Every finding on record at University Care Center

Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1), when Licensed Nurses (LNs) did not follow their policy and procedure related to medication administration. This failure had the potential for medication error.Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism (when thyroid gland doesn't make and release enough hormone into the bloodstream). A review of Resident 1's history and physical dated 12/2/24, indicated Resident 1 had the capacity to make decisions. During an interview with Resident 1 in his room on 8/4/25, at 11:58 A.M., Resident 1 stated he did not receive his morning medications on time on 7/31/25. Resident 1 stated he asked LN 1 what happened to his medications. Resident 1 stated he observed LN 1 checked the medication administration record (MAR) in their computer system. Resident 1 stated LN 1 informed him that the night LN (3) signed the medication as given to Resident 1. Resident 1 stated LN 1 gave him his medications. Resident 1 stated, That is a no, no, they are not supposed to do that. I did not receive my medication, but [name of LN] signed as given. A review of Resident 1's physician order dated 5/29/25 and 11/30/24, indicated Resident 1 was to receive:- Levothyroxine for hypothyroidism given before breakfast- Lantoprazole for acid reflux given before meals On 8/4/25 at 1:37 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 1. LN 1 stated Resident 1 was alert and oriented x 4 (oriented to person, time, place and situation). LN 1 stated while he was making his rounds on 7/31/25, Resident 1 approached him and asked about his morning medications. LN 1 stated he went to check Resident 1's MAR and found out the due medications were signed by night shift LN (3). LN 1 stated Resident 1 was to receive two medications early in the morning. LN 1 stated he went to check with another LN (2) if he had Resident 1's medications. LN 1 stated LN 2 prepared the medications for Resident 1 but was not able to give Resident 1 his medications. LN 1 stated he gave the medications to Resident 1. LN 1 stated, We usually help each other out. LN 1 stated for Resident 1's morning medications on 7/31/25, one LN (2) prepared the medications, one LN (1) gave Resident 1 his medications and one LN (3) signed in the MAR. LN 1 stated the LNs were not supposed to do that because that could lead to a medication error. On 8/425 at 4:04 P.M., a joint interview with the Director of Nursing (DON) and the Administrator (ADM) was conducted. The DON stated the expectation was whoever is preparing resident's medications should be the one giving to the resident and should be the one signing in the MAR to prevent medication error. A review of the facility's policy, titled Administering Medications revised 4/2019, indicated. Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation.1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications.

Based on observation , interview and record review, the facility failed to ensure clean and used utensils were separated during a preparation of pureed meals. This failure had the potential to affect the health and safety of all residents. An observation on 5/5/25 at 10:30 A.M., was conducted with the [NAME] (CK) and the registered dietician (RD). The CK was observed preparing a pureed meal for 9 residents in the facility. The CK placed 20 pieces of tortillas and 3 cups of turkey meat in a chicken broth and placed them in a blender. The CK used a large mixing spoon to mix the tortillas and the turkey meat in the blender. The CK stated she wanted to make sure that the mixture was smooth and was free of lumps after blending the ingredients together. Then the CK placed the large mixing spoon in a tray of clean mixing spoons and colored scoops together. An interview on 5/5/25 at 11 A.M., with the CK was conducted. The CK stated she was nervous, and it was her first survey to be watched . The CK stated it was important not to mixed used and clean utensils to prevent possible contamination thus affecting the residents' health in the facility. An interview on 5/5/25 at 11:10 A.M., with the Registered Dietician (RD) was conducted. The RD stated she saw what the CK placed the used large mixing spoon with the clean utensils. The RD stated it was not right to mix clean and used utensils together to prevent contamination. An interview on 5/7/25 at 10 A.M., with the Director of Nursing (DON) was conducted. The DON stated it was important not to mixed clean and used utensils to prevent cross contamination thus preventing resident's health decline and or condition. A review of the facility's policy dated, 2/2025 titled Food Preparation and Service indicated, food preparation area .#4 appropriate measures are used to prevent cross contamination.

Based on interview and record review, the facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST - a medical form to communicate a resident's end of life wishes) for three of 18 residents (4,128, 129) reviewed for complete and accurate medical records. This failure did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers. Findings: 1. Resident 4 was re-admitted on [DATE] to the facility with diagnoses to include dementia (type of memory loss), muscle weakness and adult failure to thrive according to the Admisison Record. 2. Resident 128 was admitted on [DATE] to the facility with diagnoses to include hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness following a stroke) according to the Admisison Record. 3. Resident 129 was admitted to 4/6/25 to the facility with diagnoses to include bacteremia (presence of bacteria in the blood), diabetes type 2, endocarditis (a serious infection of the heart's inner lining), autistic disorder and cognitive communication deficit (difficulty understanding, paying attention to conversation and remembering information) according to the admission Record. On 5/6/25 at 11 A.M.,a concurrent interview and record review were conducted with licensed nurse (LN)11. LN 11 reviewed POLST forms for Residents 4,128 and129. LN 11 stated POLST forms for Residents 4,128 and129 were incomplete.The following were reviewed: Resident 4's POLST on 4/6/25 was incomplete. Resident 128's POLST was incomplete. Resident 129's POLST was incomplete. LN 11 stated Residents 4's, 128's and 129's should be completed. LN 11 stated POLST should indicate the date when the physician and patient or legally recognized decisionmaker to determine the date the POLST was effective. LN 11 stated relationship should be indicated to verify the person who signed and the relationship to the resident. On 5/7/25 at 12:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated POLST should be completed for validity purposes and make sure resident wishes were followed.

Based on observation, interview and record review, the facility did not ensure infection control practices were implemented when: 1. Clean linens were mixed with packages that were transported from outside facility 2. Trash cans were inside the clean linen closets 3. Dusty and debris on the floor of the clean linen closets 4. A licensed nurse (LN 21) did not wear an isolation gown while administering medications to a resident (1) with a gastrostomy tube (GT-feeding tube inserted through the belly to bring nutrition and medications directly to the stomach). These failures had the potential to spread infections. Findings: 1. On 5/7/25 at 8:28 A.M., a concurrent observation and interview were conducted with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP). The closet was observed with clean linens in contact with packages. The DES stated facility have outside company doing their laundry. The DES stated the outside company transported clean linens packaged in plastic bags. The IP stated there should not be packages of plastic bags in contact with clean linens. The DES stated the packaging should be removed before placing the clean linens in the closets. 2. On 5/7/25 at 8:36 A.M., a concurrent observation and interview were conducted with the Director of Environmental Services and Infection Preventionist Nurse (IP). The facility had three closets with clean linens. The clean linen closets were observed each with a trash can. One trash can was observed with used gloves inside. The DES states the trash can were inside each closet for staff to place packages of disposable briefs. The IP stated there should not be trash cans inside the clean linen closets. 3. On 5/7/25 at 8:48 A.M., a concurrent observation and interview were conducted with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP). The clean linen closets were observed to have dust and debris on the floor. The DES and the IP stated should be cleaned. On 5/7/25 at 12:30 P.M., an interview was conducted with Director of Nursing (DON). The DON stated the clean linen plastic packaging should be removed. The DON stated the plastic packaging of the transported clean linens served as the barrier to prevent contamination. The DON stated the clean linen closet should not have a trash can and should not have dust and debris on the floor because clean linen closet should be free from trash and dust. According to the facility policy titled Laundry and Bedding, Soiled, dated September 2022, indicated .Clean linen is protected from dust .Clean linen is stored separately . 4. According to the facility face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included attention to gastrostomy (presence of an artificial opening into the stomach). Per Resident 1's physician's orders, on 4/1/2024, an order was made for Enhanced Barrier Precautions (EBP-an evidence-based practice that expands the use of gloves and gowns during high-contact resident care activities, especially for those at increased risk of acquiring or spreading multidrug-resistant organisms -MDROs) related to indwelling device: feeding tube. On 5/6/25 at 8:22 A.M., LN 21 was observed and interviewed during a medication administration for Resident 20. LN 21 had a face mask on, did hand hygiene with hand sanitizer, knocked on the door, introduced herself, identified Resident 1 with ID arm band and explained the procedure. On 5/6/25 at 8:31 A.M., LN 21 detached Resident 1's GT from the nutrition feeding tube. LN 20 attached a syringe to the GT and flushed the GT with water. LN 20 then proceeded to administer medications. On 5/6/25 at 8:45 A.M., LN 21 stated she was done with administering Resident 1's medication. LN 21 stated she did not know she needed to wear a gown when administering medications to residents with a GT who are on EBP. On 5/6/25 at 8:50 A.M., a concurrent interview and record review were conducted with LN 21 of the EBP signage posted outside of Resident 1's door. The EBP signage indicated that examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tubes .). On 5/7/25 at 2P.M., an interview with the Director of Nursing (DON) was conducted. The DON agreed that all staff need to follow and adhere to all infection control procedures. A review of the facility policy titled, Enhanced Barrier Precautions, dated December 2024, indicated that examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tubes .).

Based on observation , interview and record review, the facility failed to ensure a tube feeding formula was labeled for one resident (178) reviewed for Parenteral Nutrition. This failure had the potential to affect Resident 178 health conditions and decline. Findings: A review of Resident 178's admission Record indicated that Resident 178 was admitted to the facility on with 4/15/2025 with diagnoses that include Dysphagia (difficulty swallowing food and liquids) and Aphasia (a language disorder that affects a person's ability to communicate). During the initial tour on 5/4/25 at 9:15 A.M., an observation was conducted. Resident 178 had a gastrostomy feeding tube (a tube inserted through the stomach) with formula of Fiber source HN at 65 ml per hour with water running at 20 ml per hour per the feeding pump machine. Resident 178's feeding tube formula was not labeled . An interview on 5/4/25 at 9:32 A.M., with Licensed Nurse (LN) 2 was conducted. LN 2 stated she worked per diem for the facility and was not aware of the tube feeding formula not labeled. LN 2 stated it was important to label the feeding tube formula to follow the routes of medication administration and for Resident 178's safety. An interview on 5/7/25 at 9:32 A.M., with the Director of Nursing (DON) was conducted. The DON stated it was important to label the formula for accuracy, safety and follow the routes of medication administration and the Physician's orders, thus preventing complications. A review of the facility's policy titled, Enteral Feedings- Safety Precautions indicated preventing errors in administration 1. Check the enteral nutrition label against the order before administration. Check the following information. a. Resident name, ID and room number b. type of formula c. date and time formula was prepared. 2. On the formula label document initials, date and time the formula was hung and initial that label.

Based on observation, interview and record review, the facility failed to ensure services to meet professional standards for two of 18 sampled residents when: 1.Resident 129's PICC line (peripherally inserted central catheter- a thin tube placed in the vein of the upper arm and threaded towards the heart to deliver medications directly to the blood stream) 2. a gastrostomy tube (GT-tube inserted through the belly to bring nutrition and medications directly to the stomach) placement was not checked before medication administration for one resident (1). This failure had the potential for complications related to intravenous (IV - method of delivering medications directly into the bloodstream through a vein) therapy and causing complications related to GT health. Findings: 1. A review of the facility's admission record, Resident 129 was admitted to the facility on [DATE] with diagnoses to include bacteremia (presence of bacteria in the blood), diabetes type 2, endocarditis (a serious infection of the heart's inner lining), autistic disorder and cognitive communication deficit (difficulty understanding, paying attention to conversation and remembering information). A review of Resident 129's physician orders indicated the following: on 4/7/25 .PICC line dressing change as needed [measure external catheter length] . on 4/13/25 .PICC line dressing change every day shift every Sat[sic] {and measure external catheter length} . on 5/4/25 IV PICC - Measure catheter length with each dressing change . On 5/5/25 at 8:35 A.M., observation and interview were conducted with Resident 129. Resident 129 had a PICC line on his right upper arm. Resident 129 stated he could not recall if the nurse measured his arm or the PICC line. On 5/6/25 at 9:30 A.M., a concurrent interview and record review were conducted with licensed nurse (LN) 11. A review of the PICC line dressing change for April 2025 in the Medication Administration Record (MAR) for Resident 129, measurements for catheter length were not done. LN 11 stated PICC line measurement should have been done weekly as ordered by the physician and as needed with each dressing change. LN 11 stated the importance of measuring the catheter length was to ensure proper placement and prevent complications. On 5/6/25 at 10:39 A.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated there was no documentation to provide that Resident 129's PICC line length was measured on April 2025. On 5/7/25 at 12:15 P.M., an interview was conducted with the DON. The DON stated measuring the PICC line catheter length during dressing change was a standard of practice and should have been done. The DON stated the expectation was for registered nurses (RNs) should measure Resident 129's PICC line length weekly and should have been documented in the MAR. According to the facility's policy titled , Central Venous Catheter and Dressing Changes dated March 2022, indicated .6. measure the external length of the external central vascular device with each dressing change .Compare with the length documented at insertion . 2. Per the facility face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included attention to gastrostomy (presence of an artificial opening into the stomach) and dysphagia (difficulty swallowing). On 5/6/25 at 8:22 A.M., licensed nurse (LN) 21 was observed and interviewed during a medication administration for Resident 1. On 5/6/25 at 8:31 A.M., LN 21 entered Resident 1's room. LN 21 explained the procedure to Resident 1 and detached Resident 1's GT from the nutrition feeding tube. LN 21 attached a syringe to the GT and flushed the GT with water. LN 21 then proceeded to administer medications. On 5/6/25 at 8:45 A.M., LN 21 stated she was done with administering Resident 1's medications. LN 21 acknowledged she did not check placement prior to administering medications to Resident 1. On 5/7/25 at 2 P.M., an interview with the Director of Nursing (DON) was conducted. The DON agreed that all nurses need to check GT placement prior to administering medications and that it is important to help prevent complications. A review of the facility policy titled, Administering Medications through an Enteral Tube dated November 2018, .6. Verify placement of feeding tube .

Based on observation, interview and record review, the facility failed to consistently provide pressure ulcer preventative measures to one resident (178) when, Resident 178 was not turned every two hours. This failure had the potential for Resident 178 to develop pressure ulcers or skin breakdowns. Findings: A review of Resident 178's admission Record indicated that Resident 178 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia (a condition wherein the lungs cannot adequately transfer oxygen to the blood ) and Dysphagia( difficulty swallowing food and liquids). During the initial tour on 5/4/25 at 9:15 A.M., was conducted with Resident 178. Resident 178 was observed lying on his back with his head of bed elevated. Resident 178 had his oxygen on at 2 liters per minute and his tube feedings being infused. During an observation on 5/5/25 at 8:20 A.M., Resident 178 was lying in bed on his back with the head of his bed elevated. During an observation on 5/4/25 at 9:50 A.M., Resident 178 was lying in bed on his back with pillows under his left arm. A concurrent observation and interview on 5/5/25 at 10:40 A.M., with family member (FM) 1 was conducted. Resident 178 was still lying in bed on his back with his tube feedings being infused. FM1 stated I haven't seen anyone turned and repositioned him since I got here this morning. During an observation of Resident 178 on 5/5/25 at 12 noon, Resident 178 was lying in bed on his back with his left arm on a pillow. During an observation of Resident 178 on 5/5/25 at 12:40 P.M., Resident 178 was lying on the bed on his back with his left arm on a pillow. During an observation of Resident 178 on 5/5/25 at 2:00 P.M., Resident 178 was lying on the bed on his back with his left arm on a pillow. During an observation of Resident 178 on 5/5/25 at 3:27 P.M., Resident 178 was lying on his back with a pillow underneath his left arm. During an observation of Resident 178 on 5/5/25 at 4:20 P.M., Resident 178 was still lying on his back with a pillow underneath his left arm. An interview on 5/6/25 at 9:20 A.M., with Licensed Nurse (LN) 1 was conducted . LN1 stated it was important to turn and reposition Resident 178 to prevent skin breakdowns and provide comfort . A joint observation and interview on 5/6/25 at 1:27 P.M., with Treatment Nurse (TN) was conducted. The TN stated Resident 178 must be turned and repositioned every 2 hours to prevent skin breakdown. A joint observation and interview on 5/7/25 at 7:35 A.M., with certified nursing assistant (CNA) 3 was conducted. Resident 178 was positioned facing his right side with pillows underneath his back . CNA 3 stated she worked with Resident 178 most of the time in the morning shift. CNA 3 stated Resident 178 was dependent on his activities of daily living (ADLs). CNA 3 stated Resident 178 was incontinent of both bladder and bowel although Resident 178 had a foley catheter previously. CNA 1 stated it was important to turn and reposition Resident 178 every 2 hours because Resident 178's left arm was contracted and to prevent further skin breakdown. A record review of Resident 178's minimum data set (MDS-a federally mandated assessment tool) indicated Resident 178's Brief interview for mental status(BIMS) score was 03 which meant Resident 178's cognition (thought process) was severely impaired. A record review of Resident 178's MDS section GG (functional abilities section) indicated Resident 178 was dependent on his activities of daily living- eating, toileting and transfers. A review of Resident 178's care plan titled, 4. At risk for skin breakdown related to Braden Risk score , impaired mobility, severely contracted and weakness indicated one of the interventions in Resident 178's care plan was to turn and reposition every 2 hours to prevent skin breakdown/ bedbound. An interview on 5/7/25 at 2 P.M., with the Director of Nursing (DON) was conducted. The DON stated it was important to follow the doctor's order of turning and repositioning Resident 178 every 2 hours to prevent skin breakdown. A review of the facility's policy dated 4/2020 titled Prevention of Pressure Injuries ' indicated mobility / repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule . 2. Choose a frequency for repositioning based on the resident's risk factors .

Based on observation, interview and record review, the facility failed to provide at least 80 sq ft. ( square feet) per resident in nine of 39 resident rooms. This failure had the potential to affect resident quality of care and quality of life. Findings: Per review of the Client Accommodations Analysis form, the facility had nine resident rooms which did not meet the required square footage requirements of at least 80 square feet per resident. Room number - number of residents- sq feet 31--- 3 ----------------------------------------------209.00 33---- 3---------------------------------------------- 209.46 35-----3-----------------------------------------------211.51 36-----3-----------------------------------------------211.51 37-----3-----------------------------------------------211.51 38-----3-----------------------------------------------207.17 39-----3-----------------------------------------------208.27 40-----3-----------------------------------------------206.71 41-----3-----------------------------------------------208.27 A confidential resident group interview was conducted on 5/5/2025 at 10:00 A.M. No residents expressed any concern with resident rooms. Observations from 5/4/2025 through 5/7/2025 were conducted of rooms 31, 33, 35, 36, 37, 38, 39, 40, and 41 , during the recertification survey. No quality of care or quality of life concerns were identified and observed that negatively impacted the residents residing in these rooms. Therefore, a continuance of the room variance is recommended.

Based on interview and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to medication administration for one of three sampled residents (Resident 1). This failure had the potential to not meet the goals of treatment and needs of Resident 1. Findings: On 1/28/25 at 1:57 P.M., an unannounced onsite to the facility was conducted related to a complaint on Nursing Services. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism (underactive thyroid gland), per the facility's Admission Record. On 1/28/25, a review of Resident 1's physician order dated 12/19/24 indicated the following order: - Levothyroxine 1 tablet at 6 AM. On 1/28/25, a review of Resident 1's care plan related to levothyroxine administration indicated one of the interventions was to administer medication as ordered. On 1/28/25 at 3:15 P.M., a joint review of Resident 1's medication administration record (MAR, used to document medications taken by each patient) and an interview with Licensed Nurse (LN) 1 was conducted. The MAR for 12/20/24 through 1/1/25 was reviewed with LN 1. The MAR for administration of levothyroxine for Resident 1 indicated the following entries: - 12/20/24 at 8:24 A.M. - 12/22/24 at 8:31 A.M - 12/24/24 at 8:37 A.M. - 12/27/24 at 8:29 A.M. LN 1 stated levothyroxine was ordered to be administered at 6 A.M. and should be given on an empty stomach or before breakfast. On 1/28/25 at 3:45 P.M., a joint review of Resident 1's MAR and care plan, and an interview with the Director of Nursing (DON) was conducted. The DON stated the medication should be given one hour before and one hour after the scheduled time. The DON stated the care plan should have been followed and implemented. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .9. Care plan interventions are chosen only after data gathering .careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .

Based on interview and record review, the Licensed Nurses (LNs) failed to administer Levothyroxine (a medicine used to treat an underactive thyroid gland [hypothyroidism]) within the time frame as ordered by the physician for Resident 1. This failure had the potential to negatively affect Resident 1's absorption of the medication and had the potential for ineffective medication. Findings: On 1/28/25 at 1:57 P.M., an unannounced onsite to the facility was conducted related to a complaint on Nursing Services. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism, per the facility's Admission Record. On 1/28/25, a review of Resident 1's physician order dated 12/19/24, indicated the following order: - Levothyroxine 1 tablet at 6 AM. On 1/28/25 at 3:15 P.M., a joint review of Resident 1's medication administration record (MAR, used to document medications taken by each patient) and an interview with Licensed Nurse (LN) 1 was conducted. The MAR for 12/20/24 through 1/1/25 was reviewed with LN 1. The MAR for administration of levothyroxine for Resident 1 indicated the following entries: - 12/20/24 at 8:24 A.M. - 12/22/24 at 8:31 A.M - 12/24/24 at 8:37 A.M. - 12/27/24 at 8:29 A.M. LN 1 stated levothyroxine was ordered to be administered at 6 A.M. and should be given on an empty stomach or before breakfast. LN 1 stated she did not know the reason it should be given on an empty stomach or before breakfast. LN 1 stated the medication should be given before her shift. LN 1 stated, I will get back to you. On 1/28/25 at 3:45 P.M., a joint review of Resident 1's MAR and an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to give the medication on time, an hour before and one hour after. It is important to follow because there might be medical reason behind it. A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit .Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interaction .

Based on observation, interview and record review, the facility failed to prevent an accumulation of old food and beverage items at the bedside of one resident, Resident 2, sampled for infection prevention. The facility also failed to provide regular showers or bed baths and clean clothing to Resident 2 who had open sores on his arms and face. As a result, Resident 2 was at risk for foodborne illness and infection of his open wounds. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included depression (a mental health condition that involves a persistent feeling of sadness), severe protein-calorie malnutrition (a condition that occurs when the body doesn't get enough protein, calories and other nutrients), mood disorder (a mental health condition that involves persistent changes in a person's emotional state), malignant neoplasm of bronchus and lung (a type of tumor in the lower airways and lung), and homelessness. On 11 /13/24 an unannounced visit was made to the facility. On 11/13/24 at 2:50 P.M., an observation and interview were conducted with Resident 2 who was lying on his bed. Resident 2 was noted to have many dried scabs and open sores on the exposed parts of his arms and on his face. Reddish-brown smudges were noted on many areas of the fitted sheet on Resident 2's bed. Many food and beverage items were noted on Resident 2's overbed table and dresser. Many small flying insects were noted in Resident 2's shared room, landing on the resident's skin and on his food and beverages. Many insects were also on the privacy curtain between the two beds in the room. Resident 2 waved his arms to move the insects away and off his skin. Additionally, Resident 2 was noted as wearing soiled black sweatpants and a soiled burgundy shirt, with disheveled hair. The furniture surfaces and floor surrounding Resident 2 were notably dirty. Resident 2 stated They are cleaning the area sometimes and bathing sometimes. On 11/13/24 at 3:15 P.M., an observation and interview were conducted with Certified Nursing Assistant (CNA) 2 who stated, Old food could make him sick. He might not like all those flies landing on him. CNA 2 was not able to answer what the risk of insects landing on Resident 2's wounds and food was. On 11/13/24 at 3:25 P.M., an observation and interview were conducted with the Infection Preventionist (IP) who stated, It's not ok to have flies, they can lay eggs and get into the food. I'm not sure why the food is still there. The food shouldn't be in there for more than a couple of hours, they should throw it out and get new ones. A joint observation of a urinal on an overbed table in the room across the hall was made. A sign for Enhanced Barrier Precautions (EBP) was noted on the wall outside of the room. The IP stated the resident was on EBP precautions for a wound. The IP stated, Having a urinal on the table is an infection control risk, it should not be there. On 11/13/24 at 3:45 P.M., a joint observation of Resident 2's living situation was conducted with the Administrator (ADM). The ADM stated, If they're exposed to infestation it's a risk to their skin. Old food is a risk for foodborne illnesses. On 11/14/24 at 3 P.M., a telephone interview was conducted with the Director of Nursing (DON) who stated, I don't know how long it's ok to keep the food in the room. The risk is he might get sick. On 11/14/24 at 3:35 P.M., a telephone interview was conducted with the Certified Dietary Manager (CDM) who stated, I'm not 100% sure how long perishable foods can be left at the bedside at room temperature or in the kitchen, I'd have to check the policy. On 11/15/24 at 1:05 P.M., a telephone interview was conducted with the CDM who stated, Time temperature-controlled food can be kept at the residents bedside for two hours. The concern is risk for foodborne illness. On 11/15/24 at 1:29 P.M., a telephone interview was conducted with the Registered Dietician (RD) who stated, food can be held at room temp for two hours. The policy says that they are to remove the food after two hours. The risks are nausea, vomiting, diarrhea, bloating, dehydration. Food insecurity was in my evaluation. At admission his background was identified, he had homelessness in his diagnosis. On 11/20/24 at 3:24 P.M., a telephone interview and concurrent record review of Resident 2's shower log were conducted with the DON. Between 10/29/24 and the time of the onsite investigation, Resident 2 received one shower and had his toenails trimmed on 11/5/24. The DON stated residents are supposed to be showered or bathed twice per week and nail care is no less than once a week. The DON stated Resident 2 did not receive this care. The DON stated, It's important for him to be kept clean because it's going to create a medium for bacteria to grow and he might get infected. Nail care is no less than once a week. A review of the facility pest control contractor's report dated 10/28/24 indicated, monthly service . Spot treated employee break room for fruit fly activity. A review of the facility policy titled Infection Prevention and Control Program dated 2001 indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility policy titled Bath, shower/ tub dated 2001 indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on interview and record review the facility failed to ensure that a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) provided by an agency (a company that supplies staff) had the necessary competency to document care during their shift. As a result, CNA 1 did not document any care provided for Resident 1, sampled for death, and LN 1 documented medications were given late. Additionally, no change of condition documentation and physician notification were done regarding abnormal laboratory results, and no follow-up social services notes were documented for Resident 1's roommate who was in the room when he died . The facility was not able to provide requested evidence of the events prior to Resident 1's death in the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs), diabetes mellitus type two (a chronic disease that occurs when the body cannot control the amount of sugar in the blood) with chronic kidney disease stage three (a condition in which the kidneys are mildly to moderately damaged), acute respiratory failure with hypoxia (a chronic condition of the lungs in which oxygen is low in the blood) and pulmonary hypertension (a serious condition in which the blood pressure in the lungs is higher than normal). CNA 1 and LN 1 were not working at the facility during the investigation and did not respond to the facility request for a telephone interview. On [DATE] at 1:35 P.M. a telephone interview was conducted while at the facility with the Director of Nursing (DON) who was not onsite. The DON stated, I see that the day shift CNA did not document through her shift. I expect them obviously to be able to chart accurately meaning everything that happens to a patient during their shift should be documented, that includes ADLs (Activities of Daily Living, the basic tasks people need to do to care for themselves), toileting, and the amount eaten during meals. The DON stated the CNA and Licensed Nurse assigned to Resident 1 were agency staff and did not participate in staff trainings at the facility. The DON stated, I do not see any notes about social services following up with the roommate to see how he was doing after the death. The follow up should have been documented. On [DATE] at 3:32 P.M. a telephone interview and concurrent record review were conducted with the DON who stated the agency provided training to their staff but their skills checklists did not include documenting care provided. The DON further stated that no employee at the facility reviewed the agency portal to ensure temporary staff had skills checklists prior to allowing them to come work at the facility. A concurrent review of Resident 1's laboratory results with multiple abnormal findings were reviewed. The DON stated Resident 1 had abnormal laboratory results. The DON stated no change of condition notes were written about abnormal lab results and If there's abnormal labs it should be reported to the doctor. There is no note that says the physician was notified. A concurrent record review of Resident 1's orders indicated Basaglar KwikPen subcutaneous solution Pen-injector (a long acting insulin used to control high blood sugar) 100 u/ mL (milliliter) was due to be administered at 9 P.M. nightly. The DON stated the insulin administration was documented late on ,d+[DATE] at 11:31 P.M., one- and one-half hours past the maximum time to administer the medication. A concurrent record review of Resident 1's medication administration record (MAR) indicated Lispro (a fast-acting insulin used to control high blood sugar) if (blood glucose result of) ,d+[DATE] give 0 units; ,d+[DATE] give 2 units, ,d+[DATE] give 3 units, ,d+[DATE] give 4 units, ,d+[DATE] give 5 units, ,d+[DATE] give 6 units, 401+ administer 7 units and notify MD (Medical Doctor). A concurrent record review of the MAR indicated on [DATE] a dose of Lispro was due at 12 noon and was administered at 2:26 P.M., one- and one-half hours past the maximum time to administer the medication. A dose of Lispro was due on [DATE] at 7 A.M. and was administered at 12:07 P.M., four hours past the maximum time to administer the mediation. A dose of Lispro was due on [DATE] at noon and was administered at 1 P.M. The DON stated he did not have any documentation to clarify if two doses of Lispro were given within one hour of each other on [DATE]. A dose of Lispro was due on [DATE] a dose of Lispro at 7 A.M. and was documented as administered at 8:29 A.M., one-half hour past the maximum time to administer the medication. The DON stated, It is late. There's no excuse. Nurses should document medication as it's given. Nurses are aware that they should prep, administer then sign. A concurrent review of laboratory results drawn at 5:30 A.M. on [DATE] indicated Resident 1 had a low blood glucose level of 64. According to the laboratory report, a normal range was ,d+[DATE]. A review of the facility policy titled Administering Medications dated 2011 indicated, Medications will be administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Medications are administered within one (1) hour of their prescribed time.

Based on observation, interview, and record review, the facility failed to provide documented evidences that the maintenance department was proactive in documenting weekly maintence checks for room and facility temperatures during extreme temperature changes. As a result, the facility was unable to show documented evidence the facility and room temperatures were safe and comfortable over the past year. Findings: On 6/27/24, an unannounced visit was made to the facility, regarding a complaint of the buildings' air conditioner not functioning in the east hallway. On 6/27/24 at 1:25 P.M., an observation was conducted of the east hallway which consisted of resident rooms 10-29. All the rooms had one or more fans in them, and a small air conditioner unit was in one room. Seven ceiling fans ran the length of the hallway and were all functioning. On 6/27/24 at 1:28 P.M., an interview was conducted with Resident 3. Resident 3 stated her room was hot and had been like that for, Several days. Resident 3 stated she was told the air conditioner was broken and they were waiting for a part to fix it. On 6/27/24 at 1:45 P.M., an interview was conducted with the Director of Maintenance (DM). The DM stated he was informed the air conditioner on the east hallway, had stopped working Sunday night (7/23/24). On Monday morning (7/24/24) the DM immediately informed the Administrator (ADM) and requested a repair company to come troubleshoot the issue. The DM continued stating he was informed the blower for the air conditioner was not working and needed to be replaced. The DM stated the blower part was replaced on 6/26/24, but then something went out on the air conditioner for the north hallway, which was now being repaired. The DM stated he routinely checked temperatures in a few rooms every week, usually in the morning hours. The DM stated he did not document the room temperatures and had not documented anything for at least a year. The DM stated the room temperatures should be maintained between 72-80 degrees Fahrenheit (F). The DM stated he had not checked the room temperatures after the air conditioner went out, because he was focused on getting it fixed. On 6/27/24 at 1:39 P.M., the DM performed room temperature checks on all the rooms with a laser gun (measures the infrared radiation emitted from a surface). One room in the north hall was recorded at 81.5 F. Two rooms in the east hall were recorded at 80.5 F. The lowest room temperature was in the west hallway recorded at 74.0 F, with the hallway door being closed. The DM was asked to locate his binder that previously recorded temperatures during his weekly temperature checks. On 6/27/24 at 2:07 P.M., the DM returned, stating he could not find the binder and he had no idea when he last recorded a room temperature. The DM stated he should be logging the temperatures to prove they were done, and the temperature was safe. On 6/27/24 at 2:21 P.M., an interview was conducted with ADM. The ADM stated he started at the facility on 6/24/27 and was aware the air conditioner in one hallway was not functioning, because the DM had informed him, and a family member had complained. The ADM stated he was unaware the DM was not performing temperature checks during the outage. The ADM stated he expected the DM to be recording temperatures weekly and daily when the air conditioner was not working properly. The ADM stated temperature checks were important to sure the temperatures were safe and comfortable for their residents, staff, and visitors. According to the facility's policy, titled Maintenance Service, dated December 2009, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .8. The Maintenance Director is responsible for maintaining the following records/reports: .k. Inspection of building .m. Maintenance schedules .

Based on an interview and record review, the facility failed to ensure that pressure injuries (also known as pressure ulcers or bed sores, which are areas of skin and tissue damage caused by prolonged or intense pressure) were documented in the medical record every week per the facility's policy for one of three sampled residents (Resident 1). As a result, Resident 1's progression or deterioration of the pressure injury could not be accurately assessed. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), per the facility's Admission Record. A review of Resident 1's medical record was conducted. Per the Progress Notes dated 3/22/24, Licensed Nurse (LN) 1 documented that Resident 1 had a stage 1 (no skin break) pressure injury to the sacral (tailbone) area and was red. Per the undated Plan of Care, under Focus (Problem Area), Resident 1 had impaired skin integrity related to a stage 1 reddened sacral area. One intervention was to follow the facility protocols. On 6/11/24 at 3:06 P.M., the Treatment Nurse (TN) was interviewed. The TN stated that the protocol for a resident with a wound, such as a stage 1 pressure ulcer, was for them to do the wound assessment every week. TN stated that Resident 1 had a stage 1 pressure ulcer on admission, and there should have been a weekly wound assessment, but it was missed. LN 1 was not available for an interview. On 6/11/24 at 4 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that pressure injuries should be monitor weekly and documented in medical records. Per the facility's policy and procedure, dated 2001, titled Pressure Injury Risk Assessment, .Repeat the skin assessment weekly . Per the facility's policy and procedure, dated 2001, titled Pressure Injuries/Skin Breakdown - Clinical Protocol, .If a skin issue is noted the nurse should describe and document/report the following: Anatomical location stage, size .skin surrounding the ulcer .

Based on observations, interviews and record review, the facility failed to ensure dignity was provided to the residents when a staff member did not knock or announce herself before entering two residents' rooms (Resident 1 and unsampled residents). This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem. Findings: On 3/14/24, an unannounced onsite was conducted to the facility related to a complaint of resident abuse. a. Resident 1 was readmitted to the facility on [DATE] with diagnoses which included dementia (loss of cognitive function like thinking, remembering, and reasoning) with psychotic (loss of contact with reality) disturbance, per the facility ' s Admission Record. A review of Resident 1 ' s minimum data set (MDS, an assessment tool), dated 2/16/24, indicated Resident 1 ' s brief interview for mental status (BIMS, ability to recall) score was six, which indicated Resident 1 ' s cognitive function was severely impaired. During an observation on 3/14/24 at 9:58 A.M., a Certified Nursing Assistant (CNA) 1 went into an unsampled residents ' room, without knocking or announcing herself. During an observation on 3/14/24 at 11:37 A.M., CNA 1 went into Resident 1 and unsampled residents ' room without knocking or announcing herself. CNA 1 was chewing a gum and sat in front of Resident 1 without saying a word. Another CNA (CNA 3) walked back to Resident 1 ' s bed and saw CNA 1 sitting in front of Resident 1. CNA 3 stated to CNA 1 Oh you startled me. I didn ' t know you were here. During an interview with CNA 1 on 3/14/24 at 11:43 A.M., CNA 1 stated she was there to relieve CNA 3 on closely monitoring (one on one) on Resident 1. CNA 1 stated she did not knock or announce herself when she went into Resident 1 ' s room. CNA 1 stated she should have knocked or have announced herself to notify the residents for dignity reason. CNA 1 stated, That is their right. b. Resident 4 was admitted to the facility on [DATE] with diagnoses which included stroke, per the facility ' s Admission Record. A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 ' s BIMS score was 10 which indicated Resident 4 ' s cognitive function was moderately impaired. During an interview with Resident 4 in his room on 3/14/24 at 11:45 A.M., Resident 4 stated staff did not knock or announce themselves when they come into his room. Resident 4 stated he did not know the staff members ' name because they did not introduce themselves. Resident 4 stated, Most of the time, they just come in. Sometimes we need to know who they are and what they would like to do so we know. During an interview with the Director of Nursing (DON) on 3/14/24 at 2:13 P.M., the DON stated the expectation was for the staff members to knock and identify themselves, for dignity, and maintain residents ' rights to their privacy to their rooms regardless of the residents ' mental status. A review of the facility's policy titled, Dignity, revised February 2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .1. Residents are treated with dignity and respect at all times .7. Staff are expected to knock and request permission before entering residents' rooms .

Based on interview and record review, the facility failed to provide pain relief in a reasonable amount of time, following a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for pain management. As a result, Resident 1 had no pain relief for 6.5 hours, delaying his comfort and healing process. Findings: On 11/27/23 an unannounced visit was made to the facility regarding a complaint which involved pain management. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cancer of the prostate, per the facility ' s Admission Record. On 11/27/23, Resident 1 ' s clinical record was reviewed: According to the Admission Minimum Data Set (a clinical assessment tool) Resident 1 had a cognitive score of 15, indicating cognition was intact. According to the facility ' s Progress Note dated, 11/15/23 at 11:39 A.M., Resident 1 returned to the facility following an outpatient surgery of a suprapubic catheter insertion. According to the physician ' s order, dated 11/15/23, Dilaudid (an opioid medication used to treat severe pain), 2 milligrams (mg), give 1 tablet by mouth every four hours as needed for severe pain, give 0.5 tablet every four hours as needed for moderate pain (1/2 tablet). Assess patient every two hours for pain. According to the Medication Administration Record (MAR), dated 11/15/23, Resident 1 ' s pain assessment started at 4 P.M. but did not include Resident 1 ' s level of pain. According to the MAR, dated 11/15/23, 1 tablet of Dilaudid was administered to Resident 1 at 6 P.M. for a pain score of 8 out of 10, (1 being the least amount of pain and 10 being the worst pain). A second dose was provided at 10:05 P.M., for a pain scale of 8/10. The Progress Notes were reviewed from 11:29 A.M. to 8:07 P.M. on 11/15/23, with no mention of pain assessment or pain level. According to the care plan, titled Analgesic/Opioid (Black Box Warning) DILAUDID, dated 9/10/23, list an intervention of Administer medication as ordered. According to the care plan, titled Status post Supra Pubic Cath Placement, dated 11/15/23, list intervention of pain assessment every shift and medicate as needed. An interview was conducted with Licensed Nurse 1 (LN 1) on 11/27/23 at 11:58 A.M. LN 1 stated Resident 1 had outpatient surgery in the morning for the insertion of a suprapubic catheter on 11/15/23, and returned to the facility the same day, before lunch. Resident 1 returned with an order from the surgeon for Dilaudid Intravenously (IV) for pain. LN 1 stated she was a licensed vocational (LVN) nurse and was not allowed to give IV push medications. LN 1 said because she could not administer the IV pain medication to Resident 1, she asked LN 2, who was an Registered Nurse to administer the IV pain medication. LN 1 stated LN 2 told her the facility was not allowed to give IV push pain medication and she suggested she give Resident 1 the oral Dilaudid pain pills that previously had been ordered. LN 1 stated Resident 1 was currently out of Dilaudid pills, so she called the facility ' s pharmacy to get permission to remove Dilaudid from the Emergency kit (e-KIT, stored medication in the event of an emergency). LN 1 stated the pharmacist said No, it could not be removed because the Dilaudid tablets had already been re-ordered and they would have to wait for the previously ordered medication to arrive. LN 1 stated she did not inform the charge nurse or the Director of Nursing, regarding the lack of pain medication available. LN 1 stated she did not think of calling the surgeon or the facility ' s Medical Director, to have them consider another medication for pain relief, and I should have done that. LN 1 was asked if Resident 1 complained of pain. LN 1 stated Resident 1 said no when asked if he was in pain, but his daughter was very frantic and concerned with Resident 1's comfort. LN 1 stated Resident 1 did not have any facial grimace, but he was not moving around in the bed like he usually did and was very still, so she could tell he was uncomfortable. LN 1 stated she left her shift at 3:30 P.M., and the Dilaudid medication still had not arrived from the pharmacy. LN 1 stated she should have documented the event of no pain medication available, talking to the pharmacy, and the family ' s concern. An interview was conducted with LN 2 on 11/15/23 at 12:10 P.M. LN 2 stated she was informed by LN 1 of the IV medication order and told LN1 they (the facility) did not perform IV push meds. LN 2 instructed LN 1 to give the oral Dilaudid, and she assumed LN 1 had given the pain medication. LN 2 stated she was never informed the oral pain medication was not available, and she should have been told so she could have intervened. LN 2 stated 6 1/2 hours without pain medication after a surgical procedure was not acceptable. LN 2 stated if she had been informed, she would have called the physician to get a different order of pain medication, until the Dilaudid was delivered to the facility. An interview was conducted with the Director of Nursing (DON) on 11/27/23 at 12:21 P.M. The DON stated she was never informed of Resident 1 not getting his pain medication in a timely manner, and 6 1/2 hours was an unacceptable amount of time to wait. The DON stated she wished LN 1 would have notified her or the RN charge nurse and they would have immediately intervened. The DON stated by Resident 1 not getting his pain medication he was at risk for delayed healing, increased pain, and anxiety. According to the facility ' s policy, titled Medication and Treatment Orders, dated July 2016, .1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this State . According to the facility ' s policy, titled Resident Examination and Assessment, dated February 2014, .14. Pain: a. description of pain; b. location, duration severity; c. factors that worsen pain; d. factors that relieve pain; .f. current medications and treatments pain .3. Report other information in accordance with facility policy and professional standards of practice. According to the Facility Assessment, dated March 1, 2023, Part 2: Services and Care We offer Based on out Residents ' Needs: .Pain Management-Assessment of pain, pharmacologic and nonpharmacological pain management .

Based on interview and record review, the facility failed to follow the plan of care for monitoring a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for comprehensive care plans and following the physician ' s order. As a result, there was the potential for Resident 1 ' s suprapubic catheter to develop an infection or become dislodged when unmonitored routinely by staff. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included cancer of the prostate, per the facility ' s Admission Record. On 11/27/23, Resident 1 ' s clinical record was reviewed: According to the Admission Minimum Data Set (a clinical assessment tool) Resident 1 had a cognitive score of 15, indicating cognition was intact. According to the facility ' s Progress Note dated, 11/15/23 at 11:39 A.M., Resident 1 returned to the facility following an outpatient surgery of a suprapubic catheter insertion. According to the physician ' s order, dated 11/15/23, .Monitor Suprapubic catheter insertion site for signs and symptoms of infection every shift .clean suprapubic catheter daily with NS (normal saline) cover insertion site with dry dressing every shift, empty suprapubic catheter drainage bag every shift . According to the Treatment Administration Record (TAR), from 11/15/23 through 11/27/23: The surgical site was not checked for signs and symptoms of infection for four of 35 opportunities. The dressing to the surgical site was only changed on the day shift, instead of every shift, resulting in 10 of 33 opportunities. The catheter drainage bag was not emptied four times out of 35 opportunities. The care plan, titled Status Post Supra Public Cath Placement, dated 11/15/23, listed interventions such as: Check suprapubic catheter site for signs/symptoms of infection, monitor output for bleeding, provide catheter care every shift and when needed. An interview and document review was conducted with Licensed Nurse 1 (LN 1) on 11/27/23 at 11:58 A.M. LN 1 stated any resident with a newly inserted suprapubic catheter needed to be monitored closely for signs of infection, bleeding, dislodgement of the tube, along with the amount and type of fluid being drained out. LN 1 stated if it was not documented these symptoms were not monitored, and not done. LN 1 reviewed Resident 1 ' s TAR for monitoring the catheter site and drainage and stated there where blanks in the documentation, so it was not done. LN 1 stated by not following the physician ' s order, the resident was at risk for infection, bleeding, and catheter dislodgement. An interview was conducted with LN 2 on 11/27/23 at 12:10 P.M. LN 2 stated monitoring suprapubic catheters was important to detect early signs of infection or kinks and dislodgment of the tubing. LN 2 stated if the physician ordered monitoring of the suprapubic catheter, it needed to be documented, so it could be confirmed it was performed. If the monitoring was not done as orders, the resident was at a higher risk of complications. An interview was conducted with the Director of Nursing (DON) on 11/27/23 at 12:21 P.M. The DON stated if monitoring of the suprapubic catheter was nor documented as ordered by the physician, then it was not done. The DON stated monitoring was important to prevent early detection of possible problems that needed early interventions. According to the facility ' s policy, Suprapubic Catheter Care, dated October 2010, .General Guidelines: 1. Observe the resident ' s urine level for noticeable increases or decreases .6. Notify your supervisor immediately in the event of hemorrhage or if the catheter is pulled t.8. Observe the resident for signs and symptoms of urinary tract infections .Procedure: .6. Wash around the catheter site with soap and water .Documentation: .3. All assessment data obtained during the procedure . According to the facility ' s policy, title Charting and Documentation, dated December 2022, .2) The following information are examples of documentation that may be included in the resident ' s medical record: .c. Treatments or services performed . The Facility Assessment, dated March 1, 2023, list Staff Competencies include: Person Centered Care . documentation of resident ' s treatment . Infection control .Specialized care-catheterization insertion/care .post-op care .

Based on observation, interview and record review, the facility failed to ensure appropriate respiratory (relating to breathing) care and services were given to four residents when: 1. The physician's order for oxygen therapy was not followed for three residents. (Resident 3, Resident 4, and Resident 6) 2. There was no Oxygen in use sign on the doors for two residents (Resident 2 and Resident 4) and, 3. A resident ' s BIPAP (machine used as breathing support and administered through a face mask or nasal mask) nasal mask was exposed and not stored correctly. In addition, staff did not know when and how to clean the BIPAP ' s tubing and nasal mask. (Resident 2) This failure had the potential for residents to have further respiratory problems, and infection from an unclean respiratory equipment. In addition, residents, staff, and visitors were not aware of the safety risk regarding the use of oxygen in residents ' rooms. Findings: 1. Resident 3 was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood) according to the facility ' s Admission Record. Resident 3 was observed in bed on 10/17/23, at 10:24 A.M. with an oxygen cannula (oxygen tubing with two open prongs placed in the nose). The oxygen tubing was connected to a concentrator (machine that provides oxygen) set at 2 1/2 liters per minute (LPM-a measurement of the flow of oxygen received from an oxygen tank or concentrator). During a joint observation and interview with Licensed Nurse (LN) 2 on 10/17/23, at 2:03 P.M., LN 2 stated Resident 3 had oxygen with the concentrator set at 2 1/2 LPM. LN 2 checked the physician ' s orders and stated the oxygen should have been set at 2 LPM. Resident 4 was admitted to the facility on [DATE] with the diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) according to the facility ' s Admission Record. Resident 4 was observed in bed on 10/17/23, at 11:01 A.M., holding on an oxygen cannula. CNA 1 stated Resident 4 was on oxygen, but Resident 4 had episodes of removing the cannula. A concentrator was beside Resident 4 ' s bed and it was set between 2 LPM and 2 1/2 LPM. An interview and concurrent observation were conducted with LN 2 on 10/17/23, at 2:05 P.M. LN 2 stated Resident 4 was on oxygen and the concentrator was set between 2 LPM and 2 1/2 LPM. Upon review of Resident 4 ' s physician ' s orders, LN 2 stated the concentrator should have been set at 2LPM as ordered. Resident 6 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease according to the facility ' s Admission record. Resident 6 was observed in bed on 10/17/23, at 11:11 A.M. with oxygen on and the concentrator was set below 2LPM. During an interview with Resident 6, Resident 6 tried to speak, but had difficulty breathing while she spoke. During a joint observation and interview with LN 2 on 10/17/23, at 2:08 P.M., LN 2 stated Resident 6 used oxygen and the concentrator was set below 2LPM. Upon review of Resident 6 ' s physician ' s orders, LN 6 stated the physician ' s order was for Resident 6 to have 3 LPM of oxygen. During an interview with the MDS (Minimum Data Set- a clinical assessment tool) Nurse (MN) on 10/25/23, at 1:33 P.M., the MN stated physician ' s order for oxygen must be followed to support the resident ' s respiratory function. The MN further stated if the physician ' s order was not followed, the physician may not be able to manage the resident ' s need for oxygen. A review of the facility ' s policy and procedure (P&P) titled, Physician Orders, dated June 2013, was conducted. The P&P indicated, .Physician orders must be given, managed and carried out in accordance with applicable laws and regulations . 2. Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood) according to the facility ' s Admission Record. During an observation on 10/17/23, at 10:13 A.M., Resident 2 was in bed with her eyes closed and with oxygen on between 2 LPM to 2 1/2 LPM via nasal cannula connected to an oxygen concentrator was next to Resident 2 ' s bed. There was no sign on the door that Oxygen was in use. An interview was conducted with LN 1 on 10/17/23, at 1:10 P.M. LN 1 stated there should have been a sign on Resident 2 ' s door indicating oxygen was in use for staff to be aware of the use of oxygen in the room. Resident 4 was observed in bed on 10/17/23, at 11:01 A.M., holding on an oxygen cannula. CNA 1 stated Resident 4 was on oxygen but Resident 4 had episodes of removing the cannula. A concentrator was on the left side of Resident 4 ' s bed. There was no oxygen in use sign on the door. During an interview with MN on 10/25, at 1:33 P.M., MN stated residents who used oxygen must have a sign outside the resident ' s room to alert staff and other residents because oxygen was flammable. A review of the facility ' s P&P titled, Oxygen Administration, dated October 2010 was conducted. The P&P indicated, .Place an Oxygen in Use sign outside the room entrance door. 3. During an observation on 10/17/23, at 10:13 A.M., Resident 2 was in bed with her eyes closed and with oxygen via nasal cannula. A tubing with nasal mask was connected to a BIPAP machine on top of Resident 2 ' s bedside table. The nasal mask was exposed and not stored correctly. An interview and joint observation was conducted on 10/17/23, at 1:36 P.M. with LN 1. LN 1 stated Resident 2 ' s nasal mask for BIPAP should be stored in a dignity bag to prevent it from getting dirty. LN 1 stated the tubing and nasal mask should be cleaned by the afternoon shift staff, but he was not sure. LN 1 was not able to provide documentation regarding cleaning of BIPAP tubing and nasal mask. During an interview on 10/1723, at 2:10 P.M. with LN 2, LN 2 stated she did not know who cleaned BIPAP tubing and mask. During an interview with MN on 10/25/23, at 1:33 P.M., the MN stated BIPAP tubing, and mask should be cleaned to prevent the resident from contracting bacteria which can cause infection. During a review of the facility ' s P&P titled CPAP/BIPAP Support, dated March 2015, the P&P indicated, .Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes .

Based on observation, interview, and record review, the facility failed to develop a care plan related to skin integrity for one of one resident with a rash (Resident 2). Failure to develop a care plan related to skin integrity had the potential for residents to not receive appropriate care and treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (too much sugar circulating in the blood) according to the facility ' s Admission Record. During an interview on 10/17/23, at 1:10 P.M with LN 1, LN 1 stated Resident 2 had a treatment order for a medication to be applied on Resident 2 ' s left under breast. LN 1 stated the treatment was started two days ago. During an interview on 10/17/23, at 1:15 P.M. with Resident 2, Resident 2 stated both under breast areas were sore because of a rash. A review of Resident 2 ' s physician ' s order titled Order Summary Report, dated 10/17/23, the physician ' s order indicated, .Nystatin External Powder (medication to treat fungal infections) .apply to under both breasts topically four times a day for fungal infection for 14 Days .Order Date 10/16/23. A concurrent record review and interview was conducted with the MDS (Minimum Data Set- a clinical assessment tool) Nurse (MN) was conducted on 10/25/23, at 1:39 P.M. The MN stated Resident 2 did not have a care plan to address Resident 2 ' s rash when the physician ordered the treatment on 10/16/23. The MN stated there should have been a care plan developed because the care plan directed the care for the resident. The MN further stated the care plan should have been developed on the day the physician ordered the treatment. During a review of the facility ' s policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team, dated March 2022, the P&P indicated, The interdisciplinary team (team members with various areas of expertise who work together toward the goals of their residents) is responsible for the development of resident care plans .person-centered care plans are based on resident assessments .

Based on interview and record review, the facility failed to provide behavioral health care and services for two residents when: (Resident 1 and Resident 3) 1. Residents 1 and 3 both had a history of substance abuse were not referred to an addiction treatment program or for drug counseling services, 2. Residents 1 and 3 did not have a specific resident centered care plans (an approach to care that places a patient's needs and desires first) regarding substance abuse interventions. As a result, Resident 1 was transferred to the hospital and was diagnosed with Fentanyl (a highly addictive pain medication) overdose, and an unknown white powdery substance was found in Resident 3's room. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including psychoactive substance (drugs that affect the brain) abuse according to the facility's Admission Record. During an interview on 9/1/23, at 10:18 A.M., with the Minimum Data Set (MDS-an assessment tool) nurse, the MDS nurse stated Resident 1 was transferred to the hospital on 8/8/23 due to tremors, sweating, and difficult to arouse. During an interview and concurrent record review on 9/1/23, at 10:23 A.M., with the MDS nurse, the MDS nurse stated Resident 1 was found in Resident 3's room on the day of transfer to the hospital. The MDS nurse stated Resident 1 returned to the facility on [DATE] with physician's progress note which indicated, Substance abuse in the facility. The MDS nurse further stated the facility's social worker spoke with Resident 1 upon return to the hospital, but did not document the meeting. An interview was conducted on 9/1/23, at 10:46 A.M., with the social services director (SSD). The SSD stated Resident 1 called 911 due to an overdose of {Brand Name} drug. SSD stated she met with Resident 1 on Monday, 8/14/23 and stated Resident 1 verbalized receiving the {Brand Name} drug from Resident 3, then told SSD to leave the room. SSD stated she did not document her meeting with Resident 1 or any other follow up regarding substance abuse. A review of the emergency department (ED) note dated 8/8/23 was conducted. The ED note indicated, .Most consistent with opioid (class of drug used for pain) overdose which is confirming on his testing .Final diagnoses: Accidental {Brand Name} overdose . Resident 3 was admitted to the facility on [DATE] with diagnoses including psychoactive substance abuse according to the facility's Admission record. During an interview on 9/1/23, at 10:57 A.M. with the Assistant Administrator (AA), the AA stated the police came to the facility on [DATE] and searched Resident 3's room. The AA stated the police confiscated drugs from Resident 3's room. The AA further stated there has been no follow up regarding resident's possession of drugs because there have not been any concerns since. A telephone interview was conducted on 9/5/23, at 4:42 P.M., with the Administrator (ADMIN). The ADMIN stated staff confiscated multiple bags of white powdery substance from Resident 3's room and secured them in the medication cart. The ADMIN stated staff gave him the multiple bags of white powdery substance the following morning and he discarded them outside in their hazardous bin. During a telephone interview on 9/5/23, at 4:55 P.M., with the Director of Nursing (DON), the DON stated she was aware of Resident 1 and Resident 3's history of substance abuse. The DON stated she had expected the SSD to address both resident's problem with drug abuse. The DON stated there should be documentation regarding follow up and care plan. The DON stated there was no documentation regarding further follow up, or any referral to behavioral health or substance abuse resources. A review of the facility's policy and procedure (P&P) titled, Personal Property, dated August 2022 was conducted. The P&P indicated, .If items or illegal substances that belong to the resident are in plain view .the circumstances, description of the item(s), and rationale for confiscating are documented in the resident's record. The facility's policy and procedure titled, Behavioral Health Services, dated February 2019 was also reviewed. The P&P indicated, . The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being . The facility's policy did not address any referral to behavioral health or substance abuse resources. 2. During an interview and concurrent record review on 9/1/23, at 10:23 A.M., with the Minimum Data Set (MDS-an assessment tool) nurse, the MDS nurse stated Resident 1 was transferred to the hospital on 8/8/23 due to tremors, sweating, and difficult to arouse. After review of Resident 1's care plans, the MDS nurse stated there was no care plan regarding Resident 1's change of condition. The MDS nurse stated there should have been a care plan to monitor Resident 1's mentation and for staff to know the plan of care and prevent re-occurrence of the incident. An interview was conducted on 9/1/23, at 10:46 A.M., with the social services director (SSD). SSD stated she did not initiate a care plan regarding Resident 1's condition or Resident 3's possession of unknown substances in the room. During a telephone interview on 9/5/23, at 4:55 P.M., with the Director of Nursing (DON), the DON stated if drugs were found in a resident's room, a care plan should be developed. The DON stated Resident 3 did not have a care plan regarding the powdery white substance found in the room. The DON further stated a care plan was needed to address the problem and for staff to continue to monitor the resident. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022 was conducted. The P&P indicated, .A comprehensive, person-centered care plan should include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs .The interdisciplinary team should review and updates the care plan .When there has been a significant change in the resident's condition. During a review of the facility's P&P titled, Behavioral Health Services, dated February 2019, the P&P indicated, .Staff training regarding behavioral health includes .Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs .