Every finding on record at Victoria Care Center

Based on interview and record review, the facility failed to follow physician orders for bowel-management medications for one of three sampled residents (Resident 1) when licensed nursing staff continued to administer multiple bowel-regimen medications despite documentation that the resident was experiencing loose stools and/or diarrhea and physician orders directing staff to hold the medications when loose stools or diarrhea occurred. This deficient practice resulted in Resident 1 receiving bowel-regimen medications contrary to prescribed hold parameters while experiencing ongoing loose stools and/or diarrhea, placing the resident at risk for worsening diarrhea, dehydration, electrolyte imbalance, skin impairment, and other related complications. A review of Resident 1's Order Summary revealed the following:A physician order dated 5/16/2026 for GlycoLax Powder (a medication that draws body water into the stool to soften and prompt a bowel movement), 17 grams by mouth once daily for bowel management, mixed with 4 ounces of liquid; hold if loose bowel movement present.A physician order dated 5/22/2026 for Senna (a laxative that creates muscles of the intestine to contract and prompt a bowel movement) 8.6 mg oral tablets, two tablets by mouth once daily for bowel management; hold if loose stool present.A physician order dated 5/22/2026 for Docusate Sodium (a medication that allows water and fat into the stool to soften and prompt a bowel movement) oral liquid 100 mg/mL, 10 mL by mouth twice daily for bowel management; hold if loose stool present.A review of Resident 1's Medication Administration Record (MAR) for August 1 through August 31, 2026, indicated the resident continued to receive all three bowel-regimen medications despite documentation that the resident experienced loose stools and/or diarrhea on multiple days.A review of Resident 1's Bowel Management Report for August 2026 indicated loose/diarrhea was documented on the following dates and times:8/1/2026 at 2:14 p.m. and 9:49 p.m.8/18/2026 at 10:59 p.m.8/19/2026 at 6:43 a.m.8/22/2026 at 1:32 p.m. and 4:16 p.m.8/23/2026 at 12:08 p.m.8/24/2026 at 2:03 p.m.8/25/2026 at 2:59 p.m.8/26/2026 at 12:47 p.m.8/28/2026 at 11:03 a.m.During an interview on 8/28/2026 at 3:00 p.m. at the Cambridge Nurses' Station, Licensed Nurse 1 (LN 1) stated that bowel-management medications should have been held when the resident experienced loose stools or diarrhea and acknowledged that the physician-ordered hold parameters were not followed.During an interview on 8/28/2026 at 3:20 p.m. at the Cambridge Nurses' Station, Certified Nurse Assistant 1 (CNA 1) stated that the facility had previously provided in-service training regarding the identification and proper categorization of bowel-movement type, shape, and consistency. CNA 1 further stated that if a CNA was unsure how to categorize a bowel movement, the CNA would contact a nurse to observe and confirm the bowel movement.During a concurrent record review and interview on 8/28/2026 at 4:20 p.m. in the conference room, the Director of Nursing (DON) stated that, in accordance with facility policy and professional nursing standards, nurses were expected to follow physician orders as written. The DON further stated that if nursing staff had questions regarding an order, they were expected to contact the physician and/or the DON for clarification.A review of the facility's policy and procedure titled Medication Administration indicated, in part, Medications are administered in accordance with the written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to ensure the observance of proper sanitation and food handling practices when dietary aid (DA 1) failed to use a beard net during food handling.This failure had the potential to result in foodborne illnesses among the residents.During an observation, on 6/22/26, at 9 a.m., in the kitchen, a dietary aid (DA 1), was observed sporting a goatee (a style of facial hair defined by a small, pointed, or tufted beard grown entirely on the chin). The goatee measured approximately 1 to 2 inches in length. Additionally, DA 1 had noticeable stubble on both cheeks and upper lip. DA 1 was not wearing a beard net. When asked why he was not wearing a beard net, DA 1 stated, I forgot. This exchange was witnessed by the registered dietician (RD). The RD acknowledged the observation and deficient practice.During tray line observation, on 6/22/26, at 12:20 p.m., DA 1 was observed in the tray line/food preparation area, standing over the steam table pans/trays containing food. DA 1 was scooping food into the individual resident trays. DA 1's beard net was observed positioned under his chin. DA 1's facial hair was unsecured by a beard net. Facial hairs shed and can potentially fall into the food being served to the residents. When asked why his beard net was under his chin and not covering his beard, DA 1 stated, I forgot. The RD was present and acknowledged the observation and interview with DA 1.During a review of the facility's policy and procedure (P&P) titled, Workplace Hygiene: Who Needs a Hair Restraint?, dated 1/20/25, indicated, Under FDA Food Code, all employees who enter the kitchen or food preparation area must wear a hair restraint, including anyone with a beard who must wear a beard net.Everyone entering a kitchen must wear a hair restraint to prevent contamination, and anyone with a beard must wear a beard net - answering the common question: are beard nets mandatory in food handling? Yes, in areas where food is prepared.

Based on record review and interview, the facility failed to ensure the plan of care (POC) for respiratory (breathing) condition and a wound infection isolation protocols were accurately reflected for two (2) of 35 sampled residents (Resident 1 & 146) when:Resident 1 use of suction machine to remove excess oral secretions (fluids).Resident 146 was placed both for contact isolation precautions and enhanced barrier precautions.This failure had the potential to hinder continuity of care, insufficient management of residents' needs and not to address all aspects of residents' condition including the infection control protocols without the updated and accurate information of the care plan.Findings:1.During an observation and Resident 1's caregiver interview on 6/23/26, at 1:58 p.m. Resident 1 was observed to have occasional coughs while resting in bed. There was several medical equipment in the room including an oxygen concentrator, suction machine, tube feeding machine and Resident 1's head of the bed was observed to be elevated. According to Resident 1's caregiver, Resident 1 required oral suctioning to remove phlegm (thick, sticky mucus) and oral (mouth) secretions and had seen nursing staff using the suctioning machine.During a review of Resident 1's clinical record (CR), Resident 1's CR indicated that Resident 1 was re-admitted to the facility, arrived via stretcher, without signs of difficulty breathing, and no cough and had the following medical diagnosis Urinary Tract Infection (UTI - infection in urine), hypoxia (body not enough oxygen), COPD (Chronic Obstructive Pulmonary Disease - lung disease), and AKI (Acute Kidney Injury - kidney disease). Further review of the CR, Resident 1's plan of care for respiratory condition did not address the need for a suction machine.During a concurrent observation, interview and record review on 6/25/26, at 9:49 a.m. with the Assistant Director of Nursing (ADON), Resident 1's CR was reviewed. Resident 1 was visited in room [ROOM NUMBER], Resident 1 coughed; the suction machine by the bedside contained one-fourth filled whitish mucus-like contents. Resident 1's caregiver verified the use of the suction machine by the nursing staff to remove excessive secretions in Resident 1's mouth. The ADON stated that Resident 1's clinical record did not address the coughing episode and the need for oral suctioning in the plan of care. The ADON further stated that the physician and the responsible party (RP) will be notified and the care plan for respiratory will be updated.2.During a review of Resident 146's Face Sheet (FS), dated 6/25, the FS indicated that Resident 146 was admitted to the facility on [DATE] with the following medical diagnosis: encephalopathy (brain not working properly), osteomyelitis of the lumbar vertebra (infection of the bone in the lower back), squamous cell carcinoma of the skin (skin cancer) and methicillin resistant staphylococcus aureus infection (MRSA - a type of bacteria that is immune to common antibiotics).During the facility tour observation conducted on 6/22/26, 10:35 a.m. observed a signage at the entry of room [ROOM NUMBER] for Enhanced Barrier Precautions (EBP - an infection control measures to prevent the spread of infection) the signage indicated, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities - Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing.During the facility tour observation conducted on 6/22/26, 11:20 a.m. a signage at the entry of room [ROOM NUMBER] for Contact Isolation (specialized infection control used in healthcare setting). The signage indicated, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gowns before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.During a review of Resident 146's Physician's order (PO), dated 3/27, the PO indicated an order to place Resident 146 on Transmission Based Precautions (TBP - specialized infection control used in healthcare setting), contact isolation precaution (PPE - Personal Protective Equipment including mask, gown, eye protection, and gloves, single room placement with all services be brought to the resident (rehabilitation, activities, dining). Further review of the PO indicated an order for EBP, the same date the TBP was ordered.During a review of Resident 146's plan of care (POC) for wound infection related to MRSA, dated 3/31, the POC indicated TBP and EBP.During interview on 6/24/26, at 3:30 p.m. with the Infection Preventionist (IP 1), IP 1 explained that residents on contact isolation precaution must do hand hygiene first, put on PPEs that is gown, gloves, including mask if it is respiratory airborne precaution before entering the room, provide care, and then discard the used PPE in the trash bin inside the room then hand hygiene before exiting the room. While residents on EBP, the staff must put on the PPE for high contact resident care activities like doing patient care and wound care. If staff just talking to the resident and high contact activities are not expected, you don't need to put on PPE.During a concurrent interview and record review with the MDS coordinators (MDSC 1 & 2), Resident 146 MDS admission Assessment, PO, Medication Administration Record (MAR) and POC for wound infection were reviewed. MDSC 1 verbalized that Resident 146 was admitted with MRSA of the wound, was placed in strict contact isolation in a single room by herself and that all services were provided in the room. Resident 146's PO and POC indicated both TBP and EBP, and the MAR was signed off by the nurses. Both MDSC 1 & 2 was unable to provide the reason why the POC indicated both the TP and EBP if Resident 146 was on strict isolation precautions.During an interview on 6/25/26, at 1:28 p.m. with the Director of Nursing (DON), the DON acknowledged that the care plan was not updated and did not reflect the planned interventions implemented for caring for Resident 1's respiratory condition and Resident 146's contact isolation precautions. The DON further acknowledged that between EBP and TBP, the resident will be placed on stricter precautions, which is the contact isolation.During a review of the P&P titled, IPCP Standard and Transmission-Based Precautions, dated 1/2026, the P&P indicated, 2. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment.a. Room placement: i. Residents on Contact Precautions should be restricted to their rooms and restricted from participation I group activities; Exception is for medically necessary care. ii. Contact Precautions are generally intended to be time limited and, when implemented include a plan for discontinuation or de-escalation due to room restrictions. Personal protective equipment (PPE): i. wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens.Further review of the P&P indicated I part, .3. Enhanced Barrier Protection (EBP): used in conjunction with standards precautions and expand the use of PPE through the use of gowns and gloves during high contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.c. Examples of high-contact resident care activities requiring gown and glove use for Enhance Barrier Precautions include: i. Dressing, ii. Bathing/showering, iii. Transferring, iv. Providing hygiene, v. Changing linens, vi. Changing briefs or assisting with toileting, vii. Device care or use: central vascular lines.indwelling catheters, feeding tube.d. Room restriction: Residents are not restricted to their rooms or limited from participation in group activities while on EPB.e. Duration: Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that places them at higher risk.During a review of the facility policy and procedure (P&P) titled, Comprehensive Person Centered Care Planning, dated 4/2025, the P&P indicated in part, .the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure an extended-release medication (medication formulated to release its active ingredients slowly into the bloodstream over a prolonged period) was administered accurately in accordance with written orders of the attending physician for one of 35 sampled residents (Resident 127). This failure had the potential to alter the absorption of the medication and can increase the risk of side effects and overdose.During a review of Resident 127's admission Record (AR), the AD indicated Resident 127 was admitted to the facility on [DATE] with diagnoses that include heart failure (condition where the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (condition where the kidneys are unable to remove waste and excess fluid from the blood), and essential hypertension (high blood pressure). During a concurrent observation and interview on 6/23/26 starting at 8:36 a.m., with Licensed Nurse (LN) 2, LN 2 was observed preparing Resident 127's medications. LN 2 stated Resident 127 is unable to swallow whole tablets. LN 2 was observed crushing Resident 127's morning medications which included one tablet of Metoprolol Succinate Extended Release (ER) (long-acting medication used to treat high blood pressure). LN 2 was observed mixing the crushed medications in applesauce then administering it to Resident 127. During a concurrent interview and record review on 6/23/26 at 2:10 p.m., with LN 2, Resident 127's Order Summary Report (OSR), was reviewed. Resident 127's OSR indicated a physician's order for Metoprolol Succinate ER oral tablet 50 milligrams (mg - unit of measure) by mouth one time a day for hypertension and the order specifically indicated do not crush. LN 2 stated she was unaware that the metoprolol was extended release and explained that extended-release tablets should not be crushed. LN 2 confirmed she crushed the medication and should not have. During an interview on 6/25/26 at 2:12 p.m., with the Director of Nursing (DON), DON acknowledged extended-release medications should not be crushed. During a review of the facility's policy and procedure (P&P) titled Medication Administration - General Guidelines, undated, the P&P indicated, If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube fed, using the following guidelines. a. Long acting or enteric coated dosage forms should generally not be crushed; and alternative should be sought.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored when rectal and oral medications were observed stored next to each other in one medication cart. This failure had the potential to result in medication administration errors leading to adverse drug reactions, reduced effectiveness of treatment, and a decline in the resident's physical or mental well-being.During a review of the facility's policy and procedure (P&P) titled Storage of Medications, undated, the P&P indicated Orally administered medications are kept separate from externally used medications such as suppositories, liquids and lotions. During a concurrent observation and interview on 6/24/26 at 3:52 p.m. with the Assistant Director of Nursing (ADON), the following medications were observed next to each other in one compartment of the top drawer of the [NAME] Hall East medication cart:Two packages of acetaminophen suppositories (medication inserted rectally to reduce fever or for pain)One package of bisacodyl suppositories (medication inserted rectally to facilitate bowel movements)One bottle of dicyclomine (oral medication used to relieve stomach cramping)One bottle of antacid tablets (oral medication for upset stomach)One package of ibandronate (oral medication used to treat or prevent weak bones)Additionally, in the third drawer of the same medication cart, the following were observed next to each other:Two packages of bisacodyl suppositoriesTwo packages of ondansetron oral tablets (medication for nausea)One package of sumatriptan oral tablets (medication for headaches)The ADON confirmed the above-mentioned medications were stored next to each other. During an interview on 6/24/25 at 4:25 p.m., ADON stated rectal medications and oral medications should not have been stored together. ADON confirmed they should have been stored separate and they were not.

Based on observation, interview, and record review, the facility failed to follow its infection prevention and control practices when:Staff was observed handling soiled linen for one of 35 sampled residents (Resident 146), resulting in contaminated linen being improperly placed and managed, posing a risk of transmission of infectious agents. Soiled linen was observed left in the bathroom occupied by two unsampled residents (Resident 2 and Resident 3). 2. During a review of the facility's P&P titled, Soiled Linen, dated 5/2026, the P&P indicated, It is the policy of this facility to handle, collect, transport, process, and store soiled linen in a manner that minimizes the transmission of microorganisms, protects residents and healthcare personnel from exposure to infectious materials, and compiles the current CDC Standard Precautions and applicable federal, state, and local regulations. All personnel are responsible for following proper infection prevention practices when handling soiled linen.Collecting Soiled Linen 1. Soiled linen shall not come into contact with floor and furniture. During an observation and interview on 6/5, at 12:15 p.m. with the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) in room [ROOM NUMBER], Residents 2 and 3's bathroom, IP and DON identified and acknowledged that used soiled linens should never remain in the resident environment and should be disposed of properly. During a review of Resident 2's FS, dated 6/26, the FS indicated that Resident 2 was admitted on [DATE] with diagnoses including: Metabolic Encephalopathy ( a temporary brain problem caused by the body being out of balance (such as dehydration, infection, or toxins)), Acute Kidney Failure ( the kidneys suddenly stop working well, causing waste and toxins to build up in the blood), Vascular Dementia ( memory loss, confusion, and changes in behavior caused by reduced blood flow to the brain), and Need for Assistance With Personal Care ( the resident needs help with bathing, dressing, grooming, toileting, etc.). During a review of Resident 3's FS, dated 6/26, the FS indicated that Resident 3 was admitted on [DATE] with diagnoses including: Unspecified Dementia With Behavioral Disturbance (memory loss and thinking problems with possible agitation, wandering, or poor safety awareness), Cognitive Communication Deficit ( problems with thinking skills that affect communication—like attention, memory, understanding, planning, and judgment), Need for Assistance With Personal Care ( the resident needs help with bathing, dressing, grooming, toileting, etc.) and Acute Kidney Failure ( the kidneys suddenly stop working well, causing waste and toxins to build up in the blood). Findings: During a review of the facility's P&P titled, Soiled Linen, dated 5/2026, the P&P indicated, It is the policy of this facility to handle, collect, transport, process, and store soiled linen in a manner that minimizes the transmission of microorganisms, protects residents and healthcare personnel from exposure to infectious materials, and compiles the current CDC Standard Precautions and applicable federal, state, and local regulations. All personnel are responsible for following proper infection prevention practices when handling soiled linen.Collecting Soiled Linen 1. Soiled linen shall not come into contact with floor and furniture.3. Heavily soiled linen shall be put in a plastic bag before being taken to the soiled linen room. During an observation and interview on 6/23, at 2:30 p.m. with the hospice aid (HA), the HA was observed to be providing care to Resident 1. A pile of contaminated soiled linen was observed directly in contact with the floor. The HA was taken aback and then stated that the soiled linen must be in a plastic bag. During a review of Resident 146's Face Sheet (FS), dated 6/2026, the FS indicated that Resident 146 was admitted on [DATE] under hospice care services due to malignant neoplasm of the unspecified part of bronchus (lung) and bone, surgical aftercare following surgery of the nervous system (body's nerve signal communication), and anemia (lack of healthy blood cells that carry oxygen to the body). During an interview on 6/24, at 3:30 p.m. with the Infection Preventionist 1 (IP 1), IP 1 explained the facility's procedures for handling soiled linen. The IP 1 emphasized that soiled linens must never be placed on the floor instead, immediately following patient care, contaminated linens should be placed in a plastic bag and transported to the soiled linen room. IP 1 added that the IP is responsible for educating staff and ensures that all personnel, including hospice staff, are properly educated on infection prevention practices and protocols. During an interview on 6/25, at 1:28 p.m. with the Director of Nursing (DON), the DON acknowledged the current practices did not meet the required standards for infection control. In response to these deficiencies, the DON indicated that the facility would implement prompt coordination with the hospice agency to ensure that proper protocols are followed for the handling of soiled linens.

Based on observation, interview, and record review, the facility failed to ensure routine inspections and maintenance of electrical equipment in the facility to ensure safe operating condition and the welfare of residents and staff.This failure resulted in a burnt electrical wall socket in the kitchen and had the potential to result in a fire in the facility.During an observation, on 6/22/26, at 9 a.m., in the kitchen, a burnt electrical wall socket was noted. The electrical wall socket is a multi-plug with 4 plug sockets which can accommodate 4 different appliances plugged simultaneously. The electrical wall socket is a 3-pronged plug socket (standard electrical connector that attaches a device to a power source. The third pin is called the ground pin. It connects to the metal casing of an appliance directly to the ground to protect users from electric shocks in case of an electric fault). During observation, 3 plugs were unused while the juicer machine was plugged into the 4rth plug.During an interview, on 6/22/26, at 9:10 a.m., with the dietary supervisor (DS), in the kitchen, the DS said the burnt electric socket was due to a food warmer that used to be plugged in that location.During an interview, on 6/23/26, at 11 a.m., with the maintenance director (MNTD) and assistant maintenance director (AMD), in the lobby, both the MNTD & AMD acknowledged that the electric socket located in the kitchen was burnt. The AMD said this was caused by a food warmer that was plugged into the electric socket. It caused sparks causing burns/burn marks in the electrical wall socket and tripping the circuit breaker. (an automatic electrical safety switch designed to protect from fires and equipment damage caused by electrical overloads or short circuits). When asked if the food warmer was inspected and approved by maintenance prior to use, both MNTD & AMD said no. The kitchen staff failed to notify them of the food warmer. When asked how often the maintenance department inspects electrical appliances in the kitchen, the MNTD & AMD said once a year.When asked if the maintenance department inspects, certifies and approves any electrical and electronic appliances either owned by the facility or brought in by residents/family members prior to use in the facility, both MNTD & AMD said no.When asked if the maintenance department kept logs to record and keep track of electrical equipment inspected and approved for use in the facility and for preventive maintenance tracking, both MNTD & AMD said no.During a review of the facility policy and procedure (P&P), titled, Electrical Equipment, dated/reviewed 1/2026, indicated the following, 1. Approved Electrical Equipment UseOnly facility approved electrical equipment may be used in resident rooms and common areas.Personal electrical items (e.g., fans, televisions, radios, heaters, extension cords, etc.) brought by residents or staff must be inspected and approved by the maintenance department before use.2. Inspection & MaintenanceRoutine inspections.Maintenance staff must inspect electrical equipment monthly for frayed cords, loose plugs, or signs of damage.Repairs & Replacements: Damaged or malfunctioning equipment must be reported immediately and removed from service until repaired or replaced.4. Staff & Resident Safety ResponsibilitiesStaff must immediately report any signs of electrical hazards, such as sparks, burning smells, or flickering lights.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment when a water leak was observed underneath the sink in one medication storage room. This failure had the potential for mold growth and unsanitary and unsafe conditions for the staff.During a review of the facility's policy and procedure (P&P) titled Environmental Conditions Environmental Rounds, dated 1/2026, the P&P indicated It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds.During a concurrent observation and interview on 6/24/26 at 2:46 p.m., with the Minimum Data Set Coordinator (MDSC) 2, the [NAME] medication room was inspected. The cabinet beneath the sink in the medication room was observed with a damaged cabinet base with broken and lifted surface material and dark discoloration. Upon further inspection, water was observed actively leaking from the drain assembly beneath the sink. MDSC 2 wiped the base of the cabinet with a dry paper towel, and the paper towel became wet. MDSC 2 confirmed that the base of the cabinet is wet and stated there is an active water leak. During an interview on 6/24/26 at 2:47 p.m., with Licensed Nurse (LN) 1, LN 1 stated he is the nurse assigned to the [NAME] nursing station. LN 1 stated the sink inside of the medication room is not used and he was not aware of the water leak or the condition of the cabinet underneath the sink.During an interview on 6/24/26 at 4:55 p.m., with the Assistant Maintenance Director (AMD), AMD stated the sink is non-operational and the water supply to the sink is cut off. AMD explained the water leaking out of the pipe is condensation from the air conditioning system. AMD acknowledged that the leaking water is not clean.During an interview on 6/24/26 at 4:50 p.m., with the Maintenance Director (MNTD), the MNTD confirmed there is a water leak under the sink and stated, it looks like it's been there a long time. MNTD stated he was unaware of the water leak or the condition of the cabinet. MNTD explained that maintenance inspection rounds are done monthly to ensure equipment is in working order. MNTD stated the medication room sinks are not part of the monthly rounds but should be. During an interview on 6/25/26 at 10:58 a.m., with the Administrator (ADM), ADM stated the sink has not been used in a very long time and staff were not checking on it therefore no one was aware that there was a water leak. ADM stated it has the potential to grow mold. ADM acknowledged that the issue should have been identified and it was not.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was administered Cipro (antibiotic used to treat infections) within a reasonable amount of time after a new order. This facility failure had the potential to result in the progression of the infection to a severe infection or sepsis (a life-threatening infection). Findings: During a review of Resident 2's Progress Note (PN), dated 6/27/25 at 8:22 a.m., the PN indicated, Change in Condition . FOUL SMELLING URINE. During a review of Resident 2's PN, dated 6/27/25 at 4:20 p.m., the PN indicated, While passing meds resident noted with foul smelling urine. During a review of Resident 2's Physicians Order (PO), dated 6/27/25 at 4:53 p.m., the PO indicated a new order for Cipro to be given twice a day for a urinary tract infection (UTI). An additional note indicated it was for the same day delivery from the pharmacy. Review of Resident 2's Care Plan (CP) titled, [Resident 2's name] has foul smelling urine, initiated 6/27/25, the CP indicated, Interventions [action to be taken to improve the situation] . Cipro . Give 1 tablet by mouth two times a day for UTI for 7 days. Review of Resident 2's Medication Administration Record (MAR), dated Jun 2025, the MAR indicated a new order for Cipro dated 6/27/25 at 8:44 p.m. The MAR also indicated an x in the block for the 6/27/25 at 5 p.m. dose. There was no other mark to indicate that the Cipro was administered on 6/27/25 or that the administration time was adjusted for the first dose. Review of [NAME] et al., eleventh edition, Elsevier, Fundamentals of Nursing, page 643, in the section titled, Medication Administration, indicated, Each agency has a recommended time schedule for medications ordered at frequent intervals. You can alter these recommended times if necessary or appropriate. During a concurrent interview and record review on 7/3/25 at 4:15 p.m. with the Assistant Director of Nursing (ADON), Resident 2's PN dated 6/27/25 at 8:22 a.m. and 4:20 p.m., PO dated 6/27/25 at 4:53 p.m., and MAR dated Jun 2025 were reviewed. ADON stated the Cipro was not taken out of the Emergency Medication Kit because the nurse was waiting for the delivery of the Cipro from the pharmacy. ADON also stated the computer automatically inputs the time to give the Cipro and that was why Resident 2 did not receive the first dose of the medicine until the next day. The nurse did not adjust the time of the first dose. ADON further stated the facility will educate the nurses to adjust the time of the first dose when appropriate. During a review of the facility's policy and procedure (P&P) titled, Emergency Medication/Medication Shortages/Unavailable Medications, dated 11/2024, the P&P indicated, If the medication dose is to be administered as an emergency or within 4 hours, per physician's order, and is not immediately available in the resident's medications supply, facility nurse should immediately obtain the medication from the Emergency Medication Supply to administer the dose . If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose.

Based on interview and record review, the facility failed to follow physician's orders for Lovenox (Enoxaparin Sodium Injection- an anticoagulant/blood thinner), for one of two sampled residents (Resident 1). This facility failure had the potential to result in life-threatening condition. Findings: According to Fundamental of Nursing, by [NAME] and [NAME], Eighth Edition, on page 336, under the section, Physicians' Orders indicated, Nurses follow physician orders unless they believe the orders are in error or harm patients. During a review of Resident 1's admission record from acute hospital, dated 3/05/25 indicated, a post-operative diagnosis of deep vein thrombosis (DVT, blood clot in the vein ) and pulmonary embolism (PE, blood clot in the lungs). The hospital discharge summary included physician orders for Lovenox 100 mg to be administered subcutaneously every 12 hours. During a review of the electronic medication administration record (eMAR) and physician orders from 3/05/25 through 3/31/25 indicated, Resident 1 missed six doses of Lovenox from 3/05/25 to 3/8/25.There was also no documentation of physician notification regarding the unavailability or delay of the ordered medication. During an interview with the nurse supervisor (NS) on 3/25/25 at 10:31 a.m., the NS stated that if a medication is unavailable, nursing staff are expected to notify the pharmacy and the physician for further direction. During an interview with the director of nursing (DON) on 3/25/25 at 10:50 am, the DON acknowledged the physician should have been notified once the nurses learned the medication was unavailable. During a review of the facility policy and procedure titled Medication Orders dated 9/2010, indicated . the prescriber shall be contacted for direction when delivery of a medication will be delayed, or the medication is not available.

Based on observation, interview and record review the facility failed to ensure: 1. Care plan interventions were implemented for three of 38 sampled resident's (Residents 61, 123 and 138). 2. Medication administration and interventions were completed as identified in the care plan for one of 38 sampled residents (Resident 682). 3. Consistent turning and repositioning of one of 38 sampled residents (Resident 5). 4. A snack was provided during Dialysis (treatment that removes waste and excess fluid from the body) days for one of 38 sampled residents (Resident 36). 5. Pillows were placed to offload pressure from heels for one of 38 sampled residents (Resident 121). This failure had the potential to result in the needs of residents not being met. Findings: 1. During a review of Resident 61's Admission Record (AR), dated 02/25/25, the AR indicated, Resident 61 was admitted [DATE] with diagnoses including but not limited to, anemia (not having enough healthy red blood cells), difficulty in walking, need for assistance with personal care, unspecified dementia (a general term for a group of brain disorders that cause a progressive decline in memory, thinking, reasoning, and problem-solving). During a review of Resident 61's Facility Order Summary Report, for active orders dated 02/25/25, the Order Summary indicated, an order dated 06/11/24 for foot cradle every shift for skin maintenance. During a review of Resident 61's Treatment Administration Record (TAR), dated 02/25/25, the TAR indicated, the following interventions were not implemented: - APP (alterrnate pressure) Mattress every shift for skin maintenance order date 05/02/24 and D/C (discontinued) 02/11/25 on 02/08/25 for 1500 (3:00 p.m.). - Foot cradle every shift for skin maintenance for 1500 on 02/08/25. During a review of Resident 123's AR, dated 02/25/25, the AR indicated, Resident 123 was admitted [DATE] with diagnoses including but not limited to, hemiplegia (a condition that involves partial or complete paralysis (inability to move) and weakness on one side of the body) unspecified affecting left nondominant side, epilepsy (seizure disorder) unspecified, sleep apnea (sleep disorder with repeated episodes shallow or no breathing during sleep), dysphasia (problem with speech resulting from brain disease or damage) following unspecified cardiovascular disease (group of conditions that affect blood flow to the brain), personal history of transient ischemic attack (TIA - or a stroke, a temporary interruption of blood flow to the brain) and cerebral infarction (blood flow to the brain is blocked) without residual deficits. During a review of Resident 123's Facility Order Summary Report, dated 02/25/25, the Order Summary indicated orders dated as follows: - 07/27/23 - H/S (bedtime) monitor QS (every shift) side effects of medication: . Zolpidem (medication used for insomnia to aid in sleep). - 07/27/23 - H/S non-pharma logical interventions . Zolpidem every shift. - 08/24/23 - Monitor for episodes of insomnia. - 07/12/23 - Pain, non-pharma logical interventions . every shift ordered 07/12/23. - 11/25/24 - Apply CPAP/BIPAP (Device that delivers continuous pressure used with sleep apnea) Trilogy Evo (type of device) settings . at bedtime for sleep apnea and remove per schedule. - 11/21/24 - Apply oxygen via nasal canula (tube placed in the nose used to give oxygen) at 2 LPM (liters per minute - amount of oxygen delivered) to maintain O2 (oxygen) saturation greater than 92% (unit of measure) at bedtime and remove per schedule. - 01/28/25 - Bilateral (both sides) grab bars up in bed to aid in bed mobility every shift. - 07/12/24 - BIPAP/CPAP/AVAP at HS (bedtime) and PRN (as needed) per settings. - 11/21/24 - Check O2 sat (saturation or amount) every shift. - 02/07/24 - Monitor episodes of combativeness during are . q (every) shift. - 02/07/24 - Monitor episodes of verbal aggression towards staff q shift. - 07/12/23 - Monitor for seizure activity every shift. - 07/12/23 - Monitor level of pain q shift. - 07/12/23 - Right internal shunt (a tube implanted in brain to drain excess fluid) to side of head extending to neck . every shift. During a review of Resident 123's Medication Administration Report/Treatment Administration Record (MAR/TAR), dated 02/25/25 at 12:03 p.m., the MAR/TAR indicated, several interventions were not completed including: - Apply oxygen via nasal canula at 2 LPM to maintain O2 saturation greater than 92% at bedtime and remove per schedule for 02/18/25 and 02/19/25. - BIPAP/CPAP/AVAP at HS and PRN per settings . for 02/18/25 and 02/19/25. - Monitor for episodes of insomnia . on 02/18/25 and 02/19/25. - H/S monitor QS side effects of medication: . Zolpidem at 1500 (3:00 p.m.) for 02/18/25 and 02/19/25. - H/S non-pharma logical interventions . Zolpidem at 1500 for 02/18/25 and 02/19/25. - Pain, non-pharma logical interventions . every shift at 1500 for 02/18/25 and 02/19/25. - Bilateral (both sides) bars up in bed to aid in bed mobility every shift at 1500 for 02/18/25 and 02/19/25. - Check O2 sat every shift at 1500 for 02/18/25 and 02/19/25. - Monitor episodes of combativeness during . q shift at 1500 for 02/18/25 and 02/19/25. - Monitor episodes of verbal aggression towards staff q shift at 1500 for 02/18/25 and 02/19/25. - Monitor for seizure activity every shift at 1500 for 02/18/25 and 02/19/25. - Monitor level of pain q shift . at 1500 for 02/18/25 and 02/19/25. - Right internal shunt to side of head extending to neck . every shift at 1500 for 02/19/25. During a review of Resident 138's AR, dated 02/25/25, the AR indicated Resident 138 was admitted [DATE] with diagnosis including but not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, dysphagia following cerebral infarction, and need for assistance with personal care. During a review of Resident 138's MAR, dated 02/25/25, the MAR indicated, several interventions were not implemented including: - Up to chair for meals on 02/18/25, 02/19/25 and 02/22/25. - Pain, non-pharmacological (no medication) intervention . on 02/18/25, 02/19/25 and 02/22/25. - Bilateral grab bars up in bed to aid in bed mobility on 02/18/25, 02/19/25 and 02/22/25. - Head of bed elevated to 30 degrees on 02/18/25, 02/19/25 and 02/22/25. - House supplement with meals for nutritional support . for the 1700 (5:00 p.m.) shift on 02/18/25 and 02/19/25. - Monitor for s/sx (signs and symptoms) of bleeding R/T (related to) anticoagulation/antiplatelet therapy (medications that reduce the risk of blood clots) for the 1500 shift on 02/18/25, 02/19/25 and 02/22/25. - Monitor level of pain q (every) shift . for 1500 shift on 02/18/25, 02/19/25 and 02/22/25. - One side of bed against the wall per family request every shift for 1500 on 02/18/25, 02/19/25 and 02/22/25. - Pad alarm in bed to remind resident not to get up unassisted every shift for 1500 shift on 02/18/25, 02/19/25 and 02/22/25. - Pad alarm in wheelchair to remind resident not to get up unassisted every shift for 1500 shift on 02/18/25, 02/19/25 and 02/22/25. - Weight Bearing as tolerated left leg every shift for 1500 shift on 02/18/25, 02/19/25 and 02/22/25. - Weight Bearing as tolerated right leg every shift for 1500 shift on 02/18/25, 02/19/25 and 02/22/25. During a review of Resident 138's Facility Order Summary Report, dated 02/25/25, the Order Summary indicated, orders were dated as follows: - 10/22/23 - Up to chair for meals every evening shift. - 10/22/23 - Pain Non-pharmacological intervention done. - 10/22/23 - Bilateral grab bars up in bed to aid in bed mobility. - 10/22/23 - Head of bed elevated to 30 degrees every shift. - 10/22/23 - Monitor for s/sx of bleeding r/t anticoagulation/antiplatelet therapy q shift. Notify MD if any of the following s/sx . - 10/22/23 - Monitor level of pain q shift using the following scale . - 02/05/25 - One side of bed against the wall . - 10/22/23 - Pad alarm in bed to remind resident not to get up unassisted. - 10/22/23 - Pad alarm in wheelchair to remind resident not to get up unassisted. - 10/22/23 - Weight bearing as tolerated left leg every shift. - 10/22/23 - Weight bearing as tolerated right leg every shift. During review of facility's policy and procedure (P&P) titled, Care Planning, dated 11/2024, the P&P indicated in part, POLICY: . a comprehensive Person-Centered Care Plan for each resident based on the resident's needs to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being . 5. Based on the interdisciplinary review, the care plan will be implemented, with ongoing revisions as needed . During a concurrent interview and record review on 02/26/25 at 11:22 a.m. with Director Staff Development (DSD), Residents 61, 123, and 138's Order Summary Report and MAR/TARs, dated 02/25/25, were reviewed. The MAR/TARs indicated, missing multiple interventions on dates noted for residents. DSD stated for Residents 61, 123, and 138 the MAR/TAR for these residents had missing documentation [as noted on dates listed]. DSD stated nursing is to document interventions daily as ordered by physician and confirmed orders were written for the interventions not completed. 51706 2. During a review of Resident 682's Medical Record, indicated, Resident 682 is [AGE] years old, was transferred to the facility on [DATE] from an Acute Care Hospital after undergoing right hip fracture repair on 2/4/2025. Resident 682's most significant past medical history was Type 2 Diabetes, Chronic Kidney Disease and Hypertension. During Resident 682's admission he has been followed by physician for abnormal kidney function studies. During a concurrent observation and interview on 2/25/25 at 09:30 a.m. with Resident 682, a liter (1000 milliliters) of 0.45% Sodium Chloride intravenous (IV: Intravenous refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) was infusing by gravity and approximately 500 milliliters remained in solution bag. Resident 682 stated .[facility] tell me I'm dehydrated (not having the normal amount of water in your body that is needed). During a review of Resident 682's Care Plan, dated 2/17/25, the care plan indicated, a focus problem of elevated BUN (BUN: Blood Urea Nitrogen assesses kidney function and indicate hydration status. Elevated BUN can indicate dehydration). Interventions revised on 2/24/25 indicated, Sodium Chloride Intravenous Solution 0.45% (Sodium Chloride). Use 60 cc (cubic centimeter equivalent to 1 milliliter) intravenously, every shift for elevated BUN for 3 days ** ADD ANOTHER X 2 LITERS. During a concurrent interview and record review on 2/25/25 at 3:58 p.m. with Licensed Vocational Nurse (LVN 1), Resident 682's electronic health record for intake (the amount of food and drink a person consumes) and output, dated 2/25/25 was reviewed. The intake for a.m. was documented as 240/. LVN 1 stated, RN documents IV hydration and further stated could not see what fluid was being documented. During a review of Resident 682's Medical Order, dated 2/24/25 at 19:18 p.m. (7:18 p.m.) the Medical Order indicated, Sodium Chloride Intravenous Solution 0.45% - 60 cc for elevated BUN for 3 days **Add another x 2 Liters. During a concurrent interview and record review on 2/26/25 at 10:47 a.m. with Registered Nurse (RN 1), Resident 682's Electronic Health Record, dated 2/25/25 was reviewed. RN 1 confirmed there was no documentation entry for IV infusing on 2/25/25. RN 1 confirmed there was no supplemental documentation or progress notes. During a concurrent interview and record review on 2/26/25 at 11:37 a.m. with RN 1, Resident 682's IV Medication Administration Record, dated 2/24/25 and 2/25/25 were reviewed. The IV medication administration record indicated, no staff documentation for night shift of 2/24/25, or day shift of 2/25/25. RN 1 stated the documentation areas for the IV administration should contain a check mark with the staff's initials and confirmed those documentation areas were empty. 39912 3. During an interview on 2/25/25 at 3:30 p.m.,with Resident 5, Resident 5 stated she had multiple sclerosis (chronic autoimmune disease that affects the central nervous system). When asked if she was repositioned/turned every two hours, Resident 5 stated that she was not regularly turned and repositioned. During a review of Resident 5's Health Record, dated 1/31/25 to 2/25/25, the Health Record indicated, turning and repositioning monitoring every shift. There are multiple eight days) during various shifts where no documentation was recorded for turning and repositioning. During a review of Resident 5's Care Plan (CP), the CP indicated, a CP titled, Physical mobility, at risk for further decline in ADL (activities of daily living) self care performance related to multiple sclerosis, UTI (urinary track infection) and COPD (chronic obstructive pulmonary disease), with an intervention for Bed Mobility - requires limited to extensive 1-2 assistance with turning and repositioning. During an interview on 2/26/25 at 12:09 p.m. with the Director of Nursing (DON), the DON acknowledged that multiple shifts were missing documentation for Resident 5's turning and repositioning. During a review of the facility's policy and procedure (P&P) titled, Turning and Repositioning System, dated 06/2024, the P&P indicated, 1. Turning and positioning schedule will be dependent on each resident's needs. Residents with current pressure injury or at a higher risk for developing pressure injuries will be repositioned on a more frequent basis. 2. All residents who are at risk for skin breakdown and who require repositioning will have an individualized Care Plan developed and carried out. 3. Turning will be monitored by supervising staff. 4. Turning and repositioning will be documented by cerfified nursing assistant in the electronic health records. 45741 4. During a review of Resident 36's Admission Record (AR), the AR indicated, Resident 36 was admitted on [DATE] with diagnoses including end-stage renal disease (kidneys have completely stopped working) and was placed on renal dialysis (treatment that removes waste and excess fluid from the blood). During an interview on 2/25/25 at 8:30 a.m. with Resident 36, Resident 36 stated that she gets hungry during her dialysis treatment, but no one has offered her sack lunch (a lunch that's prepared ahead of time and packed in a bag) or snacks to take with her to her. During a review of Resident 36's Physician Order (PO), dated 2/7/25, the PO indicated, Sack of lunch during dialysis days. During an interview on 2/26/25 at 2:00 p.m. with CNA 3, CNA 3 stated that sack lunch was not offered to Resident 36's because she leaves for dialysis after lunch. During a concurrent interview and record review on 2/26/25 at 3:00 p.m. with DON, DON stated that Resident 36 should have sack lunches when going to dialysis as ordered by the doctor and outlined in the care plan. 5. During a review of Resident 121's Admission Record (AR), the AR indicated, Resident 121 was admitted on [DATE] with diagnoses including toxic encephalopathy (brain becomes damaged due to the presence of toxins), and abnormalities of gait and mobility (irregular patterns in walking and movement). During a review of Resident 121's Physician Order (PO), dated 1/10/2025, the PO indicated, offload bilateral heels with pillows. During concurrent observations and interview on 2/25/25 at 11:30 a.m. with Infection Preventionist (IP) in Resident 121's room, Resident 121 was observed with no pillows under their heels. IP stated there should have been pillows. During an interview on 2/25/25 at 11:40 a.m. with Licensed Nurse (LN) 2, LN 2 stated pillows should have been placed under the Resident 121's heels to offload pressure. During a concurrent interview and record review on 2/25/25 at 3:00 p.m. with DON, Resident 121's care plans were reviewed. DON acknowledged there was no care plan documentation addressing the use of pillows to offloads heels. DON further stated that staff must follow the physician's order, and that care plan should have aligned with the order. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/2024, the P&P indicated, Based on the interdisciplinary review, the care plan will be implemented, with ongoing revision as needed.

Based on observation, interview, and record review, the facility failed to ensure it promoted and maintained dignity and respect for three of four sampled residents (Residents 110, 240 , and 66) when: 1. Resident 110, confidential medical information was publicly displayed. This failure resulted in a violation of their right to dignity. 2. Resident 240, call light was not answered timely. This failure resulted in feeling embarrassed, frustrated, and angry. 3. Resident 66, call light was not answered timely. This failure resulted in feeling angry, frustrated, in pain, hungry, thirsty, and embarrassed. Findings: During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect, dated 11/24, the P&P indicated, It is the policy of this facility that all residents be treated with kindness, dignity and respect. 1. During an observation on 2/24/25 at 11:57 a.m. in Resident 110's room, there was an orange Swallow Guide (SG) posted at the head of their bed. The SG identified Resident 110's name and specific treatment details including diet texture, head and body positioning, details on where to place solids in their mouth, consistency of liquids, not to lie flat for 30 minutes after eating/drinking, and aspiration precautions (preventing food/liquids from entering the lungs). During an interview on 2/25/25 at 4:45 p.m. with the Administrator (ADM), ADM stated the SG at the head of Resident 110's bed should be covered. 32661 2. During an interview on 2/24/25 at 11:25 a.m. in room [ROOM NUMBER]A with Resident 240, Resident 240 stated, Sometimes have to wait an hour, for staff to respond to call light requests. Resident 240 further stated this made her feel embarrassed, frustrated, and angry since she sometimes had to void in her bed and on herself. During review of room [ROOM NUMBER]A's call light use log, Nurse Call Activity Report (NCAR), dated 2/21/25 to 2/27/25, the NCAR indicated: - On 2/21/25, at 7:30 a.m., the call duration (time resident's call light was answered) was 12:23 (12 minutes and 23 seconds). - On 2/21/25, at 8:37 a.m., the call duration was 48:59. - On 2/21/25, at 12:21 p.m., the call duration was 13:10. - On 2/21/25, at 8:34 p.m., the call duration was 31:17. - On 2/22/25, at 9:13 a.m., the call duration was 18:17. - On 12/243/25, at 1:12 a.m., the call duration was 19:25. - On 2/23/25, at 7:41 a.m., the call duration was 15:25. - On 2/23/25, at 1:35 p.m., the call duration was 20:50. - On 2/23/25, at 3:49 p.m., the call duration was 13:34. - On 2/23/25, at 8:29 p.m., the call duration was 20:19. - On 2/23/25, at 9:19 p.m., the call duration was 36:38. - On 2/24/25, at 9:34 a.m., the call duration was 15:39. - On 2/24/25, at 11:03 a.m., the call duration was 14:49. - On 2/24/25, at 2:06 p.m., the call duration was 12:27. - On 2/24/25, at 1:41 p.m., the call duration was 15:24. - On 2/25/25, at 5:19 p.m., the call duration was 13:01. - On 2/25/25, at 7:37 p.m., the call duration was 36:59. - On 2/26/25, at 6:03 a.m., the call duration was 14:10. - On 2/26/25, at 8:34 p.m., the call duration was 34:58. - On 2/26/25, at 9:33 p.m., the call duration was 27:36. 3. During an interview on 2/24/25 at 11:37 a.m. in room [ROOM NUMBER]A with Resident 66, Resident 66 stated, Night shift [11 p.m. - 7 a.m.] has the worse call light response than mid shift [3 p.m.- 11 p.m.]. Resident 66 further stated, I have to wait an hour more or less for someone from the staff to respond to the call light. Resident 66 also stated this made Resident 66 feel angry, frustrated, in pain, hungry, thirsty, and embarrassed since Resident 66 had no choice but to do Business, in the bed. During a review of room [ROOM NUMBER]A's NCAR,) dated 2/15/25 to 2/26/25, the NCAR indicated: - On 2/16/25, at 6:24 a.m., the call duration was 20:04. - On 2/16/25, at 10:57 p.m., the call duration was 14:18. - On 2/17/25, at 3:22 a.m., the call duration was 15:38. - On 2/17/25, at 9:00 a.m., the call duration was 43:41. - On 2/17/25, at 10:26 a.m., the call duration was 31:15. - On 2/17/25, at 11:32 a.m., the call duration was 24:52. - On 2/17/25, at 7:40 a.m., the call duration was 14:31. - On 2/18/25, at 10:19 a.m., the call duration was 14:04. - On 2/19/25, at 7:43 a.m., the call duration was 14:50. - On 2/19/25, at 10:01 a.m., the call duration was 26:36. - On 2/19/25, at 4:12 p.m., the call duration was 25:17. - On 2/19/25, at 7:35 p.m., the call duration was 21:28. - On 2/20/25, at 5:04 a.m., the call duration was 14:08. - On 2/20/25, at 10:51 a.m., the call duration was 17:29. - On 2/20/25, at 6:25 p.m., the call duration was 24:10. - On 2/20/25, at 11:35 p.m., the call duration was 23:31. - On 2/21/25, at 4:04 a.m., the call duration was 16:04. - On 2/21/25, at 5:52 a.m., the call duration was 14:40. - On 2/21/25, at 10:59 a.m., the call duration was 19:16. - On 2/21/25, at 1:27 p.m., the call duration was 14:35. - On 2/21/25, at 3:25 p.m., the call duration was 12:52. - On 2/21/25, at 7:59 p.m., the call duration was 13:38. - On 2/22/25, at 12:13 a.m., the call duration was 12:49. - On 2/22/25, at 10:48 a.m., the call duration was 18:13. - On 2/22/25, at 1:32 p.m., the call duration was 16:55. - On 2/22/25, at 7:30 p.m., the call duration was 13:58. - On 2/22/25, at 7:46 a.m., the call duration was 11:08. - On 2/23/25, at 10:35 a.m., the call duration was 15:03. - On 2/23/25, at 3:11 p.m., the call duration was 50:54. - On 2/23/25, at 4:25 p.m., the call duration was 18:19. - On 2/23/25, at 6:35 p.m., the call duration was 18:04. - On 2/23/25, at 7:20 p.m., the call duration was 25:56. - On 2/23/25, at 8:56 p.m., the call duration was 26:46. - On 2/25/25, at 3:14 p.m., the call duration was 20:59. - On 2/26/25, at 6:27 a.m., the call duration was 12:00. During a review of the facility's P&P titled, Call Light/Bell, dated 11/21, the P&P indicated in part, POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff . PROCEDURES: 1. Answer the light/bell within a reasonable time. During a concurrent interview and record review on 2/27/25 at 10:20 a.m. with the Director of Nursing (DON), Rooms 121A and 120A's NCARs were reviewed. DON stated a reasonable expectation for call light response time was 10 minutes. DON further stated call light response times of 40 to 50 minutes was unacceptable.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 69), had the most current Physician Orders for Life-Sustaining Treatment (POLST) a form designed to improve resident care by creating a portable medical order form that records residents' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency. This failure had the potential to result in Resident 69's end of life wishes not to be honored. Findings: During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, POLST, dated ,d+[DATE], the P&P indicated, Resident or surrogate decision maker will be offered and assisted by facility staff . to complete a POLST (Physician's Orders for Life Sustaining Treatment) document to formulate decisions regarding Life Sustaining Treatment. A copy of this document will be in the Medical Record of resident. During a review of Resident 69's POLST, dated [DATE], in Resident 69's paper medical record at the nursing station, the POLST indicated, Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate [insertion of a breathing tube down the throat into the lungs to provide oxygen to the body]. During a review of Resident 69's Physician Order (Order), dated [DATE] at 1:33 p.m., the Order indicated, CPR/Attempt Resuscitation. Trial period of full treatment. Trial period of nutrition, including feeding tubes. During a review of Resident 69's POLST, dated [DATE], in Resident 69's electronic Health Record (eHR), the POLST indicated, Trial Period of Full Treatment . primary goal of prolonging life by all medical effective means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation [using a machine to deliver air into and out of the lungs. During a concurrent interview and record review on [DATE] at 10:21 a.m. with a licensed nurse (LN2), Resident 69's paper POLST, dated [DATE], and electronic POLST, dated [DATE] were reviewed. LN2 stated the paper copy and electronic copy of the POLST do not match and they should. During a concurrent interview and record review on [DATE] at 10:30 a.m. with a Minimum Data Set licensed nurse (MDS1), Resident 69's electronic POLST, dated [DATE], POLST dated [DATE], and paper POLST, dated [DATE] were reviewed. MDS1 stated the three documents do not match and they should.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 106), was involved in review and revision of their care plan during the interdisciplinary (IDT) meeting of health professionals who plan and coordinate resident care meeting. This failure resulted in Resident 106 not being given the right to participate in deciding treatment options. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Planning/Interdisciplinary Team Conference, dated ,d+[DATE], the P&P indicated, To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan . Every effort will be made to schedule care plan meetings to accommodate the availability of the resident and family or responsible party. During an interview on [DATE] at 10:07 a.m. with Resident 106, Resident 106 stated not understanding why the facility does not invite her to the IDT meeting. During a concurrent interview and record review on [DATE] at 11:35 a.m. with a social services designee (SSD), Resident 106's IDT - Care Plan Review (IDTCPR), dated [DATE] ay 9:16 a.m. was reviewed. SSD stated SSD spoke with Resident 106 before the IDTCPR meeting. SSD also stated Resident 106 was not at the IDTCPR meeting. SSD further stated SSD did not review the IDTCPM changes with Resident 106. During a concurrent interview and record review on [DATE] at 11:50 a.m. with a minimum data set nurse assessment coordinator (MDS2), Resident 106's IDTCPR, dated [DATE] at 9:16 a.m. was reviewed. MDS2 stated, 'We never have the resident present at the meeting. MDS2 also stated the resident is never at the care plan meeting, adding, It's just been that way. MDS2 further stated after the IDTCPR meeting the revisions to the care plan are not reviewed with the resident. MDS2 finally stated the IDTCPR should have been reviewed with Resident 106 and it wasn't. During a concurrent interview and record review on [DATE] at 12:10 p.m. with the Director of Nursing (DON), Resident 106's IDTCPR, dated [DATE] at 9:16 a.m. was reviewed. DON stated Resident 106 was not at the meeting and not able to agree with or be informed of the IDT results. DON further stated all residents should be at the care plan meeting if they are able to.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with professional standards and practices for two of four sampled residents (Residents 93 and 13) when: 1. The facility did not maintain a complete, accurately documented, readily accessible, and systematically organized room transfer form for Resident 93's relocation. 2. The facility failed to monitor Resident 13's depression and mood as ordered by the physician. These failures had the potential to impact resident rights, care planning, and the provision of appropriate care due to inaccurate or incomplete documentation. Findings: 1. During a concurrent observation and interview on 2/24/25 at 10:47 a.m., with Resident 93, in room [ROOM NUMBER]A, Resident 93 stated, was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 2/13/25, without prior notification (verbal or written) from the facility and without signing any consent. Resident 93 stated she did not sign any document attesting to her giving her consent for a room change. During an interview on 2/26/25 at 9:57 a.m. with the Director of Nursing (DON), the DON confirmed the room transfer was done on 2/13/25. Resident 93 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER]. A new admit resident (+COVID-19) needed to be on isolation and room [ROOM NUMBER] was the only available room for isolation. DON added Resident 93 was informed verbally by staff prior to transfer and it is documented in the nursing progress note dated 2/14/25. The DON admitted prior notice was not given to Resident 93 since the new admit resident's positive COVID-19 diagnosis was discovered when the facility did test upon resident's arrival in the facility. Facility did not receive any report from the hospital of the new admit resident being positive for COVID-19. During a concurrent record review and interview on 2/26/25 at 10:05 a.m. with the DON, the facility Policy and Procedure (P&P) titled, Notification of Room or Roommate, dated 11/2024,was reviewed and indicated in part, POLICY: It is the policy of this facility that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place. PROCEDURES: 1. The Notification of Room or Roommate Change form is to be completed and used to document that the resident has been given written advanced notification of room or roommate change. Review of the provided Notification of Room or Roommate Change form was instead titled, STATUS CHANGE. The bottom of the form required a signature from the resident. The DON concurred there was a discrepancy where in the P&P indicated Notification of Room or Roommate Change form where as the facility was using a form titled STATUS CHANGE. The DON also concurred to the following: that no advance notification was given to Resident 93, that Resident 93 did not sign the form/consent since the facility practice was for the licensed staff to fill out the form without obtaining the resident(s) signature, that no STATUS CHANGE form was filled out by the staff for Resident 93's room transfer. 39912 2. During an interview on 2/24/25 at 2:56 p.m., Resident 13 stated is taking medication for his mood. During a review of Resident 13's Health Record, indicated Resident 13 had orders for: Depakote (drug used to treat mood disorder) oral tablet delayed release (Divalproex) 250 milligrams (mg) order date 2/11/25 - give 250 mg by mouth 2 times a day for mood disorder manifested by constant yelling. Sertraline (drug used to treat depression) oral tablet 37.5 mg, order date 2/12/25 - give 37.5 mg by mouth one time a day every Monday, Wednesday and Sunday for depression. Trazodone tablet (drug used to treat depression) 75 mg, order date 2/10/25 - give 75 mg by mouth at bedtime every Monday, Wednesday and Sunday for depression manifested by inability to sleep. Monitor episodes of depression manifested by inability to sleep, tally by hashmarks Trazodone every evening and night shift. Order date 11/11/21. Monitor episodes of mood disorder by constant yelling with apparent reason by hasmarks Divalproex every shift. Order date 5/1/21. Monitor episodes of depression manifested by verbalization of sadness, tally by hashmarks Sertraline every shift. Order date 5/1/21. During a review of Resident 13's Health Record, the Health Record indicated, no documentation for monitoring for episode of depression and mood disorder on PM shift on 2/13/25 and 2/14/25. During an interview on 2/26/25 at 12:08 p.m., with the DON, the DON acknowledged monitoring was not documented. During a review of the facility policy and procedure (P&P) titled, Documentation and Charting-General, dated 11/2024, the P&P indicated, A complete account of the resident's care, treatment, response to the care, signs symptoms, etc., as well as the progress of the resident's care in an accurate and chronological order.

Based on observation, interview, and record review, the facility failed to adhere to Infection Prevention and Control Program (IPCP) when: 1. Staff failed to follow Enhanced Barrier Precautions (EBP) when providing care for one sampled resident (Resident 682). 2. Staff failed to follow infection control protocols while assisting two unsampled residents (Residents 12 and Resident 94) with feedings. 3. Staff failed to label oxygen tubing, nebulizer mask, and nebulizer tubing for two sampled residents (Residents 232 and 93) and did not change contaminated gloves for one unsampled resident (Resident 240), which did not align with infection control protocols. 4. Staff failed to perform handwashing during wound care for one sampled resident (Resident 434). These failures had the potential to result in the spread of organisms from staff members to other vulnerable residents. Findings: 1. During an observation on 2/24/25 at 10:21 a.m. of care to Resident 682, staff Occupational Therapist (OT 1) and Physical Therapist (PT 1) were observed providing direct care to Resident 682, wearing gloves and masks. Signage from Center for Disease Controls (CDC) outside of Resident 682's room indicated, Resident 682 was on Enhanced Barrier Precautions (EBP: a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs). EBP are used in nursing homes and other long term care facilities). During an interview on 2/24/25 at 10:32 a.m. with Director of Nursing (DON), the DON stated it was the expectation If providing direct patient care for staff to wear gloves and gowns. During an interview 2/24/25 at 10:44 a.m. with OT 1 and PT 1, OT 1 and PT 1 stated they had not been wearing gowns when providing initial direct patient care to Resident 682. During a review of the facility's policy and procedure (P&P) titled, IPCP and Transmission-Based Precautions, dated 3/2024, the P&P indicated, Enhanced Barrier Precautions (EBP) used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment: protects healthcare workers and patients form the spread of infection) through the use of gown and gloves during high-contact resident activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to resident . 2. During an observation on 2/24/25 at 11:57 a.m. in the Dining Hall, Certified Nurse Assistant (CNA1) was feeding two unsampled residents (Residents 94 and 12). CNA 1 was using right hand for both residents and while alternating, placed utensil on tray between feedings. During an interview on 2/24/25 at 12:07 p.m. with the DON, the DON stated there should be one staff member to one resident when assisting with feeding. During a review of the facility's P&P titled, Feeding the Dependent Resident, dated 11/24, the P&P indicated, One staff member may feed two residents when needed while following these guidelines: Infection Control guidelines are to be followed as to prevent cross contamination. During a review of the facility's P&P titled, Hand Hygiene, dated 10/22, the P&P indicated, Use of an alcohol- based hand rub containing at least 62% alcohol or . soap (antimicrobial or non-antimicrobial) and water for the following situations . (b) Before and after direct contact with residents . (p) Before and after assisting a resident with meals . 32661 3. During an observation on 2/24/25 at 9:40 a.m. in room [ROOM NUMBER]A, Resident 232 had an undated nasal cannula, humidifier, and was missing a plastic storage bag to secure the nasal cannula when not in use. During an observation on 2/24/25 at 10:47 a.m. in room [ROOM NUMBER]A, Resident 93's nebulizer was in the bottom drawer. The nebulizer mask and the tubing were undated. There was no plastic storage bag to secure the nebulizer mask and tubing when not in use. During an observation on 2/25/25 at 9:09 a.m. in room [ROOM NUMBER]A, Resident 244, Med Nurse (MN 1) dropped the plastic wrap of a Lidocaine patch, picked it up from the floor, threw the plastic wrap in the trash, did not change gloves, and proceeded to administer the Lidocaine patch to Resident 244. During an interview on 2/25/25 at 3 p.m. with the Infection Preventionist Nurse (IPN -specialized nurse who focuses on preventing the spread of infectious disease within the healthcare facility), the IPN concurred with the findings. During an interview on 2/27/25 at 10:20 a.m. with the DON, when asked about the frequency of O2 tubing, nebulizer tubing, plastic storage bags and mask changes, DON said everything is done once a week and they should be labeled upon change. During a review of the facility Policy and Procedure (P&P) titled, Oxygen/Nebulization Therapy, dated 11/2024, the P&P indicated in part, Weekly tubing and storage bag changes, for both Oxygen and Nebulization tubing/masks with appropriate labeling. 45741 4. During an observation on 2/26/25 at 10:30 a.m. Resident 434's right medial wound care treatment with Treatment Nurse (TN 2) was observed. TN 2 with a new pair of gloves removed the soiled dressing and placed them in the garbage receptacle. TN 2 then removed the pair of dirty gloves, placed them in a garbage receptacle, and put on clean gloves without washing her hands. TN 2 proceeded to provide treatment to the wound, applied the skin protectant then grabbed the clean dressing and covered Residents 434's wound without removing her dirty gloves or performing hand hygiene after the treatment. During an interview on 2/26/25 at 10:45 a.m. with TN 2, TN 2 acknowledged not washing her hands in between glove changes and not removing her soiled gloves after completing the treatment before touching the clean dressing and applying it to Resident 434. During a review of the facility's policy and procedure (P&P) titled, Wound Care and Treatment Guidelines, dated 11/2024, the P&P indicated, The use of gloves does not replace the need to wash or sanitize hands. Hand washing must be done before treatment is initiated, after soiled dressing are removed, and after completing the treatment.

Based on observation and interview, the facility failed to ensure to provide a functional and comfortable environment for residents when pull cords for overhead night lights were missing. This failure resulted in denying residents the use of a night light and had the potential to result in adverse consequences during nighttime hours, including increased fall risk. Findings: During an initial tour observation on 2/24/25 at 9:40 a.m. the following residents rooms/beds were missing a night light pull cord: Rooms 109A, 110A, 113A, 113B, 114A, 114B, 115A, 116A, 116B, 118A, 118B, 119B, 120A, 121A, 124A, and 125A. During an interview on 2/25/25 at 12:41 p.m. in the Administrators office, with the Director of Maintenance (DM) and the Assistant Maintenance (AM), both DM and AM confirmed pull cords for the night lights were missing in the identified residents rooms.

Based on interview and record review, the facility failed to ensure the resident representative was notified promptly of a resident's fall for one of two sampled residents (Resident 1). This failure resulted in Resident 1's representative having delayed involvement in decision making regarding Resident 1's care. Findings: During a review of the facility's policy and procedure (P&P) titled, Fall Management System, dated 01/2022, the P&P indicated, Resident representative shall be notified of the fall and the resident status. During a review of Resident 1's Progress Notes (PN1), dated 1/23/25 at 3:45 a.m., the PN1 indicated, @0318 [3:18 a.m.] . Resident had unwitnessed fall . Resident stated that he sat down in his bed, get up to get ready for work, waiting for the transit and slid down from bed going to the floor, noted with confusion and forgetfulness. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting/Documentation, dated 2023, the P&P indicated, The responsible party will be notified in the event resident is not able to make decisions that there has been a change in the resident's condition and what steps are being taken. During a review of Resident 1's PN2, dated 1/23/25 at 8:39 a.m., the PN2 indicated, .@0608 [6:08 a.m.] this writer call [Resident Representative name and relationship] and notified of the incident of the unwitnessed fall and [physician's name] order to send to [hospital name] ER [emergency room ] secondary to anticoagulant [medication that stops the blood from clotting too easily] therapy. Communicate details on what had happened and this writer, provide an active listening [full attention] about all [Resident Representative name] concerns and worries about Resident current health challenges, this writer accommodates [Resident Representative name] demand that Resident needs to be send out right away, that this situation is a matter of life and death. During a concurrent interview and record review on 1/23/25 at 5:20 p.m. with the Director of Nursing (DON), Resident 1's PN1 and PN2 were reviewed. DON stated Resident 1's Representative should have been notified at the time of the fall.

Based on interview and record review, the facility failed to ensure the physician responded promptly to notification of a resident's fall for one of two sampled residents (Resident 1). This failure resulted in Resident 1's delayed transfer to the emergency room (ER) after a fall. Findings: During a review of the facility's policy and procedure (P&P) titled, Physician Services, dated 11/2023, the P&P indicated, Physician services include, but are not limited to . Advice, treatment, and determination of appropriate level of care needed for each resident. During a review of Resident 1's Progress Notes (PN1), dated 1/23/25 at 3:45 a.m., the PN1 indicated, @0318 [3:18 a.m.] . Resident had unwitnessed fall . Writer communicates with [physician name] awaiting for response. During a review of Resident 1's PN2, dated 1/23/25 at 8:39 a.m., the PN2 indicated, @0608 [6:08 a.m.] . [physician name] responded and order to send out Resident to [hospital name] ER [emergency room ] for further evaluation and treatment. During a concurrent interview and record review on 1/28/25 at 2:30 p.m., with the Director of Nursing (DON), Resident1's PN1 and PN2 were reviewed. DON stated the physician did not return the nurses call for three hours. DON further stated the expectation is for the physician to return a call promptly.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had their antibiotic (medication used to treat an infection) administered without interruption following a transfer from an acute care facility (hospital) to the skilled nursing facility (nursing home). This failure had the potential to result in Resident 1's antibiotic treatment being less effective and/or prolonging treatment. Findings: During a review of the facility's policy and procedure (P&P) titled, Continuum of Care, dated 11/2023, indicated, Initiate any treatments . necessary at the time of admission per transfer orders .Initiate medications and treatment orders. Resident 1 was a [AGE] year-old female admitted to the facility on [DATE] for aftercare following knee replacement surgery. During a review of Resident 1's Individualized Patient Discharge Instructions and Plan (IPDIP), dated 1/18/25, at 3:36 p.m., The IPDIP indicated, Visit Summary . New Medications . sulfamethoxazole-trimethoprim (Bactrim DS) [antibiotic] 1 Tab [tablet] Oral 2 times a day for 5 Days. Last Dose: 1/18/25 at 10 AM. During a review of Resident 1's Progress Note (PN1), dated 1/18/25, at 7:49 p.m., the PN1 indicated, Admission Note . admitted [AGE] year-old female to room [ROOM NUMBER]A at 1615 [4:15 p.m.] . On ATB [antibiotic] therapy for surgical incision PPX x 5 day. During a review of Resident 1's Order Summary Report (OSR), dated 1/18/25, the OSR indicated, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole Trimethoprim) Give 1 tablet by mouth two times a day for R [right] KNEE SURGICAL INCISION INFECTION PPX for 5 Days. During a review of Resident 1's Medication Administration Record (MAR), dated 1/2025, the MAR indicated, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole Trimethoprim) Give 1 tablet by mouth two times a day for R [right] KNEE SURGICAL INCISION INFECTION PPX for 5 Days . Sat [Saturday] . 18 [date] . 1700 [5 p.m.] . X [not given]. During a review of Resident1's Progress Notes (PN2), dated 1/19/25, at 7:01 a.m., the PN2 indicated, Physician Admission Progress Note . 65 YOF [year old female] . cellulitis [bacterial infection of the skin] at incision [surgical] site . PLAN . complete antibiotic for cellulitis. During a concurrent interview and record review on 1/28/25, at 2:45 p.m., with the Director of Nursing (DON), Resident 1's IPDIP, PN1, OSR, MAR, and PN2 were reviewed. DON stated the second dose of Bactrim DS should have been given on 1/18/25 and was not.