respiratory failure with hypercapnia (too much CO2 (carbon) in the bloodstream) [primary], congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea (sleep disorder where breathing stops and starts), and COPD (lung disease). Record review of Resident#1's admissions MDS, dated [DATE], reflected a BIMS score of 9, indicative of moderate impairment in cognition. Record review of Resident#1's Physician' Orders, dated August 2025 revealed: connect resident to BiPAP machine when sleeping and napping; and Remove BIPAP upon waking up. Record review of Resident #1's TAR dated September 2025 reflected the BiPAP machine was removed every morning upon the resident waking up for the period September 1 to September 16, 2025. On 9/16/25, LVN B documented the removal of Resident #1's BiPAP in the AM. Record review of Resident #1's Care Plan, undated revealed, the goal of respiratory care. The CP stated the resident required the BiPAP related to sleep apnea, morbid obesity with hypoventilation. Further review revealed the care plan noted, resident removes BIPAP per personal preference, and nursing staff were required to monitor saturation as ordered and the resident was to use the BiPAP as ordered. Record review of Resident#1's Nurse Note, dated 9/15/25 at 11:09 PM authored by LVN B, reflected: resident was upset, refused his medications, broke his cane, and threw his BiPAP machine to the floor. LVN B documented the BiPAP machine would not turn on, and the resident remained on continuous O2 through the nasal cannula. LVN B further documented that the resident was alert and oriented. During an interview with LVN A on 9/18/25 at 11:32 AM, LVN A stated, based on the nurse note dated 9/15/25 at 11:09 PM authored by LVN B, the resident threw the BiPAP on the floor and went to sleep without a BiPAP. LVN A stated per the nurse note revealed the resident was on continuous O2. LVN A stated the TAR documented by LVN B reflected removal of the resident's BiPAP in the morning. LVN A stated the resident claimed the BiPAP was not present the night of 9/15/25 but the TAR reflected the BiPAP was removed in the morning. Attempted interview on 9/18/25 at 2:03 PM with Resident #1 was unsuccessful. During an interview with the DON on 9/18/25 at 3:46 PM, the DON stated the nurse note dated 9/15/25 at 11:09 PM authored by LVN B reflected Resident #1 threw his BiPAP on the floor and refused to put it on. The DON stated, LVN B inaccurately documented on the TAR that the BiPAP was removed in the morning. The DON stated she could not explain the inaccurate documentation of the TAR by LVN B. During an interview with LVN B on 9/19/25 at 10:18 AM, LVN B stated she was the night nurse for Resident #1 on 9/15/25. LVN B stated on 9/15/25 around 11:00 PM the resident got upset and threw his BiPAP on the floor. LVN B stated the BiPAP was not re-connected to the resident and continuous O2 remained in place on the resident through a nasal cannula the entire time. LVN B stated she inaccurately charted on Resident #1's TAR that she removed the resident's BiPAP in the morning on 9/16/25. LVN B stated that she should have charted removing Resident #1's nasal canula and replacing it. During an interview with the DON on 9/19/25 at 11:18 AM, The DON stated the TAR for Resident #1 should document per MD order when the BiPAP was removed when the resident was awakened. The DON confirmed LVN B inaccurately documented in the TAR the removal of Resident #1's BiPAP in the morning on 9/16/25. The DON stated she trusted that nurses accurately documented in the clinical record and by exception would check when inaccurate documentation was noted in the clinical record. During an interview with the Administrator on 9/19/25 at 11:35 AM, the Administrator stated resident records needed to be accurate to reflect care and services given. Record review of the facility's policy titled, Documentation, undated, revealed, The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. LVN B inaccurately documented on Resident #1's TAR that his BiPAP was removed on 9/16/25 in the morning. This failure could place residents at risk for inaccurately documented interventions, monitoring, and information provided to the interdisciplinary team. The findings were: Record review of Resident #1 's face sheet, dated 9/18/25, reflected the resident was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: acute and chronic respiratory failure with hypercapnia (too much CO2 (carbon) in the bloodstream) [primary], congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea (sleep disorder where breathing stops and starts), and COPD (lung disease). Record review of Resident#1's admissions MDS, dated [DATE], reflected a BIMS score of 9, indicative of moderate impairment in cognition. Record review of Resident#1's Physician' Orders, dated August 2025 revealed: connect resident to BiPAP machine when sleeping and napping; and Remove BIPAP upon waking up. Record review of Resident #1's TAR dated September 2025 reflected the BiPAP machine was removed every morning upon the resident waking up for the period September 1 to September 16, 2025. On 9/16/25, LVN B documented the removal of Resident #1's BiPAP in the AM. Record review of Resident #1's Care Plan, undated revealed, the goal of respiratory care. The CP stated the resident required the BiPAP related to sleep apnea, morbid obesity with hypoventilation. Further review revealed the care plan noted, resident removes BIPAP per personal preference, and nursing staff were required to monitor saturation as ordered and the resident was to use the BiPAP as ordered. Record review of Resident#1's Nurse Note, dated 9/15/25 at 11:09 PM authored by LVN B, reflected: resident was upset, refused his medications, broke his cane, and threw his BiPAP machine to the floor. LVN B documented the BiPAP machine would not turn on, and the resident remained on continuous O2 through the nasal cannula. LVN B further documented that the resident was alert and oriented. During an interview with LVN A on 9/18/25 at 11:32 AM, LVN A stated, based on the nurse note dated 9/15/25 at 11:09 PM authored by LVN B, the resident threw the BiPAP on the floor and went to sleep without a BiPAP. LVN A stated per the nurse note revealed the resident was on continuous O2. LVN A stated the TAR documented by LVN B reflected removal of the resident's BiPAP in the morning. LVN A stated the resident claimed the BiPAP was not present the night of 9/15/25 but the TAR reflected the BiPAP was removed in the morning. Attempted interview on 9/18/25 at 2:03 PM with Resident #1 was unsuccessful. During an interview with the DON on 9/18/25 at 3:46 PM, the DON stated the nurse note dated 9/15/25 at 11:09 PM authored by LVN B reflected Resident #1 threw his BiPAP on the floor and refused to put it on. The DON stated, LVN B inaccurately documented on the TAR that the BiPAP was removed in the morning. The DON stated she could not explain the inaccurate documentation of the TAR by LVN B. During an interview with LVN B on 9/19/25 at 10:18 AM, LVN B stated she was the night nurse for Resident #1 on 9/15/25. LVN B stated on 9/15/25 around 11:00 PM the resident got upset and threw his BiPAP on the floor. LVN B stated the BiPAP was not re-connected to the resident and continuous O2 remained in place on the resident through a nasal cannula the entire time. LVN B stated she inaccurately charted on Resident #1's TAR that she removed the resident's BiPAP in the morning on 9/16/25. LVN B stated that she should have charted removing Resident #1's nasal canula and replacing it. During an interview with the DON on 9/19/25 at 11:18 AM, The DON stated the TAR for Resident #1 should document per MD order when the BiPAP was removed when the resident was awakened. The DON confirmed LVN B inaccurately documented in the TAR the removal of Resident #1's BiPAP in the morning on 9/16/25. The DON stated she trusted that nurses accurately documented in the clinical record and by exception would check when inaccurate documentation was noted in the clinical record. During an interview with the Administrator on 9/19/25 at 11:35 AM, the Administrator stated resident records needed to be accurate to reflect care and services given. Record review of the facility's policy titled, Documentation, undated, revealed, The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 7 residents (Residents #52 and #53) reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B wore gowns while in providing care to Resident #52 who was on EBP. 2. The facility failed to ensure LVN C did not administer insulin Lispro (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) to Resident #53, from an insulin pen labelled for a different resident (Resident #274). These failures could place residents at risk for cross contamination and infection. The finding included: 1. Record review of Resident #52's Admission Record, dated 04/08/2025, revealed a [AGE] year-old male admitted on [DATE] with re-admission on 02/27/2025 with diagnoses which included: Dementia (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life); Injury of Urethra (tube that carries urine from bladder out of the body); Urinary Tract Infection (a bacterial infection that occurs in any part of the urinary system); Obstructive and Reflux Uropathy (condition characterized by urinary tract blockage and/or backflow of urine). Record review of Resident #52's 5-day MDS assessment dated [DATE] revealed the resident had a BIMS score of 09 indicating Moderate Cognitive Impairment, and was assessed as having an indwelling catheter. Record review of Resident #52's care plan initiated 01/13/2025 revealed the resident had an indwelling catheter and was on enhanced barrier precautions with interventions which included Gloves and gown should be donned if any of the following activities are to occur: toileting/incontinent care .catheter care. Record review of Resident #52's Order Summary Report dated 04/08/2025 revealed orders which included: - Provide catheter care every shift related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (order date 02/27/2025) - ENHANCED BARRIER PRECAUTIONS (order date 02/28/2025) Observation on 04/08/2025 at 10:50 a.m. revealed CNA-A and CNA-B sanitized their hands and put on gloves to perform peri-care and catheter care for Resident #52 but did not wear a gown. There was an EBP sign posted on entrance door to Resident #52's room and a supply of PPE next to the door. During a joint interview on 04/08/2025 at 11:03 a.m. with CNA-A and CNA-B, both stated they had received training on EBP, and knew they were supposed to put on both a gown and gloves when working directly with any resident with a catheter but had just gotten nervous and forgot. CNA-A stated that by not following EBP, it could result in spread of germs and infection. During an interview with the DON on 04/08/2025 at 11:47 a.m., the DON stated that both CNA's should have followed EBP by wearing both a gown and gloves to provide foley care to Resident #52, and that both CNA's had received training on infection control including EBP. The DON stated that not following EBP could increase the risk of the spread of infection. Record review of the facility policy titled Enhanced Barrier Precautions and dated 04/01/2024 revealed: - EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing; and - EBP are indicated for resident with any of the following . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 2. Record review of Resident # 53's Admission Record dated 04/07/2025 revealed a [AGE] year old man admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #53's 5-day MDS assessment dated [DATE] revealed he had a BIMS score of 15 indicating intact cognition, and was assessed as having Diabetes Mellitus and receiving insulin injections. Record review of Resident #53's Care Plan initiated 03/07/2025 revealed he had Diabetes Mellitus with interventions for diabetes medication as ordered by the doctor. Record review of Resident #53's Order Summary Report dated 04/07/2025 revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 150-199=1 UNIT; 200-249= 2 UNITS; 250-299=3 UNITS; [PHONE NUMBER]=4 UNITS, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . During an observation on 04/07/2025 at 04:41 p.m., LVN-C was observed to administer 2 units of Insulin Lispro into Resident #53's left deltoid (upper arm) with an Insulin Lispro pen labelled for Resident #274. Further observation of the Insulin Lispro pen revealed that the pharmacy label with Resident #274's name was on the lower end of the insulin pen and handwritten on the outside of the cap of the insulin pen, in black permanent marker was Resident #53's last name. During an interview with LVN-C on 04/07/2025 at 4:46 p.m. LVN-C stated she used the Insulin Lispro pen for Resident #274 for Resident #53, because Resident #53 was out of his insulin Lispro, but it is the same medication, and she did not want Resident #52 to go without his insulin. She stated she had checked the extra supply in the refrigerator in the medication room and Resident #53 did not have any Insulin Lispro there, and when she checked the order for his medication found it was supposed to be delivered later that night, but since his insulin was due before evening meal and he did not have any, she used the Insulin Lispro pen labelled for Resident #274 to administer insulin to Resident #53 because it was the same type insulin that Resident #53 receives. She stated she sanitized and put a new pen needle on the pen and wrote Resident #53's last name on the cap of the pen. While conducting the interview with LVN-C on 04/07/2025 at 4:46 p.m., the Regional Compliance Nurse approached and when shown the Insulin Lispro pen labelled for Resident #247, but was used to administer insulin to Resident #53, she stated that LVN-C should not have used an insulin pen labelled for one resident to be used for a different resident, even if it was the same medication. She stated that this could result in Resident #247 running out of his medication early and stated that LVN-C should have used insulin from the stat-safe (an emergency kit that contains a small quantity of medications that can be dispensed when pharmacy services not available). During further interview with the Regional Compliance Nurse on 04/09/2025 at 12:31 p.m. the Regional Compliance Nurse stated that the same insulin pen should not be used for 2 different residents as it could result in spread of infection. Record review of the Nurse Proficiency Audit for LVN-C dated 4/1/2025 revealed LVN-C was assessed as satisfactory for tasks which included: Administers medications properly and Infection Control prevents cross contamination. Record review of the facility policy titled Medication Administration Procedures revised 10/25/2017 revealed the following: - Medications prescribed for one resident are not to be administered to any other resident; and - It is prohibited from borrowing one resident's medication to be used for a different resident. Record review of an article titled Sharing Insulin Pens: Are You Putting Patients at Risk? dated 10/15/2013 at https://pmc.ncbi.nlm.nih.gov/articles/PMC3816894/ revealed Backflow of blood and other biologic material into the insulin cartridge or reservoir can occur after injection (1). For this reason, insulin pens, like other injection devices, must never be used by more than one person.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 residents (Resident #53) reviewed for pharmacy services. The facility failed to ensure LVN C did not handwrite Resident #53's last name on the cap of an Insulin Lispro pen (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) which was labeled with a pharmacy label for a different resident (Resident #274) and administer insulin from that Insulin Lispro pen labeled for Resident #274 to Resident #53. This failure could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications due to incorrect labelling or not having their medications available when needed. Findings Included: Record review of Resident # 53's Admission Record dated 04/07/2025 revealed a [AGE] year-old man admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #53's 5-day MDS assessment dated [DATE] revealed he had a BIMS score of 15 indicating intact cognition, and was assessed as having Diabetes Mellitus and receiving insulin injections. Record review of Resident #53's Care Plan initiated 03/07/2025 revealed he had Diabetes Mellitus with interventions for diabetes medication as ordered by the doctor. Record review of Resident #53's Order Summary Report dated 04/07/2025 revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 150-199=1 UNIT; 200-249= 2 UNITS; 250-299=3 UNITS; [PHONE NUMBER]=4 UNITS, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . During an observation on 04/07/2025 at 04:41 p.m., LVN-C was observed to administer 2 units of Insulin Lispro into Resident #53's left deltoid (upper arm) with an Insulin Lispro pen labeled with a pharmacy label for Resident #274. Further observation of the Insulin Lispro pen revealed that the pharmacy label with Resident #274's name was on the lower end of the insulin pen and handwritten on the outside of the cap of the insulin pen, in black permanent marker was Resident #53's last name. During an interview with LVN-C on 04/07/2025 at 4:46 p.m. LVN-C stated she used Resident #274's Insulin Lispro pen for Resident #53, because Resident #53 was out of his insulin Lispro, but it was the same medication, and she did not want Resident #52 to go without his insulin. She stated she had checked the extra supply in the refrigerator in the medication room and Resident #53 did not have any Insulin Lispro there, and when she checked the order for his medication found it was supposed to be delivered later that night, but since his insulin was due before evening meal and he did not have any, she used the Insulin Lispro pen labeled for Resident #274 to administer insulin to Resident #53 because it was the same type insulin that Resident #53 receives. She stated she sanitized and put a new pen needle on the pen and wrote Resident #53's last name on the cap of the pen. The Regional Compliance Nurse approached during this interview and when shown the Insulin Lispro pen, she stated LVN-C should not have used an insulin pen labeled for one resident to be used for a different resident, even if it was the same medication. She stated this could result in Resident #247 running out of his medication early and stated that LVN-C should have used insulin from the stat-safe (an emergency kit that contains a small quantity of medications that can be dispensed when pharmacy services not available). Record review of the facility policy titled Medication Administration Procedures revised 10/25/2017 revealed the following: - Medications prescribed for one resident are not to be administered to any other resident; and - It is prohibited from borrowing one resident's medication to be used for a different resident.

Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #53) reviewed for pharmacy services. The facility failed to ensure Resident #53's Insulin Lispro was acquired and available per physician's orders. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life. The findings included: Record review of Resident # 53's Admission Record dated 04/07/2025 revealed a [AGE] year-old man admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #53's 5-day MDS assessment dated [DATE] revealed he had a BIMS score of 15 indicating intact cognition and was assessed as having Diabetes Mellitus and receiving insulin injections. Record review of Resident #53's Care Plan initiated 03/07/2025 revealed he had Diabetes Mellitus with interventions for diabetes medication as ordered by the doctor. Record review of Resident #53's Order Summary Report dated 04/07/2025 revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 150-199=1 UNIT; 200-249= 2 UNITS; 250-299=3 UNITS; [PHONE NUMBER]=4 UNITS, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . During an observation on 04/07/2025 at 04:41 p.m., LVN-C was observed to administer 2 units of Insulin Lispro into Resident #53's left deltoid (upper arm) with an Insulin Lispro pen labeled with a pharmacy label for Resident #274. Further observation of the Insulin Lispro pen revealed that the pharmacy label with Resident #274's name was on the lower end of the insulin pen and handwritten on the outside of the cap of the insulin pen, in black permanent marker was Resident #53's last name. During an interview with LVN-C on 04/07/2025 at 4:46 p.m. LVN-C stated she used Resident #274's Insulin Lispro pen for Resident #53, because Resident #53 was out of his insulin Lispro, but it was the same medication, and she did not want Resident #53 to go without his insulin. She stated she had checked the extra supply in the refrigerator in the medication room and Resident #53 did not have any Insulin Lispro there, and when she checked the order for his medication found it was supposed to be delivered later that night, but since his insulin was due before evening meal and he did not have any, she used the Insulin Lispro pen labeled for Resident #274 to administer insulin to Resident #53 because it was the same type insulin that Resident #53 receives. She stated she sanitized and put a new pen needle on the pen and wrote Resident #53's last name on the cap of the pen. The Regional Compliance Nurse approached during this interview and when shown the Insulin Lispro pen, she stated LVN-C should not have used an insulin pen labeled for one resident to be used for a different resident, even if it was the same medication. She stated this could result in Resident #247 running out of his medication early and stated that LVN-C should have used insulin from the stat-safe (an emergency kit that contains a small quantity of medications that can be dispensed when pharmacy services not available). During a joint interview with the DON and Regional Compliance Nurse on 04/08/2025 at 3:00 p.m., the DON stated that each Nurse is responsible for ordering medications when they see that the medication is starting to get low. The DON noted that when insulin is given per sliding scale, the amount of insulin administered varies, and this can make knowing when to re-order difficult, but stated that each insulin pen is only good for 30 days after it is opened. The Regional Compliance Nurse stated that they would need to review their medication order procedure. Record review of the facility policy titled Medication Administration Procedures revised 10/25/2017 revealed the following: - Medications prescribed for one resident are not to be administered to any other resident; and - It is prohibited from borrowing one resident's medication to be used for a different resident.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident # 274) reviewed for respiratory care. The facility failed to ensure Resident #274's oxygen was set at the correct oxygen setting of 3 L/min as ordered by the physician, instead of 10 L/min, which it was set at on 04/06/2025 at 11:45 a.m. This failure could place resident at risk of developing respiratory complications, and experiencing adverse side effects. The findings included: Record review of Resident # 274's Admission Record dated 04/07/2025 revealed he was a [AGE] year old man initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: Chronic obstructive Pulmonary Disease (COPD - a group of lung disease that block airflow and make it difficult to breathe). Record review of Resident #274's 5-day MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Further review revealed Resident #274 was assessed as being dependent for all his hygiene, dressing and transfer needs. Record review of Resident #274's Care Plan initiated 01/28/2025 revealed he had impaired cognitive function/dementia, impaired visual function and had oxygen via nasal prongs at 3-4 L/min. The Care Plan also addressed his removal of his oxygen at times with interventions to notify the Nurse if the oxygen was off the resident. Record review of Resident #274's Order Summary Report dated 04/07/2025 revealed orders for: - May use oxygen @ 3-4 l/m via nasal canula every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE; and -O2 at (3-4) liters per (NASAL CANULA) Observation and Interview of Resident #274 in his room on 04/06/2025 at 11:45 a.m. revealed his nasal canula was around his neck, resting on his chest, with the nasal prongs at the back of his head. Observation of his oxygen concentrator revealed his oxygen was set at 10 L/min. Resident #274 did not appear to be in any distress or have any difficulty breathing, and was able to verbally state no when asked if he was having trouble breathing or having shortness of breath. During an observation and interview with LVN-E in Resident #274's room on 04/06/2025 at 11:49 a.m., LVN-E stated Resident #274 will sometimes remove his oxygen tubing and stated they had just cleaned and changed Resident #274 earlier that morning and he had the nasal canula on then. LVN-E proceeded to correctly place the nasal canula on Resident #274, and then after being asked what setting his oxygen was supposed to be set at, she stated 3 liters and checked his oxygen setting, and stated it had been set at 10 L/min, and immediately changed the setting to 3 L/min. LVN-E stated that sometimes Resident #274's family member will increase his oxygen setting thinking he needs more oxygen, but stated she had not seen Resident #274's family member there that morning and could not remember if she had checked his oxygen setting after cleaning him earlier that morning. LVN-E stated that with his oxygen setting set to 10 L/min and no humidification, it could have dried out his nasal membranes and caused nose bleeds. During an interview on 04/06/2025 at 11:52 a.m. with the Regional Compliance Nurse, she stated that Resident #274's oxygen should not have been set at 10 L/min, and that the Nurse should check his oxygen setting each time she works with the resident and check his oxygen saturation levels at least once per shift and as needed. The Regional Compliance Nurse further stated she will address the oxygen setting with the Nurse and noted that humidification was not needed for oxygen settings less than 4 L/min. Observation of Resident #274's room on 04/07/2025 at 3:11 p.m. revealed Resident #274's nasal canula was dangling off the side of the bed, and his oxygen was set at 3 L/min. The DON entered the room, observed the nasal canula dangling off the side of the bed, and she stated that he frequently removes his nasal canula. The DON obtained a pulse oximeter (device used to measure saturation of oxygen in a person's blood) to check his oxygen saturation level and stated it was 98% on room air, within normal limits. The DON stated she would contact the doctor to see if Resident #274 needed to continue to receive oxygen therapy since he was maintaining adequate oxygen saturation levels without the oxygen. Record review of the facility policy titled Oxygen Administration revised 03/21/2023, revealed The amount of oxygen by percent of concentration of L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. Further review revealed Turn on oxygen after properly setting for volume and place device in position.

Based on interviews and record reviews the facility failed to review and revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 26 residents (Resident #126) reviewed for care plans. The facility failed to revise a care plan to address Resident #126's oxygen usage. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Record review of Resident #126's face sheet, dated 4/9/25, revealed an original admitted [DATE] with diagnoses that included: cerebral infarction (a condition in which blood flow to the brain is blocked), atherosclerotic heart disease (a condition in which there is damage to the major blood vessels of the heart), and type 2 diabetes (a condition in which the body has trouble controlling the blood sugar). Record review of Resident's #126's Re-admission MDS assessment, dated 2/7/25, revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #126's Physician's orders initiated on 2/7/25 revealed Resident #126 could receive oxygen up to 5 liters as needed. Record review of Resident #126's ongoing care plan initiated on 2/10/25 revealed that the Resident's oxygen's use was not documented in the care plan. During an interview with MDS LVN-D on 4/9/25 at 10:00am she stated Resident # 126's oxygen use was not documented on his current care plan. She stated having the oxygen usage on the care plan was important for care staff to be aware of the resident's care needs so that the needs are met. During an interview with the ADON on 4/9/25 at 10:20 a.m., she stated Resident #126's oxygen's use was not documented on his current care plan. She stated the Resident's oxygen usage should have been documented on the resident's care plan and it had been omitted. She stated that having this information documented on the resident's care plan by nursing staff would allow the resident care needs to be met. Record review of the facility's policy titled Comprehensive Care Planning-GP-MC 03-18.0 in the Nursing Policy and Procedure Manual that was undated revealed The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #274) reviewed for accommodation of needs. The facility failed to ensure Resident #274's call light was within reach while he was lying on his bed in his room on 04/06/2025 at 11:45 a.m. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident # 274's Admission Record dated 04/07/2025 revealed he was a [AGE] year-old man initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities); Legal blindness; acquired absence of right leg above knee; and acquired absence of left leg below knee. Record review of Resident #274's 5-day MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. Further review revealed Resident #274 was assessed as being dependent for all his hygiene, dressing and transfer needs, and required use of a mechanical lift for transfers. Record review of Resident #274's Care Plan initiated 01/28/2025 revealed he had impaired cognitive function/dementia, impaired visual function and had a communication problem, with interventions which included Ensure/provide a safe environment: Call light in reach . Observation and Interview of Resident #274 in his room on 04/06/2025 at 11:45 a.m. revealed his call light was looped over and behind the bed frame at head of his bed, not within reach of Resident #274. Resident #274 was only able to answer in one-word answers to questions and when asked if he could use his call light, Resident #274 moved his hand around on the bed as if looking for the call light, then stopped, but did not answer. During an observation and interview with LVN-I in Resident #274's room on 04/06/2025 at 11:49 a.m., LVN-I stated they had just cleaned and changed Resident #274 earlier that morning and must have moved the call light out of the way while they were cleaning him and forgot to replace the call light within his reach afterwards. LVN-I removed the call light from the bed frame at head of bed and secured it to the linens next to Resident #274's hand. LVN-I stated Resident #274 had a visual impairment and needed total care, and without his call light in reach would not be able to call for help if needed. During an interview with the Regional Compliance Nurse on 04/06/2025 at 11:52 a.m., she stated that Resident #274's call light should have been replaced and secured within his reach after they had completed cleaning and changing him and before leaving the room. The Regional Compliance Nurse stated that without his call light in reach, Resident #274 would not be able to call for help. During a follow-up interview with the Regional Compliance Nurse and the DON on 04/08/2025 at 4:30 p.m., the Regional Compliance Nurse stated the facility does not have a policy on Call Lights.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #5) reviewed for accuracy and completeness of clinical records, in that: The facility failed to accurately document Resident #5's wound care status in her wound administration record. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical records. Findings included: Record review of Resident #5's face sheet, dated 08/19/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: heart failure, end-stage renal disease with dialysis (kidney failure which required blood to be filtered several times a week by a special machine), protein-calorie malnutrition (insufficient intake to meet required body's nutritional needs for protein and calories causing weight loss and muscle loss), atherosclerotic heart disease (hardening of the arteries), atrial fibrillation (irregular heart beat), peripheral vascular disease (narrowing of the arteries to the hands and/or feet), cirrhosis of liver (liver disease that can lead to organ failure), and cardiac defibrillator (mechanical device implanted in the body to assist the heart with beating). Record review of Resident #5's Admission MDS, dated [DATE], revealed a BIMS score of 12 out of 15, which indicated the was independent in making decisions, and the resident was admitted to the facility with a skin tear and 3 unstageable DTIs (form of pressure-induced damage to underlying tissues, which include muscles and bones while the skin surface remains intact). Record review of Resident #5's care plan revealed the resident had a skin tear to her left lower leg, and DTI to left lateral (outer) heel, right heel, and sacrum. Under interventions was listed, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #5's Weekly-Ulcer Assessment, dated 07/19/24, for the Skin Tear on the resident's left lower extremity (leg) revealed she was admitted with skin tear, the physician was notified and gave an order to cleanse the skin tear to the left lower extremity with wound cleanser, pat dry with gauze, apply Therahoney to wound bed, cover with dressing, and wrap with kerlix every other day or as needed until resolved. Record review of Resident #5's Weekly-Ulcer Assessment, dated 07/19/24, for the DTI on the resident's right heel revealed she was admitted with DTI, the physician was notified and gave an order to cleanse the DTI to the right heel with wound cleanser, pat dry with gauze, apply skin prep, and leave open to air till resolved. Record review of Resident #5's Weekly-Ulcer Assessment, dated 07/19/24, for the DTI on the resident's left lateral heel revealed she was admitted with DTI, the physician was notified and gave an order to cleanse the DTI to the left heel with wound cleanser, pat dry with gauze, apply skin prep, and leave open to air till resolved. Record review of Resident #5's Weekly-Ulcer Assessment, dated 07/19/24, for the DTI on the resident's sacrum (area between the two hip bones to the lowest vertebra of the spine) revealed she was admitted with DTI, the physician was notified and gave an order to cleanse the DTI to the sacrum with wound cleanser, pat dry with gauze, apply skin prep, and leave open to air till resolved. Record review of Resident #5's Physician Order Summary report, dated 08/19/2024, revealed the following wound orders: - Cleanse skin tear to left lower extremity with wound cleanser, pat dry, pat dry with gauze, apply Therahoney to wound bed, cover with pad, wrap with kerlix every other day and as needed until resolved, with a start date of 07/19/2024. - Cleanse DTI to left lateral heel with wound cleanser, pat dry with gauze, apply skin prep, leave open to air every day until resolved, with a start date of 07/19/2024. - Cleanse DTI to right heel with wound cleanser, pat dry with gauze, apply skin prep, leave open to air every day until resolved, with a start date of 07/19/2024. - Cleanse DTI to sacrum with wound cleanser, pat dry with gauze, apply skin prep, leave open to air every day until resolved, with a start date of 07/19/2024. Record review of Resident #5's July 2024 WAR revealed wound care to the resident's skin tear to her left lower extremity, wound care to the DTIs on her left heel, right heel and sacrum were not documented as provided on 07/22/2024 and 07/28/2024. Further review revealed there was no documentation of if attempts to provide wound care to the resident were made on 07/22/2024 or 07/28/2024. During a telephone interview on 08/20/2024 from 12:17 p.m. to 12:40 p.m., LVN B stated she worked on 07/22/2024 and 07/28/2024. LVN B stated she only provided wound care to Resident #5 on 07/28/2024, could not remember if she documented the wound care was done on 07/28/2024 and did not know why she did not document on the WAR that wound care was provided to Resident #5 on 07/28/2024. During a telephone interview on 08/20/2024 at 2:29 p.m., the Interim DON stated she was the Interim DON from 06/01/2024 to 08/09/2024. The Interim DON stated she assisted LVN B with her workload by providing wound care to Resident #5 on a Monday (07/22/2024) and forgot to document that wound care was provided due to being so busy. During an interview on 08/20/2024 at 1:43 p.m., the Administrator stated wound care should be documented in the WAR after it had been completed. The Administrator stated just because wound care was not documented as being completed did not indicate that wound care was not provided to the resident. The Administrator stated that the nurse could have been busy and forgot to document that wound care was done and she could not think of any harm to the resident. During an interview on 08/20/2024 at 2:00 p.m., the Regional Compliance Nurse, who was the acting Interim DON, reviewed Resident #5's July 2024 WAR and verified wound care was not documented as provided to the resident on 07/22/2024 and 07/28/2024. The Regional Compliance Nurse stated wound care should be documented in the WAR after it was provided to residents and there would be no harm to the resident by not documenting it completed on the WAR. Record review of the undated Dressing Change Checklist policy revealed verifies orders for wound treatment from .chart documents procedures per facility policy.

Based on interview, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 4 of 10 residents (Residents #3, #4, #5, and #9) reviewed for clinical records, in that: 1. The facility failed to ensure Resident #3's wound care treatments as ordered by the physician were documented. 2. The facility failed to ensure Resident #3's weekly skin assessments were documented per facility policy on a weekly basis. 3. The facility failed to ensure Resident #4's weekly skin assessment was documented accurately on 5/1/24. 4. The facility failed to ensure Resident #5's weekly skin assessments were documented per facility policy on a weekly basis. 5. The facility failed to ensure Resident #9's wound care treatments as ordered by the physician were documented. 6. The facility failed to ensure Resident #9's weekly skin assessments were documented per facility policy on a weekly basis. These deficient practices could place residents at risk for improper care due to inaccurate records. Findings included: 1. Record review of Resident #3's Admission Record, dated 5/8/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Pleural Effusion (buildup of fluid between the tissues that line the lungs) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , Osteomyelitis (serious infection of the bone), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #3's Care Plan, dated 12/5/23, revealed: The resident has an unstageable pressure ulcer to Lt. heel . Administer treatments as ordered . Record review of Resident #3's quarterly MDS assessment, dated 4/6/24, reflected the resident had a BIMS score of 15, suggesting intact cognition. Further review revealed the resident had an unstageable pressure ulcer. Record review of Resident #3's Order Summary Report, dated 5/8/24, revealed: Cleanse stage iv pressure ulcer to Lt. heel with wound cleanser, pat dry with 4x4 gauze, apply Therahoney to wound bed, apply Hydrofera Blue, cover with silicone foam dressing QOD &PRN every day shift every other day for Wound Care. Record review of Resident #3's April WAR revealed the resident did not have wound care to the pressure ulcer on the left heel documented on the following days: 4/7/24, 4/12/24, 4/14/24, and 4/18/24. Record review of Resident #3's May WAR revealed the resident did not have wound care to pressure ulcer to left heel documented on 5/4/24. Record review of Resident #3's progress notes revealed there was not documentation of wound care treatments on the above-mentioned dates. Attempted interview on 5/11/24 at 3:57 pm with LVN E was unsuccessful. 2. Record review of Resident #3's EMR revealed weekly skin assessments were not documented for the following dates: 2/28/24, 3/13/24, 3/27/24, and 4/24/24. 3. Record review of Resident #4's Admission Record, dated 5/8/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Chronic Kidney Disease (condition in which kidneys are damaged and cannot filter blood) , cognitive communication deficit (difficulty with thinking and language), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Hemiplegia (paralysis of one side of the body) . Record review of Resident #4's comprehensive MDS assessment, dated 4/28/24, reflected the resident had a BIMS score of 14, suggesting intact cognition. Further review of this MDS revealed the did not have any arterial ulcers. Record review of Resident #4's Order Summary, dated 5/8/24, revealed: Cleanse arterial wound to Lt great toe with wound cleanser, pat dry with 4x4 gauze, apply betadine and LOTA QD till resolved. every day shift for Until Healed . Record review of Resident #4's Care Plan, dated 5/8/24, revealed The resident has arterial ulcer of the Lt. great toe r/t Vascular insufficiency . Record review of Resident #4's Initial Skin Assessment, dated 4/25/24, revealed .Left great toe around toenail bed has an infected/gangrene ulcer . Record review of Resident #4's Weekly Ulcer Assessment, dated 4/29/24, revealed Resident #4 had an arterial wound to the left great toe. Record review of Resident #4's Weekly Skin Assessment, dated 5/1/24, revealed the resident did not have any wounds. Record review of Resident #4's Weekly Ulcer Assessment, dated 5/6/24, revealed Resident #4 had an arterial wound to the left great toe. 4. Record review of Resident #5's Admission Record, dated 5/8/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), Dysphagia (difficulty swallowing) , cognitive communication deficit (difficulty with thinking and language) , and Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #5's Care Plan, dated 6/20/23, revealed: .The resident with potential for pressure ulcer development . Record review of Resident #5's quarterly MDS assessment, dated 3/8/24, reflected the resident had a BIMS score of 10, suggesting moderate cognitive impairment. Record review of Resident #5's EMR revealed weekly skin assessments were not documented for the following dates: 2/6/24, 2/20/24, 3/5/24, 3/19/24, 4/2/24, 4/16/24, and 4/30/24. 5. Record review of Resident #9's Admission Record, dated 5/8/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Cellulitis (common bacterial skin infection) of Left Lower Limb, Ulcer to Left Lower Leg, Reduced Mobility, Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Pressure Ulcer of Left Heel and Dementia (group of thinking and social symptoms that interferes with daily functioning) . Record review of Resident #9's Care Plan, dated 6/5/23, revealed: The resident has unstageable pressure ulcer to Lt. heel .Has non-pressure wound to Lt. 2nd toe Administer treatments as ordered .The resident has Venous wound to LLL .Administer treatments as ordered . Record review of Resident #9's quarterly MDS assessment, dated 4/16/24, reflected the resident had a BIMS score of 10, suggesting moderate cognitive impairment. Further review revealed the resident had an unstageable pressure ulcer. Record review of Resident #9's Order Summary Report, dated 5/11/24, revealed: .Cleanse non-pressure wound to Lt. 2nd toe with wound cleanser, pat dry with 4x4 gauze, apply skin prep, LOTA QD till resolved. every day shift for Wound Care . Cleanse unstageable pressure ulcer to Lt. heel with wound cleanser, pat dry with 4x4 gauze, apply Santyl nickel thick to wound bed, cover with calcium alginate and 4x4 gauze, wrap with kerlix QD & PRN till resolved every day shift for Wound Care . Cleanse venous wound to Lt. lower leg with Anasept wound cleanser, pat dry with 4x4 gauze, cover with adaptic, collagen wound care, cover with calcium alginate and super absorbent pad, wrap with kerlix QD &PRN. every day shift for Wound Care . Cleanse skin tear to Lt. lower posterior leg with wound cleanser, pat dry with 4x4 gauze, apply Therahoney, cover with adaptic and wrap with kerlix QD till resolved. every day shift for Skin Tear .Discontinued . Record review of Resident #9's March WAR revealed the resident did not have wound care treatment to the left second toe, left lower posterior leg, unstageable pressure ulcer to left heel, and venous wound to left lower leg documented on the following days: 3/17/24, 3/24/24, 3/26/24, 3/30/24, and 3/31/24. Record review of Resident #9's April WAR revealed the resident did not have wound care treatment to the left second toe, left lower posterior leg, unstageable pressure ulcer to left heel, and venous wound to left lower leg documented on the following days: 4/8/24, 4/12/24, 4/13/24, and 4/14/24. Record review of Resident #9's May WAR revealed the resident did not have wound care treatment to the left second toe, unstageable pressure ulcer to left heel, and venous wound to left lower leg documented on the following days: 5/4/24 and 5/5/24. Record review of Resident #9's progress notes revealed there was documentation of wound care treatments on the above-mentioned dates. 6. Record review of Resident #9's EMR revealed weekly skin assessments were not documented for the following dates: 2/14/24, 2/28/24, 3/13/24, 3/20/24, and 4/24/24, and 5/8/24. During an interview on 5/8/24 at 12:51 pm, LVN C said she was unaware of Resident #3's and Resident #9's missed treatments. She stated one day Resident #3 was at dialysis and asked the floor nurse to complete the wound care treatment when he returned but could not recall what day. LVN C said she did not audit resident records, the ADONs were responsible for auditing resident records. LVN C said the charge nurses were responsible for completing wound care treatments on her days off. LVN C said she did not know why the treatments were missed. LVN C said she worked on 3/21/24 and 3/31/24 but worked on the floor passing medications. She added she also worked on 4/5/24, 4/12/24, and 4/18/24 but did not know what happened on those days. LVN C said weekly skin assessments were completed weekly and there was a schedule at the nurses' station. LVN C further stated nurses were to document all skin issues observed, adding alerts were triggered by PCC and this informed her if she needed to assess the resident further. LVN C said if the weekly skin assessments were not completed accurately, she may not receive alerts. LVN C said the charge nurses were responsible for completing weekly skin assessments every week. LVN C further stated she did not know why the weekly skin assessments were not completed for the above-mentioned residents. During an interview on 5/11/24 at 11:40 am, LVN D said when skin assessments were completed only new skin issues were supposed to be documented. LVN D further stated he documented anything he saw whether it was a new issue or not. During an interview on 5/11/24 at 12:30 pm, ADON A said nurses were alerted by PCC when a resident's weekly skin assessment was due. ADON A further stated she did not believe weekly skin assessments were completed for all residents and said she believed weekly skin assessments were only required for residents receiving skilled services. ADON A said she and ADON B were responsible for ensuring weekly skin assessments were completed. They were also responsible for auditing resident records, including treatments and assessments. ADON A further stated records were audited every morning and any missing documentation was brought to the nurses' attention for completion. ADON A said she was not aware of the missing treatments for Resident #3 and Resident #9, adding they were assigned to ADON B. ADON A further stated sometimes the nurses complete the treatments but did not document them and other times they missed the treatments and it was the responsibility of the ADONs to let the nurses know if something was red meaning it had not been completed, in the EMR. ADON A said she probably knew there were missing weekly skin assessments for residents mentioned above and probably told the nurses to follow up but that was a lot of follow ups. During an interview on 5/11/24 at 2:00 pm, ADON B said there was a list at each nurses' station that listed when weekly skin assessments were due and that skin assessments were to be completed weekly on all residents. ADON B further stated resident records were reviewed in the morning meetings every Monday - Friday and either she or ADON A attended these meetings; adding if there was anything that needed to be addressed, it was addressed. ADON B said the DON completed the audits and if she saw something missing throughout the day, this was brought to the attention of the ADONs and LVN C, adding that she became aware of missing documentation of the DON brought it to her attention. ADON B said the floor nurses were responsible for completing weekly skin assessment and all skin issues should be documented head to toe. ADON B further stated the DON was responsible for ensuring weekly skin assessments were documented accurately. ADON B said the floor nurses were responsible for wound care treatments during the week and the RN supervisor on the weekends in the absence of LVN C. ADON B further stated when treatments were not completed, they appeared red in PCC and it was addressed with the nurse to know why it had not been completed and offered help, if needed. ADON B said she was not aware of Resident #3's and Resident #9's missed treatments. During an interview on 5/11/24 at 2:34 pm, RN F said she completed Resident #3's and Resident #9's treatments on some of the days but did not document them. RN F further stated she did not know on which days this happened. She stated sometimes she was busy and left documentation for the end of the shift and forgot to document. RN F further stated other days, she did not have time to complete wound care treatments and asked the night shift nurse to complete the treatments but was unable to recall on what days she forgot to document and what days she was unable to complete treatments. RN F said the expectations was for treatments were to be documented immediately after administration. RN F said she was not aware skin assessments were to be completed on a weekly basis until a few months ago, about February or January. RN F further stated she did not remember why she did not complete weekly skin assessments when she was assigned to Resident #5 and Resident #9, adding she was probably too busy or thought she had completed them and had not. Attempted interview on 5/11/24 at 3:57 pm with LVN E was unsuccessful. During an interview on 5/11/24 at 5:20 pm, the DON said she tried to audit resident records and that auditing was a collaboration between herself and the ADONs. She further stated the facility did not have a requirement as to how often resident records were audited. The DON said ADON A (treatment nurse) was responsible for ensuring wound care treatments were completed when she was at the facility and the charge nurses in the treatment nurse's absence. The DON said she was not aware of the missing treatments and skin assessments. Record review of the facility's policy, titled Documentation, dated 2003, revealed: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations . of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness . The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets . Document completed assessments in a timely manner and per policy. Complete documentation in the electronic health record in a timely manner . Record review of the facility's policy, titled Skin Assessment, revised 8/15/16, revealed: . All residents should have a skin assessment on a weekly basis completed in PCC Record review of the facility's policy, titled Skin Integrity Management, revised 10/5/16, revealed: . Wound care should be performed as ordered by the physician .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #1, #8, and #10) reviewed for infection control, in that: 1. The facility failed to ensure CNA G used proper hand washing technique during catheter care for Resident #1. 2. The facility failed to ensure CNA G used proper hand hygiene during catheter care for Resident #10. 3. The facility failed to ensure RN F used proper infection control practices during wound care for Resident #8. These deficient practices could place residents at risk for infection and delayed wound healing. Findings included: 1. Record review of Resident #1's Admission Record, dated 5/8/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood). Obstructive and Reflux Uropathy (obstructed urinary flow). Record review of Resident #1's Care Plan, dated 1/2/24, revealed: The resident has Indwelling Catheter . Record review of Resident #1's quarterly MDS assessment, dated 3/5/24, revealed the resident had a BIMS score of 9, suggesting severe cognitive impairment. Further review of this document revealed Resident #1 had an indwelling catheter and required substantial/maximal assistance (helper does more than half the effort.) for toileting and bathing. Record review of Resident #1's Order Summary Report, dated 5/8/24, revealed an order for catheter care every shift, dated 12/6/23. Observation of catheter care for Resident #1 on 5/10/24 beginning at 10:12 am revealed CNA G, after completing hand hygiene, used a clean paper towel to close the faucet after drying her hands and then wiped her hands with the same paper towel before she threw it in the trash bin and donned gloves. Further observation following catheter care for Resident #1 revealed CNA G removed her gloves and gown, washed her hands for 11 seconds, used a clean paper towel to close the faucet after drying her hands and then wiped her hands with the same paper towel before she threw it in the trash bin. During an interview on 5/10/24 at 10:29 am, CNA G said she had not realized she wiped her hands with the same paper towels she used to close the faucet after providing catheter care for Resident #1. CNA G further stated she cross contaminated by doing that and this could spread germs to the resident and herself. CNA G said hands were supposed to be washed for at least 20 seconds. 2. Record review of Resident #10's Admission Record, dated 5/10/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood), Malnutrition, Dementia (group of thinking and social symptoms that interferes with daily functioning), and Anxiety (feeling of dread, fear, or uneasiness). Record review of Resident #10's Care Plan, dated 1/4/23, revealed: The resident has an ADL Self Care Performance Deficit . Record review of Resident #10's quarterly MDS assessment, dated 3/15/24, revealed the resident did not have BIMS score listed. Further review of this document revealed Resident #10's cognitive skills for decision making was severely impaired and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) for toileting and bathing. Observation of Peri-care (washing the genitals and anal area) for Resident #10 on 5/10/24 at 1:52 pm revealed CNA G sanitized her hands for 5 seconds without allowing hands to dry before she began peri-care. Further observation revealed CNA G sanitized her hands for 2 seconds once peri-care was completed. During an interview on 5/10/24 at 2:13 pm, CNA G said when using hand sanitizer, it was supposed to be rubbed and allowed to dry so that it was effective. 3. Record review of Resident #8's Admission Record, dated 5/8/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), Asthma (condition in which airways become inflamed, narrow, and produce extra mucus, making it difficult to breathe), and Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of Resident #8's Care Plan, dated 10/2/23, revealed: The resident has a stage iii pressure ulcer to Rt. Lateral malleolus .Administer treatments as ordered . Record review of Resident #8's comprehensive MDS assessment, dated 4/5/24, revealed the resident had a BIMS score of 15, suggesting intact cognition. Further review of this document revealed the Resident #8 had an unhealed pressure ulcer. Record review of Resident #8's Order Summary Report, dated 5/8/24, revealed an order for Cleanse stage III pressure ulcer to Rt. lateral malleolus [bone on the outside of the ankle joint] with wound cleanser, pat dry with 4x4 gauze, cover with calcium alginate and a dry dressing QD till resolved. every day shift. Observation of wound care to Resident #8's right lateral (side) ankle on 5/10/24 beginning at 8:48 am revealed RN F gathered supplies, donned PPE, explained procedure, removed resident's items from bedside table, removed gloves, and washed hands for 14 seconds. Further observation revealed RN F returned to treatment cart, retrieved tray with supplies and placed on bedside table, closed the door, sanitized hands, and donned gloves. RN F removed her gloves and returned to treatment cart. RN F then used scissors to cut tape without sanitizing the scissors. RN F closed the door, sanitized her hands, opened door, and returned to the treatment cart to retrieve more gloves. RN F re-entered the resident's room, closed the door, donned gloves without sanitizing or washing her hands, the right glove tore while she donned it. RN F proceeded to remove Resident #8's dressing and completed wound care. Further observation revealed RN F cut the clean dressing without sanitizing the scissors. RN F placed the dressing on the wound and secured with tape. RN F removed right glove and then the left touching the outside of the glove with her bare right hand. RN F then removed the gown touching the outside of the gown with her bare hands and placed in a biohazard bag. RN F did not sanitize or wash her hands before or after leaving Resident #8's room. During an interview on 510/24 at 9:22 am, RN F said it was important to wash hands for at least 30 seconds to make sure she was getting all the germs off her hands. RN F further stated there was no reason for her not sanitizing the scissors prior to cutting the tape and the dressing. RN F said she grabbed them without thinking. RN F said the gloves tore all the time and she should have donned a new pair after her gloves tore during Resident #8's wound care. RN F said she should not have touched the outside of the gown with her bare hands to avoid contaminating them. RN F further stated she had not realized she did not sanitize her hands before or after she left Resident #8's room. During an interview on 5/11/24 at 12:30 pm, ADON A said she was responsible for infection control and provided training quarterly. ADON A further stated staff were expected to sanitize or wash their hands when providing resident care, after removing gloves and before donning new gloves. ADON A added staff were expected to wash their hands for at least 20 seconds, dry them, use a clean paper towel to close the faucet, and dispose of the paper towel without wiping their hands with that paper towel. ADON A said she expected staff to remove their gloves and then the gown, pulling the gown off from the back and rolling it with the inside out without touching the outside of the gown. During an interview on 5/14/2024 at 2:05 pm, the DON stated it was her expectation for staff to practice appropriate infection control. If staffs' hands were heavily soiled, then proper handwashing should occur with soap and water . If a glove tore and hands were heavily soiled, then the glove should be changed after washing hands. During an interview on 5/14/2024 at 2:10 pm, the Administrator stated staff knew to use infection control practices when they took care of residents. The Administrator further stated staff should adhere to the CDC guidelines which the facility followed. Record review of the facility's policy titled, Infection Control Plan: Overview dated 03/2004, revealed: . The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. The facility will require staff to Donn and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility . Record review of the facility's policy titled, Fundamentals of Infection Control Precautions updated 03/2004, revealed: . Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after performing any invasive procedure .Before and after entering isolation precaution settings . Before and after assisting a resident with personal care . Before and after changing a dressing; Upon and after coming in contact with a resident's intact skin . After handling soiled . dressings .After handling soiled equipment .After removing gloves . Recommended techniques for washing hands with soap and water include: wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a new disposable towel; and turning off the faucet on the hand sink with the disposable paper towel . Recommended techniques for performing hand hygiene with an ABHR: Include applying product to the palm of one hand and rubbing hands together, covering all surfaces of hands and fingers, until the hands are dry . Non-invasive resident care equipment is cleaned daily or as need between use . Staff will wear intact disposable gloves in good condition and change after each use, which helps reduce the spread of microorganisms .

Based on interview and record review, The facility failed to designate one or more individual(s) as the infection preventionist(s) had completed specialized training in infection prevention and control for 1 of 1 Infection Preventionist (ADON A) reviewed for infection control training. The facility's Infection Preventionist did not have specialized infection control training. This failure could have placed the residents at risk for infectious outbreaks that may lead to decline in health. Findings included: Record review of email received on 5/11/24 at 3:58 pm from the Admin revealed Nursing Home Infection Preventionist Training Course for the Admin and the DON after investigator requested certification/training for ADON A. During an interview on 5/11/24 at 11:21 am LVN C said ADON A was responsible for infection control. During interview on 5/11/24 at 12:30 pm, ADON A said she was responsible for the facility's infection control. During an interview on 5/11/24 at 3:13 pm, ADON A said she was a certified Infection Preventionist but did not know where her certification was. ADON A further stated administration might have had a copy. During interview on 5/11/24 at 3:15 pm, the DON said ADON A was the infection preventionist and was certified. Record review of the facility's infection control policy titled, Infection Control Plan: Overview , dated 03/2024, revealed .Facility IP, DON, and Administrator will complete the CDC train course to provide initial and ongoing education of all healthcare workers in the theory and practice of infection control and prevention .

Based on observation, interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. LVN A did not check that the crash cart did not have the defibrillator. 2. LVN A stopped CPR after 30 minutes (7:45 PM-8:15 PM) because of wrong information they received from the Hospice Nurse at 8:15 PM. 3. LVN B brought a crash cart to R#1's room but forgot to bring the AED; and the resident was not hooked to the defibrillator. LVN B stopped CPR at the directions from LVN A at 8:15 PM 4. LVN C assumed LVN A called 911. LVN C did not check that the defibrillator was not present. LVN C stopped CPR at the directions from LVN A at 8:15 PM. 5. LVN D assumed LVN A called 911. LVN D was aware that R#1 was Full Code but stopped CPR at the direction of LVN A. 6. Hospice RN told the facility by telephone not to call 911 at 8:15 PM and stopped CPR at 8:15 PM, assuming R#1 was DNR. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and even death. These failures resulted in an IJ on [DATE] at 1:59 PM. While the IJ was removed on [DATE] at 5:10 PM , the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal. The findings were: Record review of R#1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was admitted on [DATE] (5 day rehab stay) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female; age 82. Advanced Directive was Full Code. RP (responsible party) was listed as: family member. Record review of R #1's 5 Day Medicare MDS, dated [DATE], revealed: BIMS (brief interview of mental status) Score was 9 ( ,d+[DATE] (moderate impairment). ADLs (activities of daily living): B/B (bowel and bladder) episodes of incontinent of both. Transfer and bed mobility limited assistance by one staff member. ROM (range of motion) no issues. Record review of R #1's Care Plan dated [DATE]/, read, Resident is a Full Code. Date Initiated: [DATE] o Request for CPR to be initiated will be followed. Date Initiated: [DATE] Target Date: [DATE] o Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMS Date Initiated: [DATE] Created by: (LVN F) (MDS Coordinator) . Record review of R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R #1's Advance Directive acknowledgement date [DATE] signed by the RP revealed that the resident had a right to formulate a DNR (Do Not Resuscitate). Record review of Resident #1's LVN A's nurse notes read: [DATE] 19:45 (7:45 PM) Nursing Progress Note / Note Text: This nurse was informed by (CNA E )that the resident did not appear to be breathing. Nurse went to assess, vital signs were not obtainable. Nurse notified hospice nurse, she stated she would head back to the facility. RP also notified of change in condition. DON notified as well. [DATE] 19:46 (7:46 PM) Nursing Progress Note / Late Entry: Note Text: Resident was listed as a full code so code blue was initiated. 100 and ,d+[DATE] hall nurses responded. This nurse (LVN A) grabbed the crash cart, passed it to nurse (LVN C). she and (LVN D). initiated CPR while this nurse called hospice. [DATE] 20:02 (8:02 PM) Nursing Progress Note / Late Entry: Note Text: After several attempts to notify hospice nurse . of change in condition, she (Hospice Nurse) responded and assured this nurse that resident was a DNR. She had spoke to the (RP) about it and that we should have a copy. This nurse (LVN A) let her know (R#1) was listed as a full code and should we call 911. She (Hospice Nurse) assured this nurse (LVN A) that the (R#1) was a DNR and to stop CPR. She was on her way back to the facility to pronounce resident. [DATE] 20:30 (8:30 PM) Nursing Progress Note / Note Text: Hospice nurse pronounced (R#1) at 20:23 (8:23 PM). Family is at bedside. Record review of facility's internal investigation, (SR # 3), dated [DATE] revealed: Time Line of Incident on [DATE] was as follows: o 7:45 PM CNA E reported to LVN A that R#1 was not breathing and unresponsive o 7:45 PM LVN A assessed R#1, vital signs unobtainable o 7:45 PM LVN B called a Blue Code o 7:45 PM LVN A grabbed the crash cart o 7:46 PM to 8:15 PM LVN A, B, C, and D initiated CPR o 8:15 PM Hospice RN called facility and told LVN A to stop CPR and not call 911 because (family member) did not want any heroic measures taken. CPR was stopped. o 8:23 PM Hospice Nurse arrived at facility and pronounced R#1 deceased Facility requested a copy of the Out-of-Hospital DNR and the community hospice did not have one on file. Unsigned and undated typed statement by the Hospice Nurse revealed that, the Hospice Nurse did not have a written Out-of-Hospital DNR but instead relied on a conversation she/he had with a family member at the time the R#1 was admitted to Hospice ([DATE]). 911 was not called during the CPR incident on [DATE]. Written statement dated [DATE] and singed by LVN A revealed: at 7:45 PM R#1 was found unresponsive by CNA E. Resident assessed and no vital signs. LVN A was informed by the DON that R#1 was full code. LVN A the electronic chart and confirmed R #1 was full code. LVN A grabbed the crash cart and was assisted with CPR by LVN B, C, and D. Hospice Nurse told her (by telephone at 8:15 PM) that R #1 was DNR and to stop CPR and not call 911. Unsigned and undated typed statement by LVN B revealed, she/he had the code blue and assisted with CPR from 7:42 PM to until a little after 8:00 PM when told to stop CPR by LVN A. Unsigned and dated [DATE] typed statement by LVN C revealed: LVN C called the code blue at 7:45 PM and assisted with CPR. LVN C asked (LVN A) where is 911 .they are usually here and (LVN A) said no [because] hospice nurse said to stop (CPR), resident (R#1) (is) a DNR . Written, undated, signed statement by LVN D revealed: heard the code blue, started (CPR) with other nurses, and was told to sop (CPR) by (LVN A) Record review of LVN A's employee file revealed, she completed Licensed Nurse Proficiency on CPR on [DATE]. Record review of LVN B's employee file revealed, she completed Licensed Nurse Proficiency on CPR on [DATE]. Record review of LVN C's employee file revealed, she completed Licensed Nurse Proficiency on CPR on [DATE]. Record review of LVN D's employee file revealed, she completed Licensed Nurse Proficiency on CPR on [DATE]. Record review of facility's Cardiopulmonary Resuscitation policy dated revised [DATE], read: .when the resident is unresponsive, immediately call for emergency help .No matter what stage of CPR you are in, when the AED arrives stop what you are doing and connect the AED to the resident . During an observation on [DATE] at 5:15 PM, the facility had 3 crash carts (Hall 1, 2, and 3) and 2 AEDs (Hall 1 and 5); there was no AED for Hall 2 (Hall 2's AED was under repairs). During an observation on [DATE] at 8:45 AM, the crash carts in halls 1, 2 and 3 had the following supplies: backboard, Amb bag, 02 and administration set, disposable gloves, daily check of crash cart by day and night shift, and code status of residents. AED was present except for Hall 2. During an observation on [DATE] at 9:10 AM, the facility was conducting a mock CPR drill which complied with the facility's policy on CPR. Corporate nursing staff provided the training. Observation revealed LVN I found a mannequin resident unresponsive and called a code blue, and directed LVN J to call 911 and initiate emergency services and directed LVN F to get the crash cart with the AED. LVN K documented the event. LVN F connected the mannequin resident to the defibrillator and followed AED instruction. CPR cycles continued a virtual EMS arrived and took over the CPR cycle. LVN F virtually notified the physician and RP. The trainer was RN L. During an interview on [DATE] at 9:25 AM, Administrator revealed that R#1 was a Full Code; the Hospice Nurse told LVN A to stop CPR and not call 911 because R#1 as DNR. After the [DATE] CPR incident, the hospice nursed did not provide the Out-of-Hospital DNR form. The Administrator added that 911 was not called and the MD was not called. During a telephone interview on [DATE] at 10:12 AM, Hospice Director revealed: R #1 was put on Hospice on [DATE] . R#1 did not have an Out-of-Hospital DNR; and the hospice nurse made a mistake in conveying the DNR information on [DATE] to the facility. During a telephone interview on [DATE] at 10:36 AM, Hospice Nurse ([DATE]) revealed, R#1 was put on hospice on [DATE]. The Hospice Nurse made the decision based on wrong information that R#1 was DNR and stopped CPR and told the facility not to call 911 after 30 minutes of CPR. The Hospice Nurse stated, .there was nothing in writing that resident [R#1] was DNR. Hospice Nurse further revealed she/he declared R #1 deceased at 8:23 PM when she got to the facility. She stated, it was a mistake on my part to assume (R #1) had an out of hospital DNR. During an interview on [DATE] at 11:33 AM, the RP revealed, they wanted R#1 to be DNR but did not complete and signed an Out-of-Hospital DNR form. RP assumed that the Advanced Directive was the Out-of Hospital DNR form. During a telephone interview on [DATE] at 1:25 PM, LVN A revealed, they were notified at 7:45 PM that (R#1) was unresponsive. Per discussion with the DON on [DATE] around 7:45 PM LVN A was notified that R #1 was Full Code and (LVN A) verified the Full Code status in the electronic record. LVN stated, .it was my mistake for not calling EMS .if a resident is full code and CPR is being administered CPR, EMS should be immediately called .I believed that the (R#1) was DNR because (R#1) was put on hospice the day of the incident ([DATE]). LVN A further revealed they did not call the physician throughout the CPR incident because my mind thought (R#1) was DNR .we did not administer the electric shock from the crash cart because I assumed she was DNR although I saw her code as Full Code . LVN A added that around 8:15 PM the hospice nurse told them that R#1 was DNR and not to call 911 and stop CPR . LVN A revealed they received certification from the American Red Cross on CPR and AED. During a joint interview on [DATE] at 2:04 PM, DON revealed the facility's CPR directed staff to call 911 when a code was called and CPR started; and to bring the AED with the crash cart and hook up the resident. The DON stated she told LVN A on [DATE] around 7:45 PM that R#1 was Full Code and to check R#1's electronic record. The Administrator added that LVN A did not call 911, the AED was not present, and LVN A stopped CPR at the direction of a hospice nurse. During an interview on [DATE] at 2:34 PM, LVN B stated, they assumed LVN A called 911, they forgot to bring and use the defibrillator, and stopped CPR at the direction of LVN A. During an interview on [DATE] at 3:05 PM, LVN C revealed they called the code blue; and LVN A told LVN C that R#1 was Full Code. LVN C added that a crash cart was taken to R#1's room without an AED. LVN C stated, I was waiting for 911 . but told to stop (around 8:15 PM) by LVN A because the Hospice Nurse said the resident was DNR. LVN C stated that R#1 was not hooked up to the AED machine and did not know why the AED was not with the crash cart. During an interview on [DATE] at 3:36 PM, LVN D stated, revealed the role they took was oxygen bagging of R#1 and then LVN D switched to compressions. LVN D also was told by LVN A the electronic record revealed R#1 was Full Code. LVN D assumed LVN A called 911. The crash cart was brought by LVN B and the defibrillator was not present. LVN D stated, the AED was not present with the crash cart, they knew R#1 was Full Code, 911 was not called by LVN A, and CPR was stopped at the direction of LVN A. During a telephone interview on [DATE] at 4:00 PM, CNA E revealed, she found R#1 not breathing on [DATE] at 7:45 PM and immediately notified LVN A. During a joint interview on [DATE] at 5:10 PM, the Administrator and DON revealed that during their internal investigation a nurse [LVN D] stated that the AED was not taken with the crash cart during the [DATE] incident and they had no explanation for the defibrillator not taken or hooked to the (R#1) as per the facility's CPR policy. The Administrator revealed the facility had 3 crash carts and 2 working AEDs; Hall 2's AED was under repairs. The Administrator added that LVN A was suspended [DATE] pending an investigation. Record review of LVN A's time card revealed that last time she/he clocked into the facility was [DATE]. During an interview on [DATE] at 8:10 AM, the Administrator revealed that the facility had two shifts (6AM-6PM and 6PM to 6AM). The facility intended on conducting a mock CPR drill for the 6PM shift tonight; and a second mock drill for the 6AM shift tomorrow ([DATE]). The Administrator added that a CPR quiz was given to the 6PM shift on [DATE]. During an interview on [DATE] at 8:42 AM, LVN F (MDS Nurse) stated, R#1 was listed as Full Code in the electronic record face sheet and CP based on the MD's order dated [DATE]. LVN F stated that the RP did not bring an Out-of -Hospital DNR form when the resident was admitted on [DATE]. Also, LVN F's review of the hospital record revealed that no Advanced Directive or Hospital DNR was present in the hospital record received by the facility. LVN F stated the RP did not bring an Out-of Hospital DNR form during the admission process and only presented an Advanced Directive which stated the RP would obtain an Out-of -Hospital form. The RP acknowledged by signature the facility's Acknowledged form which stipulated the need for an Out-of Hospital DNR for if R#1 was to be coded as DNR in facility records. Therefore LVN F stated, at admissions, R#1 was Full Code until the RP brought to the facility the Out-of Hospital DNR fomed completed and signed. The physician's admission order was Full Code. During an interview on [DATE] at 9:43 AM, the facility's MD H revealed, nursing staff should follow the CPR policy when a resident is full code; assess the resident, call 911, and continue CPR, attach the defibrillator, and allow EMS to take over the CPR. MD H stated, .I cannot give a reason why the nurses (LVN A, B, C, and D) did not follow the CPR policy for (R#1) on the day of the incident ([DATE]) . Record review of facility's 802 form (Resident Matrix) dated [DATE] revealed there were two Hospice Residents (R#2 and #3) in the facility. Record review of facility's DNR list date [DATE] revealed 22 residents with a DNR code. Record review of facility's employee list dated [DATE] revealed 86 employees on payroll. Record review of facility's Resident Rights policy undated read, .facility must treat each resident with .care .in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . Record review of facility's Abuse/Neglect policy dated revised [DATE] read, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation Neglect: is the failure of the facility, its employees or service providers to provide goods and services to resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of facility's Advance Directives policy, undated, read, .An Out-of-Hospital DNR order form will tell health care providers, including emergency medical services personnel, not to use cardiopulmonary resuscitation (CPR) and other life sustaining treatments . Record review of American Red Cross web-site ( https://www.redcross.org/training/first-aid-cp ) revealed: These are the recommended steps involved in hands-only CPR, per the American Red Cross: 3 Call 911. Or ask a bystander to call for help. Kneel beside the person. You want your knees to be near the side of their body and spread shoulder-width apart. Place your hands on their chest. Put your shoulders directly over your hands. Give constant chest compressions. Keep doing this until help arrives. 7 STEPS OF CPR? 1. CALL 911. Before beginning the steps of CPR, call 911 immediately. 2. ASSESS THE SCENE OF THE EMERGENCY. After you call 911, you should assess the scene. 3. OPEN THE VICTIM'S AIRWAY. To begin CPR, you need to position the victim. 4. CHECK FOR BREATHING. 5. CHEST COMPRESSIONS. 6. RESCUE BREATHS. 7. REPEAT THE CYCLE. The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on [DATE] at 1:59 PM; and a plan of removal was requested. On [DATE] at 5:45 PM, the facility provided a Plan of Removal and it was accepted on [DATE] at 9:03 AM. It was documented as follows: [Name of Facility] Plan of Removal Interventions: On [DATE] All resident records were audited by the DON, ADON, and/or regional nursing staff to ensure that a code status was present and that the care plan reflected that order. On [DATE] all licensed nurses were inserviced by the DON, ADON, and/or regional nursing staff regarding: o Initiating CPR in the absence of a DNR. Either: A Texas Out of Hospital DNR or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] o How to obtain the residents code status in PCC (resident record, EMAR, POC) o Nurses not stopping CPR unless: Order for DNR has been verified A DNR is located in the facility Receive a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] EMS takes over the CPR/Code o Notifying the physician and family of any resident change in condition. o How to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] o How to enter an Advanced Directive (Full Code or DNR) order in PCC On [DATE] all nursing assistants were inserviced by the DON, ADON, and/or regional nursing staff on how to locate a resident's code status in PCC (resident record, EMAR, POC) On [DATE] the social service director was inserviced to follow-up on new admissions within 1 business day to address the resident's code status and to document the resident or resident representative's decision. On [DATE] the medical director [ MD H]was informed about the incident and facilities response [MD H] was informed that we inserviced staff on: Advance Directive Order Entry Documentation Initiating CPR in the Absence of a DNR Nurses not stopping CPR until or unless A DNR is located in the facility Receive a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] EMS takes over the CPR/Code [MD H] was also informed that the facility staff conducted mock codes Facility conducted First Responders Inservice (CPR, Calling [DATE], Obtaining the AED). This training was completed on [DATE] at 2:00pm. Facility will conduct random Mock Codes Facility will complete return demonstration Mock Codes on 100% of nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides). As of [DATE] at 6:00 pm the facility was at 80.8% completion. As of [DATE] at 6:30 am the facility is at 100% completion. Mock Codes Return Demonstration training began on [DATE] @ 9:30 AM. Facility staff in serviced on Abuse & Neglect Policy. Completed 100% by [DATE] at 8:00AM. [LVN A], suspended pending investigation 100% of staff was inserviced, educated and trained by [DATE] 100% of all facility staff were inserviced on Abuse/Neglect Policy. 100% of all facility staff were inserviced on Advance Directives. 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were inserviced on CPR/ 1st Responder. 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were inserviced on Return Demonstration Mock Codes. 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were inserviced on How to Obtain a Resident Code Status and Obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were inserviced on Not Stopping CPR until/unless all criteria is met Order for DNR has been verified A DNR is located in the facility Receive a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] EMS takes over the CPR/Code The AED, Defibrillator, and Documentation are all addressed in the in-service named 1st Responder provided on [DATE] at 2:00pm. The facility Administrator met with the Hospice Administrator and discussed the event and plan of action moving forward. Hospice provided Twin Pines North with inservicing on Advance Directives, Code Status and Notifications. Hospice provided education to their nurses and corrective measures were put in place for the specific nurse. All hospice residents were audited, and hospice companies were informed about facilities policies regarding Code Status. Code Status will be confirmed on admission and kept up to date by using our monitoring tool dated [DATE], DON or Designee to review all Advance Directive Orders 5 days per week and take further action as required. Monitoring: At least 5 times per week, orders will be reviewed by the DON and/or ADON and ensure that advanced directive orders are entered correctly . Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need At least 3 times per week, nurse managers will observe nursing staff demonstrating through a mock CPR exercise compliance with facility CPR policies and procedures. Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. The DON and/or ADON will interview at least 10 licensed nurses per week and questions will include: o When can you stop CPR? o Where to locate a resident's code status? o How to initiate a resident/representative request for DNR Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need.The DON/ADON will review Real Time and PCC at least 5 times per week to monitor that the physician/family was notified of resident changes in condition. Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. The administrator will monitor to ensure that the social service director addressed code status within 1 business of new admissions. Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. Findings will be reviewed by the QAPI committee and changes will be made as needed. In the daily standup meeting, the IDT will discuss any new admissions' code status and take further action as required. Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. The DON and/or designee will review all advance directive orders 5 days per week and take further action as required. Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. Hospice advance directives will be reviewed on admission and 5 days per week and during IDT stand-up Monitoring began on [DATE], monitoring will continue through [DATE] and will be reviewed during QA for evaluation of any continued need. Verification of the Plan of Removal: During joint interview on [DATE] at 1:43 PM, the Administrator and DON revealed that mock CPR exercises started on [DATE] at 9:30 AM and ended on [DATE] at 6:30 AM and all nursing staff attended the mock CPR drills; total # of nursing staff was 48. During an observation on [DATE] at 2:00 PM , the facility conducted a mock CPR drill which complied with the facility's policy on CPR. Corporate nursing staff provided the training. (RN L) Observation revealed CNA A found a mannequin resident unresponsive and LVN I, checked the Advance Directive in the electronic record, called a code blue and assessed the mannequin resident, and directed LVN S to call 911 and initiate emergency services; and directed LVN I to get the crash cart with the AED. LVN Q to documented the event. LVN I connected the mannequin resident to the defibrillator and followed AED instruction. CPR cycles continued a virtual EMS arrived and took over the CPR cycle. LVN S virtually notified the physician and RP. The trainer was RN L. Record review of attendance at mock CPR drills from [DATE] to [DATE] revealed 48 nursing staff signatures were present. Record review of sign in sheets revealed 100% in-service completed (from [DATE] to [DATE]) on the following topics: 100% of all facility staff were in-serviced on Abuse/Neglect Policy.(Completed [DATE]) 100% of all facility staff were in-serviced on Advance Directives. (Completed [DATE]) 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were in-serviced on CPR/ 1st Responder.(Completed [DATE]) 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were in-serviced on Return Demonstration Mock Codes. (Completed [DATE]) 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were in-serviced on How to Obtain a Resident Code Status and Obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 100% of all nursing staff (includes RNs, LVNs, CMAs, CNAs, Hospitality Aides) were in-serviced on Not Stopping CPR until/unless all criteria is met (Completed [DATE]) Order for DNR has been verified A DNR is located in the facility Receive a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] EMS takes over the CPR/Code Record review of facility's Order Listing Report dated [DATE] through [DATE] revealed resident list with code status were present Record review of facility's Action Plan Monitoring dated [DATE] to [DATE] revealed code status orders were reviewed. During an interview on [DATE] at 11:29 AM, DON stated, in the morning she or a designee review the AD orders using the facility' monitoring tool .no issues identified as of [DATE] . Record review of in-service on [DATE] on locating code status for CNA, CMA, and Hospitality Aides revealed 24 total signatures and 24 nurses; total=48 (100%) During an interview on [DATE] at 10:12 AM, the DON stated that, the Charge Nurse on duty will be entering the orders and not the social worker. Also, the nurses are responsible for entering the orders upon admissions or changes in PCC. Record review of in-service on [DATE] on new admissions revealed the Social worker signed the attendance sheet. During an interview on [DATE] at 12:14 PM, the SW Director stated, I received an in-service on [DATE] on new admissions and code status; role is to check the code status of new admissions and assist the resident or RP is they wish an out of hospital DNR; and I meet daily at morning meeting with Administrator to discuss new admissions but nursing staff enters orders in PCC. During interview on [DATE] at 3:25 PM, CNA M (Night Staff) stated, in the training on Abuse and Neglect to report any allegations to the Administrator .the resident has the Right to be Full Code or DNR .call for help is a resident is unresponsive .I participated in the Mock Codes and it is important to call 911 .I find the code status in PCC .stop CPR when EMS arrives or the doctor orders the stoppage . During interview on [DATE] at 3:32 PM, CNA N (Day Shift), .it residents are abuse report to the Administrator .if you find an unresponsive call the nurse and check PCC for the code .I participated in the Mock drills and leaned if resident if full code call code blue and room number .someone needs to call 911 .EMS takes over the CPR .remember to grab the crash cart with the AED . During interview on [DATE] at 3:38 PM, CNA O (Day Shift), stated, .on abuse tell the Administrator .no retaliation for reporting .each resident has the right to be Full Code or DNR my family member is in the facility with a DNR code and we need to honor wishes .I participated in the Mock drills and we all need to work together 911 is called and the code status needs to be checked .EMS takes over and they determine when to stop CPR .what stood out was get the crash cart and AED During interview on [DATE] at 3:44 PM, LVN P (Day Shift), .on abuse and neglect we were told to report to the Administrator .from the Code training we were told to check the status which can be found in PCC .in the chart and in the crash cart .if DNR I will check the MD orders if Full Code initiate CPR and 911 .EMS takes over CPR EMS or the MD can stop the CPR if resident deceased I mock drills and what stood out was that is a tea effort .and call 911 and hook the resident to AED . During interview on [DATE] at 3:55 PM, LVN I, (Day Shift) stated, .from the Abuse and Neglect training what stood out is to report the Administrator .you need to know the resident's code status .the PCC has the code status and the crash cart .I participated in mock drills and what stood out to assess and call 911 for Full Code .with the crash cart always bring the AED and continue CPR when 911 arrives EMS takes over another nurse cannot tell you to stop CPR .what stood out was call 911 . During interview on [DATE] at 4:00 PM (Day Shift) LVN Q (Day Shift), .the main message from abuse was that there are different type of abuse and report it to the Administrator .from the Advanced Directive training we need to check the code status in the PCC and the crash cart .I participated in Mock drill CPR and learned to follow the CPR policy and work as a team .what I remember was to attached the AED . During interview on [DATE] at 4:10 PM , CNA R (Night Shift) stated, .from Abuse training report to the DON .participated in mock codes .if resident is unresponsive call nurse .call nurse .assist . During interview on [DATE] at 4:13 PM, , LVN C (night shift) stated, call 911 and check that the AED is presents .do not listen to a hospice nurse to stop CPR .I participated in Mock drills . During an interview on [DATE] at 3:36 PM, LVN D (night) stated, .training highlights included: check the code status, verify whether resident is DNR, do not listen to a hospice and check the record, call 911 if resident if full code .and the crash cart needs to come with an AED During an interview on [DATE] at 2;34 PM, LVN B (Night) stated, .I received training and remembered to use the AED .continue CPR until EMS arrives . Record review of resident face sheets, R#7 admitted [DATE], R#8 admitted [DATE] and R#4 admitted [DATE] revealed AD FULL Code was present on the face sheet, doctor's orders and CP. Record review of facility's consolidated order listing report dated [DATE] revealed 61 residents with code status documented. Observation on [DATE] at 11:20 AM of Crash Carts (hall 1, Hall 2 and Hall 5) revealed that the resident list with code status were present. On [TRUNCATED]