Every finding on record at Villa Gardens Health Care Unit

Based on interview and record review, the facility failed to ensure there was a Registered Nurse (RN, a healthcare professional who completed an Associate Degree in Nursing [AND] or Bachelor of Science in Nursing [BSN] from an approved program. Then, they pass a comprehensive national test [NCLEX-RN] and meet state licensure and certification requirements that develop care plans, give treatments and medications, perform diagnostic tests, work with physicians to coordinate care, and supervise Licensed Vocational Nurse [LVN] and Certified Nursing Assistant [CNA] ) for eight (8) consecutive hours, seven (7) days a week on 1/18/2025, 1/19/2025, 1/21/2025, and 1/22/2025 based on the facility assessment. This deficient practice had a potential impact on the quality of care and outcomes that the residents might experience in those days with no RN coverage, which an RN was generally responsible for more advanced care activities such as assessments and administering intravenous (IV, given directly into the blood stream) fluids or medications.Findings: During a concurrent interview and record review on 12/4/2025 at 1:16 PM with Director of Staff Development (DSD), Staff Sign in Sheet dated 1/18/2025 was reviewed. DSD stated the facility did not have an RN on the evening shift (3 PM to 11:30PM). DSD stated a registry (temporary assignment that requires you to travel to a medical facility to provide coverage when it lacks staff for the day) RN was scheduled for the evening shift but called off. DSD stated the facility did not have an RN coverage for 1/18/2025. DSD stated the facility should have an RN 8 hours daily in case of emergency that was beyond the LVN's scope of practice which could result in the residents not receiving the care they need. During a concurrent interview and record review on 12/4/2025 at 1:19 PM with DSD, Staff Sign in Sheet, dated 1/19/2025, was reviewed. DSD stated the facility did not have an RN that day. The Director of Nursing (DON) was on vacation from 1/18/2025 to 1/26/2025 and the RN from the registry that was scheduled to work that day also called off. DSD stated the facility did not have RN coverage for 1/19/2025. During a concurrent interview and record review on 12/4/2025 at 1:37 PM with DSD, Staff Sign in Sheet, dated 1/21/2025 to 1/22/2025 were reviewed. DSD stated the RN from the registry did not show up for work for both days. DSD stated the facility did not have an RN coverage for both dates. During a concurrent interview and record review on 12/5/2025 at 12:28 PM with the DON, the Facility Assessment was reviewed. The DON stated the facility assessment indicated one RN for 8 hours per day (24 hours per day). The DON stated the regulations indicated the facility needs to have an RN 8 hours a day. During a concurrent interview and record review on 12/5/2025 at 12:29 PM with the DON, the Staff Sign in Sheet dated 1/18/2025 to 1/19/2025 was reviewed. The DON stated there was no RN coverage for both dates. The DON stated she went on vacation, and the registry staff did not show up for work. The DON stated the facility was not able to get replacement for an RN coverage on 1/18/2025 to 1/19/2025. During a concurrent interview and record review on 12/5/2025 at 12:30 PM with the DON, Staff Sign in Sheet dated 1/21/2025 to 1/22/2025 was reviewed. The DON stated there was no RN coverage for both dates. The DON stated the facility should have tried to replace the RN registry staff that was scheduled who did not report to work for 1/21/2025 and 1/22/2025. During an interview on 12/5/2025 at 12:33 PM, the DON stated on 1/18/2025, 1/19/2025, 1/21/2025 and 1/22/2025, the facility did not have RN coverage. The DON stated they did not follow the regulations to have RN coverage for those days. The DON also stated they do not have a policy for nursing services or sufficient staffing.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by failing to: 1. Ensure an opened box of disposal gloves was left on top of Resident 31's dirty linen container. This failure had the potential to result in the spread and development of infection through cross contamination (when bacteria or other microorganisms are unintentionally transferred from one person or object to another). 2. Resident 36's used nasal cannula was left on the resident's wheelchair. This failure had the potential to expose Resident 36 to harmful bacteria when the resident reinserts the nasal cannula prongs. 3. a. Ensure Resident 5's tube feeding machine (enteral feeding pump, delivers liquid nutrition /formula directly into the stomach or small intestine via a feeding tube) and intravenous pole (IV pole, a medical stand used to suspend bags of IV fluids, medications, or nutritional solutions so they can be delivered to a resident) were free of dried feeding formula stains. b. Ensure soiled towels were not left on top of the trash bin and soiled Hoyer Lift (a mechanical device used to lift and/or transfer a person) sling was placed inside the soiled linen cart for Resident 5.These deficient practices have potential to contaminate clean items and can place the residents at risk for infection. 4. Ensure Licensed Vocational Nurse 1 (LVN 1) doff (take off personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) while in an enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) resident room in accordance with Centers of Disease Control (CDC, the national public health agency of the United States) guidelines. This deficient practice had the potential to result in an increased risk for the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff throughout the facility, while increasing the risk of [preventable] infections. 5. Ensure the medication room was maintained in a clean, clutter-free (being free from unnecessary items and mess) by allowing personal staff items to be stored in the medication room. This failure had potential to risk the resident's safety by compromising the integrity of medication storage.Findings: 1. During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 10/27/2025, with diagnoses including but not limited to syncope (when the brain does not get enough oxygenated blood due to a sudden drop in blood pressure, causing you to faint), heart failure (a heart disorder which causes the heart to not pump the blood efficiently), and kidney disease (when kidneys are damaged and cannot filter blood well). During a review of Resident 31's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 10/29/2025, the MDS indicated resident can independently make decisions regarding daily life tasks and needs maximum assistance (helper does more than half the effort) with transfers. During an observation on 12/2/2025 at 8:45 AM in Resident 31's room, an open box of medium-sized disposal gloves was on top of Resident 31's dirty linen hamper. Staff entered and exited the room without addressing the box of gloves. During a concurrent observation and interview on 12/2/2025 at 8:57 AM with Registered Nurse Supervisor 2 (RNS 2), in Resident 31's room, an open box of medium-sized disposal gloves was on top of Resident 31's dirty linen hamper. RNS 2 stated it is an infection control issue because the gloves are no longer clean. During a concurrent interview and record review on 12/4/2025 at 10:33 AM with the Infection Preventionist Nurse (IPN), the facility's P&P titled, Infection Prevention & Control Program, dated 6/2025 was reviewed. The P&P indicated personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) are worn to protect residents from cross-contamination. The IPN stated there is cross-contamination between the box of gloves and dirty linen hamper. IPN stated using contaminated PPE can spread germs to the residents. During a concurrent interview and record review on 12/5/2025 at 11:30 AM with the Director of Nursing (DON), the facility's P&P titled, Personal Protective Equipment, revised 7/2020 was reviewed. The P&P indicated, [PPE] is maintained at each nurses' station or nearby designated location. DON stated it is not appropriate to store the gloves on top of the dirty linen hamper. 2. During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2025, with diagnoses including but not limited to bronchiectasis (a condition where damage causes the tubes in your lungs to widen), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and history of falls. During a review of Resident 36's MDS, dated [DATE], the MDS indicated resident was moderately impaired in cognitive skills for daily decision making and needs partial assistance (helper does less than half the effort) with transfers. During a review of Resident 36's Order Summary Report, dated 12/2025, the report indicated, resident needed oxygen at 2 liters per minute via nasal cannula as needed for COPD. During a concurrent observation and interview on 12/5/2025 at 9:03 AM with the Occupational Therapist (OT), in the hallway, OT assisted Resident 36 to walk towards the Therapy Room. The OT pushed a wheelchair behind Resident 36. There was an oxygen tank in the rear storage basket of the wheelchair. A nasal cannula was connected to the oxygen tank and the other end of the nasal cannula which was meant to be placed in the resident's nostrils, was left on the seat of the wheelchair. OT stated the nasal cannula should have been stored in a pouch. During a concurrent observation and interview on 12/5/2025 at 9:05 AM with the IPN, in the Therapy Room, Resident 36's nasal cannula was left on the seat of the wheelchair. IPN stated that leaving oxygen tubing on the wheelchair is improper handling and increases risk of infection for the resident. During a concurrent interview and record review on 12/5/2025 at 12:20 PM with the DON, the facility's P&P titled, Oxygen Therapy, revised 7/2022 was reviewed. The P&P indicated, When nasal cannula or oxygen mask is not in use, place in a plastic bag or other infection prevention pouch to prevent contamination. DON stated staff did not follow the policy. DON stated staff should have put the oxygen tubing in a bag during therapy to prevent contamination. 3. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE], transient ischemic attack (TIA, is a temporary blockage of blood flow to the brain), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and pneumonia (a lung infection). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 5 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral and toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer, and toilet transfer. a. During an observation on 12/2/2025 at 8:45 AM inside Resident 5's room, Resident 5's tube feeding machine had a beige colored stain on the top surface of the machine. The IV pole where the tube feeding machine was attached had beige colored splatter on the body and feet part of the pole. Resident 5's tube feeding machine was placed next to the resident's bed. During a concurrent observation and interview on12/3/2025 at 9:49 AM with LVN 2, LVN 2 stated it was a dried tube feeding formula on the top of the tube feeding machine. LVN 2 stated, It was not supposed to be there. The staff should always clean the tube feeding machine because bacteria can grow from it. LVN 2 stated Resident 5 can become a high risk for getting sick. During an interview on 12/3/2025 at 4:28 PM with Infection Preventionist Nurse (IPN), IPN stated Resident 5's spilled tube feeding formula should not be left on the top of the tube feeding machine because bacteria can grow on it and Resident 5 can have infection from it. IPN stated the staff should not have left the feeding formula at the foot of the IV Pole, because bacteria can grow from it and it was not safe practice for Resident 5. During a concurrent observation and interview on 12/4/2025 at 8:11 AM with IPN, IV pole was observed to have dried beige colored splatter stains on the pole and at the base of the stand. IPN stated the IV pole had dried formula on the surface of the TF machine and IV Pole. IPN stated the staff should keep it clean because of infection control causing bacteria to harbor and make the resident sick. During a concurrent review and record review of the facility's P&P titled, Housekeeping Cleaning Protocol, revised 7/2021, the P&P indicated, housekeeping services will routinely provide a clean environment which prevents the spread of infection. Employees are to pick up paper, debris and minor spills when they see them. Standard Room Cleaning in Resident Room Area-Use a hospital-grade disinfectant/germicide wipe or apply hospital-grade disinfectant/germicide to a clean cloth and wipe the medical equipment such as IV, GT machines and poles, oxygen concentrators, etc. b. During an observation on 12/3/2025 at 2 PM inside Resident 5's room, there were bundled soiled white towels on top of the trash bin. The used Hoyer Lift sling was left in the corner of the room, next to Resident 5's wheelchair which was full of resident's personal belongings. During a concurrent observation and interview on 12/3/2025 at 2:01 PM with CNA 1 inside Resident 5's room, CNA 1 stated the clean linens were on top of Resident 5's wheelchair and should have been placed inside Resident 5's closet. CNA 1 stated the Soiled Hoyer lift sling should have been in the dirty linen cart. CNA 1 stated he was going to put it in a bag and put it away in the dirty linen cart earlier, but he forgot. CNA 1 stated the soiled towels, and dirty linens should have been placed inside the dirty linen cart. CNA1 stated Residents' room should be kept clean to avoid spread of infection. During an interview on 12/3/2025 at 4:32 PM with IPN, IPN stated the soiled towels on top of the trash bin should not be there because it can spread germs. IPN stated the staff should have put it inside the dirty linen cart and not on top of the trash bin. During an interview on 12/3/2025 at 4:34PM with IPN, IPN stated the staff should not leave dirty Hoyer lift sling laying around the resident's room. The soiled Hoyer lift sling can spread germs and residents can have infection. During an interview on 12/5/2025 at 12:13 PM with the DON, the DON stated if the Hoyer lift sling was dirty, the staff should have put it inside the soiled linen cart. The DON stated the soiled towels should not have been left at the top of the trash bin. The DON stated the staff was not following the infection control policy. During a concurrent interview and record review on 12/5/2025 at 12:23 PM with the DON, the facility's P&P titled, Linen Handling, initiated 11/2024, indicated to prevent contaminating surfaces, after handling soiled linen or transferring soiled linen bags into the soiled linen cart. Treat all soiled linen as being infectious and contaminated. The DON stated the Staff should have collected the soiled towels and should be placed in a plastic bag and put in a dirty linen cart. The staff should not put the soiled towel on top of the trash bin because that was dirty. 4. During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) and encounter for gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 5 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent medication observation via GT and interview on 12/4/2025 at 8:15 AM in Resident 5's room, LVN 1 was observed with a gown, which was opened from the back, showing LVN 1's scrubs. LVN 1 was then observed touching his scrubs and back with used gloves while untying his gown to remove his PPEs. LVN 1 stated he was touching his clothes which can transmit infection. During an interview on 12/4/2025 at 11:15AM, the Infection Preventionist Nurse (IPN) stated, It is not ok to reach behind your back with used gloves on because you can touch your clothes and back, which can spread infection. IPN also stated the staff should remove the gown and gloves together per Centers for Disease Control and Prevention (CDC) guidelines. During an interview on 12/5/2025 at 11:46 AM, the DON stated for PPE doffing, the facility uses the CDC guidelines. The DON also stated the gloves should be removed first prior to removing the gown for infection control reasons. During a review of the CDC undated guidelines, the guidelines indicated an example of removing PPEs in the following sequence: 1. Gown and Gloves (grasp the gown in the front with used gloves and pull away from the body so ties break) 2. Goggles or Face Shield 3. Mask or Respiratory 4. Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. 5. During an observation on 12/5/2025 at 9:02 AM in the medication room, the following personal items and medications were found in the medication room: 1 opened box of expired N95 (a type of respirator that filters at least 95% of airborne particles). Expired 6/10/2022. 1 used toothbrush with a dry white substance on bristles wrapped in brown paper 1 used toothbrush with dry white substance on bristles and used toothpaste wrapped in brown paper. Five (5) cans of a V8-Bloody [NAME] spicy drink. 1 pink and yellow bag unmarked with the following items inside: 1 unmarked black case with 2 hearing aids with brown crust residue. seven (7) battery packets. 2 unknown white boxes in a clear bag. 1 business card. 1 open box of cereal marked Honey Bunches of Oats with a half empty clear bag with cereal inside. Expired 3/26/2025. 1 red and white box of KN95 (a protective face mask that conforms to the other standards for respiratory protection) with no expiration date. 1 pack of gold colored birthday candles. 1 gold and silver colored celebration sign marked Happy New Year. 1 clear blue container lid. 1 brown Christmas ornament. 1 open box of blue face masks with no expiration date. 1 open box of Honeywell N95 masks with no expiration date. 1 white box with 8 clear bags with Niosh N95 masks with no expiration date. During an interview on 12/5/2025 at 9:15 AM with RNS 1, RNS 1 stated it is not ok to have personal items in the medication room because it can cause an infection to the residents. RNS 1 stated food does not belong in the medication room. RNS 1 stated, The food was for the staff and not the residents, it should not be in the medication room. During a concurrent interview and record review on 12/5/2025 at 12 PM with the Director of Nursing (DON), the P&P titled, Medication Storage—Storage of Medication, dated 1/2023 was reviewed. The P&P indicated, the medication storage room should be clean and free of clutter. The DON stated anything that was expired should have been thrown away. During a review of the facility's P&P titled, Medication Storage—Storage of Medication, dated 1/2023, indicated, Medication storage should be kept clean, well lite, organized and free of clutter.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of two (2) of three (3) sampled residents (Residents 5 and 40) in accordance with its Policy and Procedure (P&P) by failing to ensure:1.a. Resident 5's Famotidine (medication used to treat and prevent conditions caused by too much stomach acid such as heartburn [burning chest pain] and gastroesophageal reflux disease [GERD, stomach acid flows back up the esophagus (canal that connects the throat to stomach)], was not left unattended on top of the medication cart on 12/3/2025. Licensed Vocational Nurse 1 (LVN 1) also failed to administer Famotidine 30 minutes prior to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) feeding on 12/3/2025 as indicated on the physician's order.1.b. LVN 1 used 2 resident identifiers prior to administering Resident 5's medication on 12/3/2025.1.c. LVN 1 flushed Resident 5's GT before and after Keppra (medication for seizures) and Metoprolol (medication that affects the heart and circulation) administration as indicated on the physician's order.2. LVN 3 used 2 resident identifiers prior to administering Resident 40's medication on 12/3/2025.This deficient practice had the potential to result in ineffectively managing Residents 5 and 40's medical condition and place the residents for medication errors and compromised resident safety. Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 9/6/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 5 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 5's Physician Order, dated 8/27/2025, the Physician Order indicated enteral feeding (delivers liquid nutrients directly into the stomach or intestines via a soft tube when someone cannot eat enough by mouth) Osmolite 1.2 Calories at 60 milliliters (ml – unit of measure) via pump two times a day every day. Turn off at 7 AM and turn on at 3 PM. During a review of Resident 5's Care Plan, the Care Plan indicated potential for GI distress related to GERD, revised 7/23/2025. The Care Plan interventions included were to administer medications as ordered and observe signs and symptoms of GI bleed. During a review of Resident 5's Care Plan, the Care Plan indicated alteration in nutrition due to enteral feeding, revised 9/6/2025. The Care Plan interventions included were to administer enteral feeding and water flush per order, and flush tube at least with 30 ml of water before and after medication administration. During a review of Resident 5's Physician Order, dated 10/17/2025, the Physician Order indicated Famotidine oral tablet 40 milligrams (mg – unit of measure), give one time a day for GERD, and give 30 minutes prior to start GT feeding. During a review of Resident 5's Physician Order, dated 10/30/2024, the Physician Order indicated flush GT with 10 ml of water before and after each medication. a. During a concurrent medication administration observation and interview on 12/3/2025 at 12:25 PM, LVN 1 was observed leaving the crushed Famotidine in a cup unattended on top of the medication chart while inside Resident 5's room. LVN 1 stated he should not have left the medication on top of the cart unattended because another resident could come and take the medication. b. During the same concurrent medication observation inside Resident 5's room and interview on 12/3/2025 at 12:25 PM, Resident 5 was in bed with her GT off. LVN 1 was observed using one resident identifier, when giving Resident 5 her Famotidine medication at 12:45PM. LVN 1 stated he did not but should have used 2 resident identifiers prior to administering medication to avoid misidentifying the resident. LVN 1 also stated the GT feeding will start at 3PM. During an interview on 12/3/2025 at 3:45 PM, Registered Nurse 1 (RN 1) stated Resident 5's Famotidine should have been given 30 minutes prior to the feeding, which was supposed to start at 3PM according to the physician's order. RN 1 also stated Resident 5 should have been administered her famotidine at 2:30 PM as indicated on the physician's order. c. During a concurrent medication administration observation on 12/4/2025 at 8:15 AM, LVN 1 was observed giving Resident 5's medication via GT. LVN 1 was observed flushing the tube with 10 ml of water initially, then administering Keppra and Metoprolol consecutively without flushing in between. LVN 1 stated he should but did not flush between medications. LVN 1 added Resident 5 can get adverse side effects of the medication. LVN 1 also stated that he did not follow the physician's order. During an interview on 12/4/2025 at 11:08 AM, RN 1 and RN 3 stated physician's orders should be followed and if an order indicated to flush 10 ml before and after each medication, then the licensed nurse should be flushing 10 ml between the Keppra and Metoprolol. RN 1 and RN 3 also stated there needs to be 2 resident identifiers prior to medication administration. RN 1 and RN 3 stated medications should not be left unattended on top of the medication cart. RN 1 and RN 3 also stated medications ordered to be given 30 minutes prior to GT feeding should be 30 minutes before turning on the feeding. During a review of the facility's P&P titled, Medication Administration General Guidelines, dated 2007, the P&P indicated medications are administered in accordance with written orders of the prescriber. P&P also indicated during administration of medications, no medications are kept on top of the cart. During a review of the facility's P&P titled, Enteral Feeding, dated 5/2016, the P&P indicated to review the physician order for completeness such as amount and frequency of water to flush the tube and medication administration. 2. During a review of the admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included but are not limited to left knee replacement, Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dysarthria (a motor-speech disorder caused by damage to the brain, nerves, or muscles that control speech, resulting in difficulty with muscle strength and coordination), anarthria (the complete loss of the ability to articulate speech, resulting from damage to the brain or nervous system that impairs the motor control of the muscles used for speech) and lack of coordination. During a review of Resident 40's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/20/2025, indicated Resident 40 is cognitively intact, with no or very little impairment. Resident 40 requires supervision or touching assistance for mobility such as rolling left to right, sit to lying, lying-to-sitting on the side of bed, sit to stand, transferring chair/bed-to-chair, toilet transfer, and walking 10 feet. During an observation on 12/4/2025 at 9:19 AM in Resident 40's room during a medication pass observation with LVN 3, LVN 3 was observed identifying Resident 40 by her wrist band only, no second identifier was used. During an observation on 12/4/2025 at 9:20 AM in Resident 40's room during medication pass with LVN 3, LVN 3 stated there is no photo identifier available in Resident 40's electronic record. During an interview on 12/4/2025 at 9:25 AM, with LVN 3, LVN 3 stated she only used one identifier before administering medications to Resident 40 by checking the wrist band. During an interview on 12/4/2025 at 11 AM, with LVN 3, LVN 3 stated that it is important to use a two-person identifier because it can correctly identify the resident and prevent medication errors. She also stated that the wrong medication can be given to the wrong resident. During an interview on 12/5/2025 at 11:48 AM, with the Director of Nursing (DON), the DON stated it is important to use a two-patient identifier to identify the correct resident. During a concurrent interview and record review on 12/4/2025 at 11:45 AM with the Registered Nurse Supervisor 3 (RNS 3), the facility's P&P titled, Medication Administration—General Guidelines, dated 1/2023, was reviewed. The P&P indicated that two-patient identifiers should be used before administering medications. RNS 3 stated, it is important to use two-patient identifiers to identify the right patient when giving medication and can help prevent protentional adverse reactions. During a review of the facility's P&P titled, Medication Administration—General Guidelines, dated 1/2023, indicated, residents are identified before medication administration using at least two resident identifiers. And, the two methods of identification include checking a residents identification band, a photograph attached to medical record, and verifying resident identification with other nursing care center personnel.

Based on observation, interview, and record review, the facility failed to ensure food was handled, prepared, and stored in accordance with the facility's policy by failing to ensure:1. Expired products were removed from the kitchen dry storage.2. Food items were dated, labeled, and kept clean after opening in the dry storage area and walk in refrigerator. These failures had the potential to result in harmful bacteria growth that could lead to food borne illnesses to 38 of 38 medically compromised residents who receive food in the kitchen.During a concurrent observation and interview on 12/2/2025 at 7:49 AM in the kitchen dry storage area and walk in refrigerator with [NAME] 1, the following were observed:1. Two (2) unopened containers of cooking wine were observed covered in dust and labeled with the dates 11/14/2022 and 11/13/2025. [NAME] 1 stated that both containers of cooking wine were expired.2. One (1) gallon opened container of vinegar had dried drippings on the exterior, and one (1) unopened container of vinegar was labeled with a handwritten date of 10/8/2023. [NAME] 1 stated that the date indicated when the products were received or delivered. [NAME] 1 also noted that the manufacturer's expiration date was not printed on the container or label. [NAME] 1 was observed wiping dust off both vinegar containers.3. 1 gallon opened container of molasses had dried drippings and dried material on the cap. [NAME] 1 stated that the container was dirty.4. 1 opened container of ketchup was observed with drippings on the exterior.5. 2 salad dressing containers/dispensers were labeled with the date 11/1/25. [NAME] 1 stated she did not know what the date referred to. One of the two containers had drippings on the holder/cover. [NAME] 1 emphasized the importance of clearly labeling and dating items so that all staff are aware of which food items can still be served or should be discarded. [NAME] 1 stated that if expired food items were served to residents, it could result in illness or hospitalization. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised 1/2025, the P&P indicated: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label, and date unused portions and open packages. Discard food past the use-by or expiration date.

Based on observation, interview, and record review, the facility failed to ensure two (2) of three (3) dumpsters (large trash container designed to be emptied into a truck), containing garbage (mostly decomposable food waste or yard waste) and refuse (dry material such as glass, paper, cloth or wood that does not readily decompose) were covered or entirely covered as indicated on the facility's Solid Waste Disposal policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry disease such as rodents, parasitic worms , or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. During an observation on 12/2/2025 at 7:36 AM, next to the facility kitchen loading dock and door, 2 of 3 dumpsters filled with garbage were observed without a lid and another one with a lid but was not entirely covering the dumpster. During a concurrent interview and record review on 12/3/2025 at 4:40 PM with the Infection Prevention and Control Nurse (IPN), the photo documentation of the dumpsters taken on 12/2/2025 at 7:36 AM and the policy and procedure (P&P) titled Solid Waste Disposal, were reviewed. The IPN confirmed that one (1) dumpster overflowing with trash did not have a lid/cover. The IPN stated open dumpsters can attract flies and other pests. These pests can get into the kitchen or the facility and contaminate the food and kitchen equipment that can cause illness to the residents and potentially result in hospitalization. The IPN stated that the P&P indicated to keep lids closed on all outside trash receptacles. The IPN stated the P&P of the facility was not followed. During a concurrent interview and record review on 12/4/2025 at 8:02 AM with the Director of Dining Services (DDS), the P&P titled Solid Waste Disposal was reviewed. The DDS stated the Director of Environmental Services (DES) oversees the outside dumpsters. The DDS stated the dumpster lids should be completely closed at all times according to the facility policy. The DDS stated that the P&P was not followed. During an observation of the facility dumpster area on 12/4/2025 at 7:30 AM, 1 of 3 dumpsters was observed overflowing with trash and was not entirely closed/ covered with its lid. During an observation of the facility dumpster area on 12/5/2025 at 8 AM with the IPN, 2 of 3 dumpsters were observed overflowing with trash and were not completely covered/closed. The IPN stated that both dumpsters should be completely closed because open dumpsters can attract flies and other pests which could be harmful to the residents. During a concurrent interview and record review on 12/5/2025 at 8:40 AM with the DES, the photo documentation of the dumpsters taken on 12/2/2025, 12/4/2025, and 12/5/2025 and the Solid Waste Disposal P&P were reviewed. The DES confirmed the dumpsters were not covered or completely closed as shown on the pictures. The DES stated that according to the P&P, lids should be kept closed on all outside trash receptacles. The DES stated the open dumpsters exposed trash and can potentially attract flies and rodents and can get into the open kitchen door when it is open. The DES stated the flies can contaminate the food and cooking equipment that if served to the residents, can potentially cause residents to get sick and hospitalized . During a review of the P&P titled, Solid Waste Disposal P&P, dated 1/20/25, indicated that lids should be kept closed on all outside trash receptacles.

Based on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for one (1) of four sampled residents (Resident 5) for the environment care area in accordance with the facility's policy and procedure when facility failed to leave Resident 5's wheelchair. which was at the resident's bedside, overflowing with the resident's personal belongings. This deficient practice resulted in unsafe and unsanitary conditions placing Resident 5 at risk for infection, uncomfortable living, and harm. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE], transient ischemic attack (TIA, is a temporary blockage of blood flow to the brain), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and pneumonia (a lung infection). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 9/6/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 5 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral and toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer, and toilet transfer. During an observation on 12/3/2025 at 1:55 PM inside Resident 5's room, Resident 5's wheelchair was overflowing with resident's personal belongings (2 blankets, 2 pillows, white linens, towels, and bilateral lower leg brace). During a concurrent observation and interview on 12/3/2025 at 2:01 PM with Certified Nursing Assistant 1 (CNA 1) inside Resident 5's room, Resident 5's wheelchair was overflowing with resident's personal items. CNA 1 stated, Resident 5's bilateral leg brace when not in use, blankets, pillows and linens should be inside the resident's closet. CNA1 stated clean linens and towels should be placed inside a black bag and not left on top of the wheelchair. CNA1 stated they need to keep Resident 5's room clean, organized, and free of clutter to avoid spread infection and ensure safety. During a concurrent observation in Resident 5's room and interview on 12/3/2025 at 2:08 PM, Resident 5 stated she did not like that her room was messy because it does not feel like home. Resident 5 stated she liked her room clean and organized. During an interview on 12/3/2025 at 4:35 PM with Infection Preventionist Nurse (IPN), IPN stated Resident 5's wheelchair should be free of clutter. IPN stated Residents have their own cabinets to put their belongings. IPN stated clean linens need to be kept in a clean plastic bag. IPN stated if the staff combines dirty and clean items, it could cause cross contamination. During a concurrent observation and interview on 12/4/2025 at 8:05 AM with Licensed Vocational Nurse 2 (LVN 2) inside Resident 5's room, Resident 5's wheelchair was observed with 2 pillows. LVN 2 stated those were Resident 5's extra pillows. LVN 2 stated they should not keep the pillows on the wheelchair. During an interview on 12/5/2025 at 12:12 PM with Director of Nursing (DON), the DON stated resident's personal belongings should not be left on the wheelchair because the staff does not know if the personal items were clean or not. The DON stated the staff should not leave the extra pillows on top of Resident 5's wheelchair to ensure the pillows were kept clean. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights and Community Responsibilities, revised 11/2016, the P&P indicated, each residents has the right to have a safe, clean, comfortable and homelike environment, including but not limited to receiving treatments and supports for daily living safely.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 38) received sufficient notice prior to the resident's last coverage date (LCD) for Medicare Part A (insurance which covers inpatient hospital care, skilled nursing facility [SNF], hospice [focuses on the care, comfort, and quality of life of a resident with serious illness, who is approaching the end of life], laboratory tests, surgery, home health care [wide range of health care services that can be given in the resident's home for an illness or injury]) services.This deficient practice had the potential for Resident 38 to not be aware of possible charges for services rendered that were not covered after the resident's last Medicare coverage day.Findings:During a review of Resident 38's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of heart failure (the heart can't pump enough blood for the body needs), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with activities of daily living [ADL]). During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool), dated 11/23/2025, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 38 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with lower body dressing and putting on/ taking off footwear but requires partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) with upper body dressing and toileting hygiene. During a review of Resident 38's Notice of Medicare Non-Coverage (NOMNC- given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization), dated 11/26/2025, the NOMNC indicated the effective date of coverage of the current services would end on 11/27/2025.During an interview on 12/4/2025 at 4PM, the Director of Nursing (DON) stated Resident 38 was informed on 11/26/2025 regarding the resident's last covered date (LCD) which was on 11/27/2025.During an interview on 12/5/2025 at 10:15AM, the DON stated the facility uses the SNF notices - Quick Reference for guidance with the issuance of NOMNC form. During a review of the facility's undated guidance titled, SNF notices - Quick Reference, the guidance indicated generic notice to be issued two days before effective date (last paid day/LCD).

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Three medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 12 percent (%) for one (1) of three (3) sampled residents (Resident 5) observed during medication administration (med pass). This deficient practice resulted in Resident 5 not receiving medications as ordered which had the potential to result in harm due to unmet individual medication needs. Findings:During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) and encounter for gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 9/6/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 5 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 5's Physician Order, dated 8/30/2023, the Physician Order indicated Metoprolol Tartrate (used to treat heart related conditions) tablet 12.5 milligrams (mg, unit of measurement) via gastrostomy tube (GT - tube to allow feedings administered to the stomach) one time a day related to essential (primary) hypertension (high blood pressure). Hold for Systolic Blood Pressure (SBP - pressure in the arteries when the heart beats [contracts]) less than 110 or heart rate less than 60.During a review of Resident 5's Physician Order, dated 10/17/2024, the Physician Order indicated Levetiracetam (Keppra - medication for seizures [sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg/ milliliters (ml - unit of measure) solution. Give 5 ml via GT two times a day for Seizure Prophylaxis (prevention).During a review of Resident 5's Physician Order, dated 10/30/2024, the Physician Order indicated flush GT with 10 ml of water before and after each medication. During a review of Resident 5's Physician Order, dated 8/27/2025, the Physician Order indicated enteral feeding (delivers liquid nutrients directly into the stomach or intestines via a soft tube when someone cannot eat enough by mouth) Osmolite 1.2 Calories at 60 ml via pump two times a day every day. Turn off at 7 AM and turn on at 3 PM.During a review of Resident 5's Physician Order, dated 10/17/2025, the Physician Order indicated Famotidine (medication used to treat and prevent conditions caused by too much stomach acid such as heartburn [burning chest pain] and gastroesophageal reflux disease [GERD, stomach acid flows back up the esophagus (canal that connects the throat to stomach)] oral tablet 40 mg one time a day for GERD, and give 30 minutes prior to start GT feeding.During a concurrent medication observation and interview on 12/3/2025 at 12:25PM, Licensed Vocational Nurse 1 (LVN 1) was observed giving Famotidine tablet to Resident 5 at 12:45PM. LVN 1 stated the GT feeding will start at 3 PM.During an interview on 12/3/2025 at 3:45PM, Registered Nurse 1 (RN 1) stated Resident 5's Famotidine should have been given 30 minutes prior to the feeding. RN 1 also stated if the GT feeding starts at 3 PM, Famotidine should be given at 2:30 PM and not before or after that time to follow the physicians order.During a concurrent medication administration observation on 12/4/2025 at 8:15 AM, LVN 1 was observed giving Resident 5's medication via GT. LVN 1 was observed flushing the tube with 10 ml of water initially, then administering Keppra and Metoprolol consecutively without flushing in between. LVN 1 stated he should but did not flush between medications. LVN 1 added Resident 5 can get adverse side effects of the medication. LVN 1 also stated that he did not follow the physician's order. During an interview on 12/4/2025 at 11:08 AM, RN 1 and RN 3 stated physician's orders should be followed and if an order indicated to flush 10 ml before and after each medication, then the licensed nurse should be flushing 10 ml between the Keppra and Metoprolol. RN 1 and RN 3 also stated medications ordered to be given 30 minutes prior to GT feeding should be 30 minutes before turning on the feeding.During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated medications are administered in accordance with written orders of the prescriber.During a review of the facility's P&P titled, Enteral Feeding, dated 5/2016, the P&P indicated to review the physician order for completeness such as amount and frequency of water to flush the tube and medication administration.

Based on interview and record review, the facility failed to implement its protocol for Antibiotic (medication used to kill bacteria and to treat infections) Stewardship Program by failing to ensure a culture ( growing microorganism like bacteria from a resident ) in a laboratory to diagnose infections, identify the specific germs, and tests which antibiotics effectively kill or stop it) was obtained before ordering antibiotic for one (1) of 1 sampled resident (Resident 36).This deficient practice had the potential for Resident 36 to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics) and suffer adverse side effects from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 36's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC - a severe opportunistic infection causing fever, sweats, weight loss and anemia), carrier of other infectious diseases, and antineoplastic chemotherapy (uses drugs to kill or stop cancer cells from growing, working by targeting rapidly dividing cells).During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 11/6/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene.During a review of Resident 36's Discharge Instructions from the General Acute Care Hospital (GACH), dated 10/30/2025, the Discharge Instructions indicated the facility was one of the recipients who received the residents medical report on 10/30/2025 at 4:54PM.During a review of Resident 36's Physician Orders, dated 10/30/2025, the physician orders indicated the following:1. Azithromycin (antibiotic) tablet 500 milligrams (mg - unit of measure) - Give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for mycobacterium avium complex (MAC)2. Ethambutol Hydrochloride (HCL) oral tablet 400mg (Ethambutol HCL) - Give 2 tablets by mouth one time a day every Monday, Wednesday, and Friday for mycobacterium avium complex (MAC).During a review of Resident 36's Physician Orders, dated 11/3/2025, the Physician Orders indicated Rifampin (antibiotic) oral capsule 300mg - Give 2 capsules by mouth one time a day every Monday, Wednesday, and Friday for mycobacterium avium complex (MAC). Give on empty stomach.During a concurrent interview and record review of Resident 36's medical records on 12/3/2025 at 11:55AM, Infection Preventionist Nurse (IPN) stated Resident 36 did not have a culture done. IPN also stated all infections should have a lab/culture (procedure used to check microorganisms from resident tissue or fluid sample) done before administering an antibiotic but for Resident 36, it was not done.During an interview on 12/4/2025 at 3 PM, the facility's Policy and Procedure (P&P) titled Antibiotic Stewardship Program, dated 4/2016, was reviewed. IPN stated Resident 36 did not obtain a culture. IPN also stated that neither the hospital nor physician was followed up as to whether a culture was obtained or not. IPN stated the policy does indicate that Resident 36 needs to have a lab/culture prior to administering an antibiotic.During a review of the facility's P&P titled Antibiotic Stewardship Program, dated 4/2016, the P&P indicated the Infection Preventionist (IP) will collect and review whether a culture was obtained before ordering antibiotic.

Based on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to inform and provide a written information regarding the right to formulate an advance directive for one (1) of two (2) sampled residents (Resident 26). This deficient practice had the potential to cause conflict in carrying out Resident 26's wishes regarding health care decisions during an emergency. Findings: During a review of Resident 26's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and thrombocytopenia (a condition where a person has a lower-than-normal number of platelets in their blood). During a review of Resident 26's History and Physical (H&P), dated 2/27/2024, the H&P indicated Resident 26 had fluctuating capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS, a federally mandated assessment tool), dated 9/2/2024, the MDS indicated Resident 26 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 26 was dependent (helper does all the effort) with toileting, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 26 required substantial assistance (helper does more than half the effort) with shower and partial assistance (helper does less than half the effort) with upper body dressing and personal hygiene. During a review of Resident 26's Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records resident's treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration) prepared on 1/17/2024, the form did not indicate what was discussed with the resident. The POLST form did not indicate whether Resident 26 had an advance directive, had an advance directive but not available, or there was no advance directive. During a concurrent interview and record review on 10/3/2024 at 5:26 PM, Licensed Vocational Nurse 5 (LVN 5) stated the advance directives acknowledgement form should be in the chart to make sure Resident 26 was notified of the choice to formulate an advance directive if she does not have one. LVN 5 verified Resident 26 did not and should have an advance directives acknowledgement form. During an interview on 10/4/2024 at 10:56 AM, the Social Services Director (SSD) stated the advance directives acknowledgement form should be in the chart. The SSD also stated the advance directives acknowledgement serves as an indicator that facility have had a conversation with the resident about having an advance directive. The SSD stated if the resident did not have one then the facility could provide information about having to formulate a health care directive. The SSD further stated the advance directives acknowledgement form would contain the information whether the resident has an advance directive or not. During a review of the facility's Policy and Procedure (P&P) titled, Advanced Directive, revised March 2024, the P&P indicated that upon admission to the community, social services staff or designee will inform and provide written information to the resident concerning their right to formulate an advanced directive. The policy also indicated that an acknowledgement for advanced directive form will be completed, signed, and placed in the resident's medical record. The policy further indicated that information about whether the resident has executed an advanced directive shall be displayed prominently in the medical record.

Based on interview and record review, the facility failed to prevent falls (move downward, typically rapidly and freely without control, from a higher to a lower level) for one (1) of two (2) sampled residents (Resident 35) by failing to identify causative factors of the resident's fall, and revise the care plan with new resident- specific interventions (programs or activities that are designed to address the specific needs of the resident to ensure their well-being) to prevent further falls. On 7/14/2024 at 8:24 AM, Resident 35 was found sitting on the floor at 6:15 AM awake, very confused, and soaking wet with urine, there was no documented evidence of interventions provided to address resident's confusion and incontinence (involuntary loss of bowel and bladder control). This failure resulted in Reisdent 35 had six (6) falls incidents (8/5/2024, 9/9/2024, 9/10/2024, 9/23/2024 at 1:45 AM and 2:30 AM, and 9/29/2024) with the potential for injuries. On 9/23/2024, the resident sustained forehead laceration and skin tear to her left elbow after the second fall (2:30 AM). Findings: During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 35 was admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of a facility's form titled Patient Diagnoses Information, dated 10/4/2024, the form indicated Resident with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (uncontrolled, involuntary muscle movements ranging from shakes, tics and tremors to full-body movements), dementia (a progressive state of decline in mental abilities) and repeated falls. During a review of Resident 35's Minimum Data Set (MDS- a federally mandated assessment tool), dated 9/9/2024, the MDS indicated Resident 35 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 35 was partial/moderate assistance (helper does less than half the effort needed to complete the activity) with toileting hygiene, supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with bathing, toilet transfers (the ability to get on and off a toilet or commode), dressing, putting on/taking off footwear and setup or clean-up assistance (helper helps only prior to or following the activity completion) with eating, oral and personal hygiene. During a review of Resident 35's Fall Risk Assessment, dated 9/9/2024, the Fall Risk assessment indicated some of Resident 35's fall risk factors to include diagnoses of Parkinson's, dementia, bowel incontinence (inability to control bowel movements), previous falls, unsteady gait and disoriented (confused and unable to think clearly) times two (2) (only able to recall 2 elements of the four: person, place, time, and situation). During a review of Resident 35's Bowel and Bladder assessment dated [DATE], the assessment indicated Resident 35 as occasionally incontinent (usually 2 or more times per week but not daily) with bladder [urination], and functionally incontinent (unable to get to toilet without assistance) with bladder [urination]. The assessment also indicated Resident 35 has episodes of confusion, uses a walker, and needs extensive assistance with transfers. During a review of Resident 35's Fall Risk care plan, revised 9/30/2024, the care plan indicated Resident 35 had the following falls: a. Actual fall on 7/5/2024 b. Alleged fall on 7/14/2024 c. Actual fall 8/25/2024 (at 11:35 PM) d. Unwitnessed fall on 9/9/2024 e. Actual fall on 9/10/2024 f. Actual fall 9/23/2024 at 1:45 AM and 2:30 AM g. Actual fall on 9/29/2024. The care plans also indicated Resident 35 is at risk for falls related to history of falls, impaired mobility, lack of safety awareness, psychoactive med use, unsteady gait, urinary frequency, and weakness, with a goal of no injuries related to falls over the next quarter [12/4/2024]. The care plans dated from 7/14/2024 to 9/29/2024 did not include interventions to address the resident's incontinence at night and confusion. During a review of Resident 35's Progress Notes, dated 7/1/2024 through 10/4/2024, the circumstances for Resident 35 falls were as follows: a. Progress Notes dated 7/14/2024 at 8:24 AM indicated Resident 35 was found sitting on the floor at 6:15 AM awake, very confused, and soaking wet with urine. Resident 35 stated she did not know where she was and is wet because of water from the ceiling. b. Progress Notes dated 9/13/2024 at 1:24 PM indicated Resident 35 had a fall on 9/9/2024 attempting to reach for something and a fall on 9/10/2024 due to Resident 35 ambulating unassisted from bed, trying to get something from her closet. This fall resulted in a laceration to her right temple and multiple discolorations to both arms. c. Progress Notes dated 9/23/2024 at 3:54 AM indicated Resident 35 was found at 1:45 AM sitting on [floor] left side of the bed, stating she was in her apartment with her spouse, being robbed. d. Progress Notes dated 9/23/2024 at 4:09 AM indicated Resident 35 was found sitting on the floor around 2:30 AM sitting by her bed with a superficial laceration to forehead and skin tear to left elbow. Resident 35 stated she did not know what happened and her pants were observed halfway down, The note also indicated after fall, Resident 35 wanted to be taken to the toilet. e. Progress Notes dated 9/24/2024 at 11:33 AM indicated Resident had two falls on 9/23/2024, an unwitnessed at 1:45 AM and was found on the floor again at 2:35 AM. During a review of Resident 35's SBAR Communication Form, dated 8/25/2024 at 11:35 PM, the SBAR indicated Resident 35 stated she was putting the bedsheet on the floor for sleeping when she lost balance and fell . During a review of Resident 35's SBAR Communication Form, dated 9/23/2024, the SBAR indicated Resident 35 had two fall incidents, the first Resident 35 stated robber was in her apartment and the second fall, Resident 35 jumped out of her bed. The SBAR also indicated Resident 35's fall resulted in a forehead laceration and skin tear to her left elbow. During an interview on 10/4/2024 at 10:12 AM with Licensed Vocational Nurse 2 (LVN2), LVN 2 stated Resident has a history of falls, unsteady gait and is incontinent during the nighttime. During a concurrent record review and interview with the Director of Nursing (DON) on 10/4/2024 at 3:19 PM, Resident 35's fall history and revised fall risk care plan interventions were reviewed. The revised interventions were as follows: a. Fall on 7/5/2024, revised intervention added a night light leading to the bathroom. b. Fall on 7/14/2024, revised intervention added to remind Resident 35 not to close [room] door and/or wander at night. c. Fall on 8/25/2024, revised intervention added, Resident 35 moved closer to nurses' station. d. Fall on 9/10/2024, revised intervention added to remind Resident 35 to use the call light. e. Both falls on 9/23/2024, revised intervention of added floor mat (a pad that provides a cushioned land during a fall that reduces that chance of injury from a fall) on the side of Resident 35's bed at night. The DON stated Resident 35 has a history of falls including a fall with injury at previous facility and this facility. The DON also stated Resident 35 does not use call light even if reminded to do so because of forgetfulness and confusion. During a concurrent review of Resident 35's medical record and interview on 10/4/2024 at 6:18 PM with the DON and Administrator (ADM), the DON was unable to provide documented implemented interventions that address Resident 35's incontinence at night. ADM stated facility needs to continue to assess the plan, interventions and get creative as an interdisciplinary team (IDT - a coordinated group of experts from several different fields) to ensure Resident 35 is safe in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Post Fall Assessment, revised 12/14/2022, the P&P indicated Nursing should consider initiating immediate interventions during the same shift the fall occurred and based on the fall circumstances with given examples including increased toileting with specific times, increased assistance or supervision at specific high-risk times and increased monitoring using sensory devices. The P&P also indicated the care plan will be reviewed and updated with interventions to prevent further falls or injury. During a review of the facility's P&P titled, Falls Prevention and Management Program, revised 12/14/2022, the P&P indicated: a. The falls prevention and management program serves to improve or maintain the quality of life for residents. Staff will properly assess a resident's risk for falling, provide adequate interventions to minimize that risk and try to prevent a resident from falling, and then evaluate the effectiveness of those interventions. b. Nursing being able to identify causative factors should a fall occur, and then accelerate the care plan with new interventions to prevent further falls; c. Consider using purposeful rounding to proactively address resident needs on a scheduled basis. A member of the care team rounds on the residents at an individually structured time such as hourly from 6 am to 10 pm and every two hours at night except for high-risk residents every hour. This could include scheduled and prompted toileting. It includes anticipating resident needs rather than responding to a call light.

Based on observation, interview, and record review the facility failed to follow its oxygen therapy (a treatment that provides extra oxygen) policy for two (2) of three (3) sampled residents (Residents 8 and 37) by failing to: 1. Ensure Resident 8's humidifier bottle (plastic bottle of water that adds moisture to the flow of oxygen) was dated and not empty during oxygen therapy. This failure had the potential to result in adverse effects (an undesired harmful effect resulting from a medication or other intervention) of oxygen therapy for Resident 8 including nasal membrane (moist tissue that lines the nasal cavity and produces mucus) drying. 2. The facility failed to follow Resident 37's physician order to receive two (2) liters of oxygen per minute (LPM) via nasal cannula (oxygen tubing used to deliver supplemental oxygen that is placed directly on the nostrils) continuously and failed to store empty portable oxygen cylinder tanks separately from full portable oxygen cylinder tanks as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential to result in oxygen toxicity (lung damage that happens from breathing in too much extra oxygen) to Resident 37 if receiving more oxygen than required. Storing empty and portable oxygen cylinders in the resident's room also had the potential for harm and injury to Resident 37, other residents, facility staff, and visitors. Findings: 1. During a review of Resident 8's Face Sheet, (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways, making it difficult to breathe), dependence on supplemental oxygen and shortness of breath (SOB- difficulty breathing). During a review of Resident 8's Minimum Data Set (MDS- a federally mandated assessment tool), dated 6/30/2024, the MDS indicated Resident 8 had moderately impaired cognitive skills for daily decision making and Resident 8 received oxygen therapy for respiratory treatment. The MDS also indicated Resident 8 required setup or clean-up assistance (staff help only prior to or following the activity completion) with eating and oral hygiene, partial/moderate assistance (staff does less than half the effort needed to complete the activity) with toileting and substantial/maximal assistance (staff does more than half the effort needed to complete the activity) with dressing and bathing. During a review of Resident 8's Physician Order, dated 10/1/2024 through 10/31/2024, the Physician's order indicated an order for continuous oxygen each shift, titrate (adjusting the amount of oxygen a patient receives to maintain a target oxygen saturation level) from 2 liters (L) to five (5) L per minute via nasal cannula (NC- a tube that provides oxygen through the nose) continuously for SOB keep oxygen saturation (the amount of oxygen carried by red blood cells) above 90 percent (%). During a concurrent observation and interview on 10/1/2024 at 2:29 PM with Licensed Vocational Nurse 1 (LVN 1), at Resident 8's bedside, Resident 8 was observed receiving four (4) L of oxygen via NC with an empty, undated humidifier bottle attached to the oxygen concentrator (a medical device that produces a higher concentration of oxygen from the room air). LVN 1 stated Resident 8's humidifier was undated, empty and should not be. LVN 1 stated the facility policy is to date the humidifier bottle with the open date and should be changed when empty. LVN 1 also stated it is important to have water in the humidifier bottle during oxygen therapy because it is easy for Resident 8 to get a dry nose with the high oxygen [amount] the resident was receiving. LVN 1 added that the humidifier will prevent the drying of Resident 8's nose. During an interview on 10/4/2024 at 3:36 PM with Director of Nursing (DON), the DON stated Resident 8's humidifier bottle should not be empty because of the risk of Resident 8's nasal passages (the two sections of the nasal cavity that allow air to pass through the nose and into the body) drying. During a review of facility's policy and procedure P&P titled, Oxygen Therapy, revised 7/2022, indicated: a. Oxygen therapy is administered by a licensed nurse as ordered by the physician. b. Set oxygen flow rate as ordered and assess equipment for proper functioning. c. If oxygen liter flow is at 4 L per minute of higher, or the resident has problems with excessive drying of the nasal passages, a pre-filled or reusable humidifier may be used with distilled water. d. Label humidifier bottle with open date. e. When humidifier bottle is empty or essentially empty, detach and reattach a new prefilled bottle and label with open date. 46919 2. During a review of Resident 37's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), pleural effusion (a condition where fluid builds up in the thin cavity between the lungs and the chest wall), and hypotension (low blood pressure). During a review of Resident 37's History and Physical Examination (H&P), dated 8/22/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set (MDS-a federally mandated Resident assessment tool), dated 8/31/2024, the MDS indicated Resident 37 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 37 required supervision or touching assistance with eating and oral hygiene. Resident 37 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, upper and lower body dressing, sit to stand, and chair/bed-to-chair transfer. Resident 37 was on intermittent (not continuous) oxygen therapy. During a review of Resident 37's Physician's Order, with a report date range of 10/1/2024 to 10/31/2024, the Physician's Order indicated a start date of 8/24/2024, for continuous oxygen, each shift at 2 LPM via nasal cannula continuously for respiratory failure keep oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) greater than 90%. During a review of Resident 37's Care Plan titled, Alteration in Breathing Patterns related to history of respiratory failure, dated 8/24/2024, the care plan indicated an intervention for oxygen continuous at 2 LPM via nasal cannula. During an observation in Resident 37's room, on 10/1/2024, at 9AM, Resident 37 was sitting on his bed eating his breakfast. Resident 37 was receiving four (4) LPM of oxygen via nasal cannula. Resident 37 had three (3) portable oxygen cylinder tanks against the wall by the foot of the bed. Two out of the three portable oxygen cylinder tanks were empty. During a concurrent observation of Resident 37's bathroom and interview with Licensed Vocational Nurse 2 (LVN 2), on 10/1/2024, at 3:46 PM, LVN 2 checked Resident 37's oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a resident in need of supplemental oxygen) in the bathroom and stated Resident 37 was receiving 4 LPM of oxygen. LVN 2 stated Resident 37 was only ordered for 2 LPM of oxygen. During the same concurrent observation of Resident 37's room and interview with LVN 2 on 10/1/2024, at 3:46 PM, LVN 2 stated Resident 37 had three portable oxygen cylinder tanks in his room. LVN 2 stated 2 out of the three (3) portable oxygen tanks were empty. LVN 2 stated empty portable oxygen tanks should be stored in the oxygen tank storage room. During an interview with the Director of Staff Development (DSD), on 10/1/2024, at 4:27 PM, the DSD stated empty portable oxygen cylinder tanks should be separated from full portable oxygen cylinder tanks. The DSD stated portable oxygen cylinder tanks are stored in the oxygen storage room for the safety of the residents and staff and to prevent fires. During an interview with LVN 6, on 10/2/2024, at 4:24 PM, LVN 6 stated Resident 37's oxygen cannot be increased to 4 LPM without getting an order or notifying the physician. LVN 6 stated Resident 37's physician order for oxygen was not followed on 10/1/2024. LVN 6 stated it was important to follow the physician's oxygen order because too much oxygen can drown (a term used when resident breaths in too much oxygen causing lung damage and even death) a resident. LVN 6 stated a resident can also go into respiratory distress and end up in the hospital from receiving too much oxygen. During the same interview with LVN 6, on 10/2/2024, at 4:24 PM, LVN 6 stated empty portable oxygen cylinder tanks should not be kept in the resident's room with full portable oxygen cylinder tanks. LVN 6 stated empty portable oxygen cylinder tanks were stored in the oxygen storage room. LVN 6 stated it was the responsibility of the licensed nurses and certified nursing assistants (CNA) to monitor and check the portable oxygen cylinder tanks in the residents' rooms. During a review of the facility's P&P, titled, Oxygen Therapy, revised on 7/2022, the P&P indicated, Oxygen therapy is administered by a licensed nurse as ordered by the physician or as an emergency measure until the order can be obtained. The P&P indicated to, Replace oxygen cylinders as needed based on flow rate and size. Securely store empty cylinders separately from full.

Based on observation, interview, and record review, the facility failed to to follow proper food handling practices in accordance with its policy and procedure by failing to:: 1. Properly label food items in the kitchen refrigerator. 2. Ensure there was no expired bread in the kitchen dry storage area. 3. Properly label food items in the resident refrigerator. These deficient practices have the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 35 residents who consume food by mouth. Findings: 1. During a concurrent observation and interview in the kitchen on [DATE] at 7:50 AM with [NAME] 1, there were multiple food items inside walk in refrigerator 1 without a label to indicate the date when the following food items were opened: a. One large clear container of cranberries b. One grocery bag (cook stated did not belong to the facility but could be from one of the staff) which contained coleslaw packed in a zip lock and in a small plastic container, one plastic bottle with tomato sauce and tortillas packed in a foil. During a concurrent observation and interview in the kitchen on [DATE] at 8:10 AM with [NAME] 1, there was one large pan of breaded meat without a label to indicate prepared date inside walk in refrigerator 2. Cook 1 stated he did not know who the grocery bag of food item was from and should have been placed in the employee lounge so not to contaminate other food items inside the kitchen refrigerator if they belonged to one of the employees. [NAME] 1 also stated he was not sure what kind of meat was the breaded meat item in the large pan and when it was prepared. [NAME] 1 further stated the breaded meat should have been labeled with the type of meat and date it was prepared. 2. During a concurrent observation and interview in the kitchen on [DATE] at 8:30 AM with [NAME] 1, there were three (3) bags of breadsticks and two (2) bags of Rye bread with an expiration date of [DATE] on the multiple tier bread rack. [NAME] 1 stated the expired items should be thrown away since they could develop molds and cause the residents to get sick. During an interview on [DATE] at 11:20 AM, the Director of Dining Services (DDS) stated the expired bread should be removed since it potentially could cause health issues to the residents. The DDS also stated all food items in the refrigerator should be labeled to identify what they were. The DDS further stated the residents could potentially be given and could ingest the wrong food item if not labeled properly. During an interview on [DATE] at 11:55 AM, the Registered Dietician (RD) stated, expired items should be removed, discarded, and not served after expiration for food safety and palatability. The RD also stated, the food item should be labeled with the name of item if its not in the original container and should be labeled with the date it was opened and date it was prepared for food safety and for identifying the food. The RD further stated, serving undated food items to the residents that were potentially expired could cause food borne illness. 3. During a concurrent observation and interview on [DATE] at 11:24 AM with Licensed Vocational Nurse 5 (LVN 5), multiple food items without a label to indicate the opened date, residents name and room number, date food was prepared or first opened were found inside the resident's refrigerator by the hallway close to the nurse's station, which included the following: a. One small container of red sauce b. Three (3) pints sized and one gallon of ice cream LVN 5 stated it was not acceptable for food items brought in by families in the refrigerator not to have labels with the resident's name, room number, date the food was prepared, or first opened since bacteria could grow in food items which could possibly make residents sick if consumed. During an interview on [DATE] at 1:52 PM, Licensed Vocational Nurse 3 (LVN 3) stated the foods stored inside the resident's refrigerator should be labeled to identify which resident, room number, and date it was stored. LVN 3 also stated it is to ensure the food is still good for consumption. LVN 3 further stated residents could get food poisoning if the food being consumed was expired. During a review of the facility's Policy and Procedure (P&P) titled, Dining Services - Storage and Inventory, dated [DATE] indicated that all prepared foods and foods not in the original containers must be covered, labeled, and dated. During a review of the facility's P&P titled, Dining Services - Foods Brought into the Facility by Family Members or Guests, dated [DATE] indicated that foods shall be labeled by the person who brought the food. The policy also indicated that the label shall have: the residents name and room number, as well as the date the food was prepared or first opened. The policy further indicated that foods not properly labeled or have labels that are not easily readable will be immediately discarded.

Based on observation and interview the facility failed to ensure two (2) of three (3) dumpsters were covered with a lid and were not overflowing with trash in accordance with the facility policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation of the facility's garbage area, and interview with the Director of Dining Services (DDS) on 10/1/2024 at 11:35 AM, there were 3 dumpsters located outside the facility's main kitchen area, which was about 15 to 20 feet away from the facility's kitchen exit. DDS verified 2 of the 3 dumpsters were observed without lids and both were overflowing with trash bags. DDS stated the dumpsters should have been covered with a lid and not overflowing with trash since this could attract all live animals. During observation of the facility's garbage area on 10/01/24 at 3:45 PM, about 5 empty boxes were observed in between 2 of the 3 dumpsters. The lid for one (1) of the 3 dumpsters was observed partially covering the dumpster due to boxes and trash overflowing from it. During an interview on 10/03/2024 at 9:57 AM, the Administrator stated that the lids on the dumpsters should be closed to keep pests away and to help keep the area sanitary. During a review of the facility's Policy and Procedure titled, Food and Nutrition Services, dated October 2024 indicated that the facility will properly dispose of garbage and refuse, maintaining containers in good condition (no leaks) with lids or otherwise covered. The policy also indicated that garbage storage areas will be maintained in a sanitary condition to prevent the harboring and feeding of pests.

Amended: Based on observation, interview and record review, the facility failed to implement appropriate infection control practices for 4 of 5 sampled residents (Residents 19, 24, 37 and 199) as indicated on the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 199's visitor was educated and used indicated personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside novel respiratory isolation (an isolation that requires the use of a disposable gown, eye protection [goggles or face shield], fit-tested respirator [N-95 or higher] and gloves) room. 2. The nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was placed in a bag after use as indicated in the facility's policy and procedure (P&P) and ensure the oxygen tubing was not touching the floor for Resident 37. 3. Facility staff observed infection control measures for a Resident 24 who was on Enhanced Barrier Precautions (EBP or ESP- the use of gown and glove use for nursing home residents with wounds and indwelling devices during specific-high contact Resident care activities associated with multidrug-resistant organisms [MDRO] transmission ) by failing to don (wear) personal protective equipment (PPE- a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) before checking for gastrostomy tube (Gtube- a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) placement prior to medication administration. 4. Resident 19's handheld nebulizer (delivers medicines in the form of aerosols to add moisture and help control respiratory symptoms) was stored in a clean bag when not in use. These deficient practices placed the residents, staff, and visitors at higher risk for transmitting and/or acquiring infection in the facility. Findings: 1. During a review of Resident 199's Face Sheet, the Face Sheet indicated Resident 199 was admitted to the facility on [DATE], with diagnoses that included Coronavirus disease 2019 (COVID-19 - a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]), pneumonia (PNA- an infection/inflammation in the lungs) and COPD. During a review of Resident 199's MDS dated [DATE], the MDS indicated Resident 199 had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 199 was dependent (helper does all the effort) with toileting, bathing, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 199 substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral and personal hygiene. During a review of Resident 199's Physician's Order, the Physician's Order indicated contact (measures taken to prevent the spread of germs that are transmitted through touching) and droplet precautions (measures taken to prevent transmission when infection can be spread to others by speaking, sneezing, or coughing) for COVID [19]. During a review of Resident 199's Active Infection as Evidenced by Positive for COVID-19, care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), dated 9/27/2024, the care plan indicated contact and droplet precautions. During an observation on 10/1/2024 at 9:18 AM in front of Resident 199's room, a STOP Novel Respiratory Precautions sign was posted indicating the wearing of a gown, N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air), face shield or goggles and gloves on room entry. A visitor was also observed opening Resident 199's door and entering the room with only a surgical mask on and no other PPE as indicated on the posted PPE sign. During an observation on 10/1/2024 from 9:19 AM until 9:37 AM, the visitor of Resident 199 was inside Resident 199's room without a gown, N-95 and/or gloves. During a concurrent observation in Resident 199's room and interview with Infection Preventionist Nurse (IPN) on 10/1/2024 at 9:26 AM, IPN stated the novel respiratory sign was observed and IPN stated to this isolation requires the use of the N-95 mask, gown, gloves and a face shield or goggles. IPN stated the visitor should have put on all required PPE [N-95, gown, gloves, and face shield/goggles] before entering Resident 199's room. IPN also stated Resident 199's visitor told her he did not wear the PPE because he did not know it was necessary for him. IPN stated is it important for visitors and staff to follow the novel respiratory isolation precautions to prevent the spread [of COVID-19] and for the safety of the residents and everyone. During an interview on 10/4/2024 at 3:36 PM with the DON, the DON stated per facility protocol, facility does not force visitors to wear indicated PPE for COVID-19 isolation rooms, but staff are to educate visitors [on the use and importance of isolation precautions] and encourage PPE usage. During a review the facility's policy and procedure (P&P) titled, Suspected or Confirmed COVID -19 Policy, revised 2/2024, indicated facility should provide instruction before visitors enter residents' rooms on hand hygiene, limiting surfaces touched and use of PPE according to current policy while in the resident's room. 46919 2. During a review of Resident 37's Face Sheet, the Face Sheet indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), pleural effusion (a condition where fluid builds up in the thin cavity between the lungs and the chest wall), and hypotension (low blood pressure). During a review of Resident 37's H&P, dated 8/22/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37 was assessed having intact memory and cognitive skills for daily decision making. Resident 37 required supervision or touching assistance with eating and oral hygiene. Resident 37 required substantial/maximal assistance with toileting hygiene, upper and lower body dressing, sit to stand, and chair/bed-to-chair transfer. Resident 37 was on intermittent (not continuous) oxygen therapy. During a review of Resident 37's Physician's Order, with a report date range of 10/1/2024 to 10/31/2024, the Physician's Order indicated a start date of 8/24/2024, for continuous oxygen each shift at 2 LPM via nasal cannula continuously for respiratory failure keep oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) greater than 90%. During an observation in Resident 37's room, on 10/1/2024, at 9:00 AM, Resident 37 was sitting on his bed eating his breakfast. Resident 37 was receiving 4 liters of oxygen per minute (LPM) via nasal cannula. Resident 37's oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a resident in need of supplemental oxygen) was in the bathroom. Resident 37's bathroom door was closed and the oxygen tubing touched the floor under the bathroom door. Resident 37 had a used nasal cannula hanging on top of the empty portable oxygen cylinder tanks against the wall by the foot of the bed. The nasal cannula was not stored in a bag. During a concurrent observation of Resident 37's room and interview with LVN 2 on 10/1/2024, at 3:46 PM, LVN 2 stated Resident 37's nasal cannula was on top of the portable oxygen cylinder. LVN 2 stated Resident 37's nasal cannula should be placed in a bag when not in use. During the same concurrent observation of Resident 37's bathroom and interview with LVN 2 on 10/1/2024, at 3:46 PM, LVN 2 stated Resident 37's oxygen tubing was touching the floor near the bathroom. During an interview with the Director of Staff Development (DSD), on 10/1/2024, at 4:27 PM, the DSD stated the oxygen tubings need to be changed when dirty, contaminated, or if it falls on the floor. During an interview with LVN 6, on 10/2/2024, at 4:24 PM, LVN 6 stated the facility's P&P indicated to change the oxygen tubing only as needed if it was dirty. LVN 6 stated an oxygen tubing was considered dirty if it was touching the floor. LVN 6 stated a dirty oxygen tubing can be a source of infection for a resident which can lead to respiratory problems. LVN 6 stated if a nasal cannula should be placed in a bag when it is not being used by a resident to prevent infection. During an interview with LVN 3, on 10/3/2024, at 11:10 AM, LVN 3 stated it was the licensed nurse's responsibility to change the oxygen tubing when it was dirty. 3. During a review of Resident 24's Face Sheet, the Face Sheet indicated Resident 24 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty or discomfort in swallowing), functional quadriplegia (paralysis that affects all four limbs plus the torso), and essential hypertension (high blood pressure). During a review of Resident 24's H&P, dated 8/22/2024, the H&P indicated Resident 24 had a Gtube. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) with eating, oral hygiene, upper and lower body dressing, personal hygiene, and roll left to right (the ability to roll from lying on back to left and right side). During a review of Resident 24's Physician's Order, with a report date range of 10/2/2024 to 10/31/2024, the Physician's Order indicated an order, dated 8/30/2023, for gastrostomy tube replacement, each shift, check placement of GT prior to feeding or medication administration. During a review of Resident 24's care plan, titled, Enhanced Barrier Precautions, the care plan indicated Resident 24 was at risk for infection, high risk residents with feeding tube, colonized MDRO: extended-spectrum beta-lactamase (ESBL- an enzyme that makes some bacteria resistant to many antibiotics). Resident 24's care plan intervention indicated for the proper use of PPE (Glove and Gown) during high contact of care activities. During an observation of Resident 24's medication administration on 10/3/2024, at 1:55 PM, LVN 1 entered Resident 24's room, washed his hands and donned gloves. LVN 1 proceeded to unclamp Resident 24's Gtube and inserted a 60 milliliter (ml- unit of measurement) syringe to Resident 24's medication port. LVN 1 pulled the plunger back to check for residual and disconnected the 60 ml syringe from the medication port. LVN 1 stopped and stated he did not DON his gown before checking Resident 24's Gtube residual. LVN 1 removed his gloves, donned PPE from the PPE cart inside Resident 24's room, sanitized his hands with alcohol base hand rub, and donned gloves. LVN 1 reinserted the 60 ml syringe, flushed Resident 24's Gtube with 15 ml of water, administered Omeprazole (medication used to treat heartburn and stomach ulcers), flushed the Gtube once again with 15 ml of water, and disconnected the syringe. LVN 1 doffed (removed) his gown and gloves, washed his hands, and exited Resident 24's room. During an interview with LVN 1, on 10/3/2024, at 2:12 PM, LVN 1 stated Resident 24 was on enhanced barrier precautions because she had a Gtube. LVN 1 stated it was important to don PPE before providing direct contact care to Resident 24 to protect Resident 24 from contamination and infection. During an interview with the Infection Preventionist Nurse (IPN), on 10/3/2024, at 4:09 PM, the IPN stated residents with wounds, MDRO, Gtube, indwelling catheters are placed on enhanced barrier precautions. The IPN stated staff were required to don PPE before providing direct contact care to residents on enhanced barrier precautions to prevent them from getting an infection. During a review of the facility's P&P titled, Oxygen Therapy, revised on 7/2022, the P&P indicated, When nasal cannula or oxygen mask is not in use, place in a plastic bag or other infection prevention pouch to prevent contamination. The P&P also indicated to, Change oxygen tubing if it appears dirty or becomes contaminated. During a review of the facility's P&P titled, Infection Prevention & Control Program, revised 1/2024, the P&P indicated: Enhanced Standard Precautions (ESP) are indicated for high-risk SNF residents, those with infection or colonization with an MDRO when contact precautions do not otherwise apply and/or with wounds and/or indwelling medical devices (urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters). During a review of the facility's P&P titled, Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2022, revised 9/2022, the P&P indicated for ESP staff are to perform hand hygiene and don gloves, gown and mask/goggle/shield PPE within room before beginning activity 45099 4. During a review of Resident 19's Face Sheet, the Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dependence on oxygen supplement. During a review of Resident 19's History and Physical (H&P), dated 8/3/2024, the H&P indicated Resident 19 does not have the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had an intact cognitive skill for daily decision making. The MDS also indicated Resident 19 was dependent (helper does all the effort) with toileting, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 19 partial assistance (helper does less than half the effort) with oral and personal hygiene and required supervision (helper provides verbal cues) with eating. During a review of Resident 19's Physician's Order, dated 9/20/2024, the Physician's Order indicated Resident 19 was on albuterol sulfate (treats and prevents breathing difficulties caused by lung diseases) 2.5 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) inhalation via handheld nebulization every six (6) hours for shortness of breath (SOB, difficulty breathing) due to COPD. During an observation on 10/1/2024 at 9:09 AM, Resident 19's handheld nebulizer was exposed on top of the bedside table and not stored in a clean bag. During an interview on 10/2/2024 at 4:47 PM, the LVN 6 stated the handheld nebulizer should be kept in a clean plastic bag to prevent from collecting dirt from the air and surfaces. During an interview on 10/4/2024 at 12:42 PM, the DON stated that the handheld nebulizer, masks, and nasal cannulas should be placed in a breathable bag to reduce the risk of contamination when not in use. The DON also stated when they (handheld nebulizer, masks, and nasal cannulas) get contaminated there's a risk for residents developing respiratory infection. During a review of the facility's P&P titled, Nebulized Medications, dated October 2011, the P&P indicated that nebulizers will be rinsed out after each use and stored in a clean plastic or mesh bag at the bedside.

Based on observation, interview, and record review, the facility staff failed to follow its manual catheter irrigation (a procedure that uses sterile fluid to flush a blocked or clogged indwelling catheter [a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage]) policy when Licensed Vocational Nurse 5 (LVN 5) failed to cap the drainage tube of the indwelling catheter with a sterile protective sheath during irrigation for one (1) of one sampled Resident (Resident 18) as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential for Resident 18 to develop urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 18's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH- when the prostate and surrounding tissue expands), chronic systolic congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 18's History and Physical Examination (H&P), dated 11/20/2023, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review or Resident 18's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/4/2024, the MDS indicated Resident 18 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 18 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, lower body dressing, and sit to stand. Resident 18 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) with shower/bathe self, personal hygiene, and toilet transfer. Resident 18 had an indwelling catheter. During a review of Resident 18's Physician's Order, dated 10/1/2024, the Physician's Order indicated an order to flush foley catheter (indwelling catheter- a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) with 50 cubic centimeter (cc-unit of measurement) normal saline (NS-a saltwater solution) every shift and as needed (PRN) to keep foley catheter patent/for sediments/or hematuria (blood in urine) or clogged. During a concurrent observation and interview with Resident 18, on 10/1/2024, at 1:46 PM, Resident 18 was sitting on his wheelchair in his room. Resident 18 stated he was waiting for LVN 5 to flush (irrigate) his indwelling catheter. During an interview with LVN 5, on 10/2/2024, at 2:29 PM, LVN 5 stated Resident 18's indwelling catheter was manually flushed every shift due to the presence of sediments (a buildup of various materials in the catheter that can cause blockage or encrustation) in the resident's indwelling catheter tubing. During an observation of Resident 18's foley catheter irrigation, on 10/4/2024, at 10AM, LVN 5 cleansed the connection site around the catheter and the drainage tubing with an alcohol pad and disconnected the catheter from the drainage tubing. LVN 5 placed the drainage tubing on the clean disposable absorbent pad that was placed on top of Resident 18's abdomen. LVN 5 did not cap or cover the drainage tubing before placing it on top of the disposable absorbent pad. LVN 5 flushed the catheter slowly with 50 cc of normal saline and disconnected the syringe from the catheter. LVN 5 cleansed the connection site and the drainage tubing with an alcohol pad and reconnected the catheter to the drainage tubing. During a concurrent review of the facility's Policy and Procedure (P&P) titled, Catheter, Manual Irrigation, revised on 8/2019 and interview with LVN 5 on 10/4/2024, at 12:11 PM, LVN 5 stated the P&P indicated to Carefully disconnect tubing from catheter, holding the catheter upright, cap the drainage tube with a sterile protective sheath. Secure drainage tubing close to resident on the bed. LVN 5 stated she did not cap or cover Resident 18's drainage tubing with a sterile protective sheath after it was disconnected from the catheter. LVN 5 stated the drainage tubing should be capped with a sterile sheath to prevent bacteria and germs from entering. LVN 5 stated Resident 18 can get an infection if bacteria or gems enter the drainage tubing. During a concurrent review of the facility's Policy and Procedure (P&P) titled, Catheter, Manual Irrigation, revised on 8/2019 and interview with the Administrator (ADM) and the Director of Nursing (DON) on 10/04/2024, at 2:20 PM, the DON stated LVN 5 should have followed the facility's P&P for foley irrigation. The ADM stated LVN 5 did not follow the facility's P&P for foley irrigation. During a review of the facility's P&P titled, Catheter, Manual Irrigation, revised on 8/2019, the P&P further indicated, A closed indwelling urinary drainage system should be maintained whenever possible to prevent risks of contamination.

Based on interview and record review, for one (1) of 12 sampled resident (Resident 5), the facility staff failed to: 1. Accurately and completely document the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) dose administered on 10/2/2024, after administering insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 2. Have documented evidence for the monitoring of signs and symptoms of hypoglycemia (a condition in which your blood sugar level is lower than the normal range) and hyperglycemia (a condition where too much sugar is circulating in the blood) as indicated in the resident's care plan and the pharmacist recommendations. These deficient practices placed Resident 5 at risk to not receive appropriate diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) management/care including unmonitored and untreated adverse reactions from insulin therapy, which could affect the resident's over all well being. Findings: 1. During a review of Resident 5's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a long term lung disease causing difficulty breathing), acute respiratory failure (condition then there's not enough oxygen or too much carbon dioxide in the body), and feeding difficulties. During a review of Resident 5's History and Physical Examination (H&P), dated 6/8/2024, the H&P indicated Resident 5 had a history of AODM (adult-onset diabetes mellitus or type 2 diabetes). Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/14/2024, the MDS indicated Resident 5 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 5 required substantial/maximal assist (helper does more than half the effort) with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and roll left and right. Resident 5 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) with shower/bathe self, sit to stand, and toilet transfer. Resident 5 was taking hypoglycemic (a condition where the level of sugar in the blood is too low) medication as indicated. During a review of a facility's form titled Patient Diagnoses Information, dated 10/3/2024, indicated Resident 5 with diagnoses that included type 2 diabetes mellitus (DM2 - a chronic metabolic disease that occurs when the body doesn't produce enough insulin or can't use it properly) with hyperglycemia, DM2 with hypoglycemia, long term [current] use of insulin and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). During a review of Resident 5's Physician's Order, with a report date range of 10/1/2024 to 10/31/2024, the Physician's Order indicated a start date of 7/29/2024, for Fingerstix (a brand of lancets used to check the blood sugar) sliding scale (a treatment for diabetes that involves adjusting the amount of insulin a resident receives based on their blood sugar levels) three times a day before meals for Diabetes Mellitus 2 (diabetes), notify MD (physician) if BS (blood sugar) greater than or equal to (>/=) 301 or less than or equal to (</=) 80. Give Fiasp (insulin aspart, a prescription medication that helps control blood sugar levels in residents with diabetes) 100 U/ml (units per milliliter- a unit of measurement) Flextouch (a prefilled, disposable insulin pen) with sliding scale as follows: 0 to 80 = 0 units 81 to 120 = 4 units 121 to 200 = 8 units 201 to 300 = 15 units During a review of Resident 5's Sliding Scale Insulin Administration Record, the Sliding Scale Insulin Administration Record indicated on 10/2/2024, at 6:30 AM, Resident 5's glucose (blood sugar) level was 197. The record indicated Resident 5 was given 15 units of insulin on the right thigh. The box in the Sliding Scale Insulin Administration record to contain the initials of the licensed nurse who administered the insulin to Resident 5 on 10/2/2024, at 6:30 AM was blank. During a concurrent record review of Resident 5's Sliding Scale Insulin Administration Record, dated 10/2/2024, and interview with Licensed Vocational Nurse 1 (LVN 1) on 10/2/2024 at 2:40 PM, LVN 1 stated Resident 5's 6:30 AM insulin was administered by LVN 4 who was scheduled on 10/2/2024 from 11PM to 7AM shift. LVN 1 stated Resident 5's glucose (blood sugar) level was 197 on 10/2/2024, at 6:30 AM. LVN 1 stated Resident 5 should be administered 8 units of insulin for a blood sugar of 197 as indicated on the physician's order. LVN 1 stated the Sliding Scale Insulin Administration Record on 10/2/2024, at 6:30 AM, indicated Resident 5 was administered 15 units of insulin on the right thigh. LVN 1 stated LVN 4 did not and should have initialed the box on the Sliding Scale Insulin Administration Record after administering insulin to Resident 5 on 10/2/2024 at 6:30 AM. During a concurrent record review of Resident 5's Sliding Scale Insulin Administration Record, dated 10/2/2024, and interview with the Director of Nursing (DON) on 10/4/2024, at 4:46 PM, the DON stated LVN 4 made a transcription error and wrote the wrong amount of insulin on Resident 5's Sliding Scale Insulin Administration Record. The DON stated LVN 4 should have written 8 units instead of 15 units on the Sliding Scale Insulin Administration Record. The DON stated LVN 4 did not and should have written her initial on the Sliding Scale Insulin Administration Record after administering insulin to Resident 5. The DON stated LVN did not follow the policy for charting medications. 48152 2. During a review of Resident 5's Physician's Order, with a report date range of 10/1/2024 to 10/31/2024, the Physician's Order indicated a start date of 7/29/2024, for Fingerstix (a brand of lancets used to check the blood sugar) sliding scale (a treatment for diabetes that involves adjusting the amount of insulin a resident receives based on their blood sugar levels) three times a day before meals for Diabetes Mellitus 2 (diabetes), notify MD (physician) if BS (blood sugar) greater than or equal to (>/=) 301 or less than or equal to (</=) 80. Give Fiasp (insulin aspart, a prescription medication that helps control blood sugar levels in residents with diabetes) 100 U/ml (units per milliliter- a unit of measurement) Flextouch (a prefilled, disposable insulin pen) with sliding scale as follows: 0 to 80 = 0 units 81 to 120 = 4 units 121 to 200 = 8 units 201 to 300 = 15 units During a review of Resident 5's Sliding Scale Insulin Administration Record, the Sliding Scale Insulin Administration Record indicated on 10/2/2024, at 6:30 AM, Resident 5's glucose (blood sugar) level was 197. The record indicated Resident 5 was given 15 units of insulin on the right thigh. The box in the Sliding Scale Insulin Administration record to contain the initials of the licensed nurse who administered the insulin to Resident 5 on 10/2/2024, at 6:30 AM was blank. During a concurrent record review of Resident 5's Sliding Scale Insulin Administration Record, dated 10/2/2024, and interview with Licensed Vocational Nurse 1 (LVN 1) on 10/2/2024 at 2:40 PM, LVN 1 stated Resident 5's 6:30 AM insulin was administered by LVN 4 who was scheduled on 10/2/2024 from 11PM to 7AM shift. LVN 1 stated Resident 5's glucose (blood sugar) level was 197 on 10/2/2024, at 6:30 AM. LVN 1 stated Resident 5 should be administered 8 units of insulin for a blood sugar of 197 as indicated on the physician's order. LVN 1 stated the Sliding Scale Insulin Administration Record on 10/2/2024, at 6:30 AM, indicated Resident 5 was administered 15 units of insulin on the right thigh. LVN 1 stated LVN 4 did not and should have initialed the box on the Sliding Scale Insulin Administration Record after administering insulin to Resident 5 on 10/2/2024 at 6:30 AM. During a concurrent record review of Resident 5's Sliding Scale Insulin Administration Record, dated 10/2/2024, and interview with the Director of Nursing (DON) on 10/4/2024, at 4:46 PM, the DON stated LVN 4 made a transcription error and wrote the wrong amount of insulin on Resident 5's Sliding Scale Insulin Administration Record. The DON stated LVN 4 should have written 8 units instead of 15 units on the Sliding Scale Insulin Administration Record. The DON stated LVN 4 did not and should have written her initial on the Sliding Scale Insulin Administration Record after administering insulin to Resident 5. The DON stated LVN did not follow the policy for charting medications. During a review of the facility's policy and procedure (P&P) titled, Charting Guidelines, revised on 11/2019, the P&P indicated the following: a. Charting should be done as soon as possible after a given event. b. Keep entries factual, specific, accurate and informative. c. Every nursing entry must be concluded by the name and credential of the writer. During a review of the facility's P&P, titled, Medication Administration General Guidelines, dated 1/2021, the P&P indicated, The Resident's MAR (Medication Administration Record)/TAR (Treatment Administration Record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific mediation dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided on the nursing center's master employee log. 2. During a review of Resident 5's Diabetes Mellitus, at Risk of Complications care plan dated 9/18/2024, the care plan indicated the nursing interventions to monitor for signs and symptoms (S/S) of hyperglycemia: nausea, vomiting, headache, change in level of consciousness (LOC), confusion, frequency, skin hot/dry/flushed or excessive thirst and S/S of hypoglycemia: diaphoresis (excessive sweating due to a secondary condition), dizziness, headache, palpitations (a skipped, extra or irregular heartbeat), weakness, confusion, change in LOC, increased pulse, blurred vision, shallow respirations or lethargy (abnormal drowsiness). During a review of Resident 5's Medication Regimen Review (MRR- a thorough evaluation of a patient's medication regimen to identify and address any potential issues), dated 9/19/2024, the review indicated Resident 5 was on a high-risk medication with monitoring recommendations to monitor for s/s of hypoglycemia and the s/s of hyperglycemia. The review was signed by Resident 5's nursing staff (unable to identify) and physician. During a review of Resident 5's Physician Order, dated 10/1/2024 through 10/31/2024, the orders indicated an order Basaglar Kwikpen (a disposable insulin pen that contains a long-acting, man-made insulin) to take 20 units (U- a measurement used to give insulin) at bedtime subcutaneously (under, all the layers of the skin). During a concurrent interview and record review on 10/3/2024 at 10:52 AM with Licensed Vocational Nurse 5 (LVN 5), Resident 5's Physician Order, dated 10/1/2024 through 10/31/2024, and Treatment Administration Record (TAR) dated 10/1/2024 through 10/31/2024 were reviewed. LVN 5 stated there is no entry for monitoring for s/s of hypoglycemia and hyperglycemia indicated on the TAR and there is no current physician's order for the monitoring of Resident 5's S/S of hyperglycemia and/or hypoglycemia. LVN 5 stated the doctor must not have wanted it done because there was no order. During an interview on 10/3/2024 at 11:04 AM with Medical Doctor (MD), the MD stated she is aware of the pharmacist recommendations for the monitoring of s/s of hypoglycemia and hyperglycemia for Resident 5, but did not order for the monitoring of the hypoglycemia and hyperglycemia because monitoring is a nursing order and standard to monitor for symptoms and that is a standard that does not need a written doctor's order. MD stated it is important for [staff] to monitor Resident 5 for s/s of hypoglycemia because that can cause syncope (a brief loss of consciousness) and a coma (a state of deep unconsciousness where a person is unable to move or respond to their environment) and would indicate if the insulin order needs to be changed. During a concurrent interview and record review on 10/3/2024 at 11:49 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 5's Medication Administration Record (MAR) for the month of October 2024, was reviewed. The MAR failed to have any documented evidence for the monitoring of Resident 5 for s/s of hypoglycemia and hyperglycemia. LVN 1 stated there is no entry on MAR for monitoring of Reisdent 5's s/s of hypoglycemia and hyperglycemia. LVN 1 stated, he only documents in Resident 5's chart once the resident is experiencing a sign and/or symptom of hypoglycemia and/or hyperglycemia. During an interview on 10/4/2024 at 3:36 PM with the Director of Nursing (DON), the DON stated it is important to monitor Resident 5 for S/S of hypoglycemia and hyperglycemia so that staff can act promptly to stabilize the resident, notify the MD and to see if the insulin therapy needs to be modified accordingly. During an interview on 10/4/2024 at 4:23 PM with the DON, the DON stated there is no specific place for nurses to document the monitoring of Resident 5's S/S of The DON stated if something is not documented, she cannot ensure it was done. During a review of the facility's P&P titled, Adverse Drug Reactions, revised 2/2009, indicated residents who may be taking a medication known to have a possible adverse drug reaction, will be assessed [by facility] for evidence of any adverse reactions. During a review of facility's policy and procedure (P&P) titled Medication Regimen Review (MRR) and Reporting, dated 9/2018, the P&P indicated MRR as the thorough evaluation of the medication regimen of a resident, with the goals of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The policy indicated resident-specific MRR recommendations are documented and acted upon by the nursing care center and/or physician and recommendations that do not require physician intervention, the director of nursing or licensed designee will address the recommendations. During a review of the facility's P&P titled, Charting Guidelines, revised 11/2019, indicated the policy purpose is to provide facility guidelines for appropriate documentation in the health record and staff are to document normal findings as well as abnormal findings that shows the resident was assessed. The P&P indicated the following: a. Charting should be done as soon as possible after a given event. b. Keep entries factual, specific, accurate and informative. c. Every nursing entry must be concluded by the name and credential of the writer. During a review of the facility's P&P, titled, Medication Administration General Guidelines, dated 1/2021, the P&P indicated, The Resident's MAR (Medication Administration Record)/TAR (Treatment Administration Record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific mediation dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided on the nursing center's master employee log.

Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 1 sampled resident (Resident 24) as indicated on the facility's call system policy. This deficient practice had the potential for Residents 24 to not being able to call the facility staff for assistance especially during an emergency, which could lead to an injury or harm to Resident 24. Findings: During a review of Resident 24's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (complete immobility due to severe disability from another medical condition without injury to the brain or spinal cord) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 24's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/20/2024, the MDS indicated Resident 24 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 24 was dependent (helper does all the effort) with eating, oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 10/2/2024 at 10:32 AM, Resident 24's call light was on the floor on the right side of the resident's bed. Certified Nursing Assistant 1 (CNA 1) stated Resident 24 would not be able to call for help if her call light is on the floor. During an observation and interview on 10/4/2024 at 10:06 AM, Resident 24's call pad (facility previously provided Resident 24 a call light) was on the floor on the right side of the resident's bed. Licensed Vocational Nurse 3 (LVN 3) entered Resident 24's room and heard the resident asking LVN 3 where her call light was. LVN 3 stated the call light is there for Resident 24 to call on staff for any needs she may have especially for emergencies so the staff could respond as soon as possible. LVN 3 also stated that is important to ensure the call lights are within residents' reach to prevent incidents such falls. During a review of the facility's Policy and Procedure (P&P) titled, Call System, dated February 2009, the P&P indicated to provide each resident with a call system to enable them to request assistance. The policy also indicated to make sure call cords are placed within the residents reach at all times.

Based on interview and record review the facility failed to document and perform a wound care treatment for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1's wounds getting worse in condition. Findings: During a review of Resident 1's Admission Record, Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's History and Physical Examination (H&P), dated 11/10/23, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/15/23, MDS indicated the resident was moderately impaired with cognition (ability to think, remember, and reason), but needed partial/moderate assistance (helper does less than half the effort) with transfers (how a resident moves to and from bed, chair, wheelchair, standing position), was dependent with dressing (how a resident puts on, fastens and takes off all items of clothing), toileting hygiene and needed setup or clean-up assistance with eating and personal hygiene. During a review of Resident 1's Physician Order Sheet dated 1/19/24 at 10:45 AM, the Physician Order Sheet indicated: 1. Cleanse left dorsal (referring to the back) foot status post (s/p; referring to a state after an intervention, usually surgical) surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) with Normal Saline (NS; a mixture of sodium chloride [salt] and water) gently pack with Medihoney (a type of wound treatment gel), collagen powder (wound filler dressing [a pad applied to a wound to promote healing and protect the wound from further harm]) and calcium alginate (Ca Alg; a wound dressing), apply nonadherent (nonstick) dressing and roll gauze (a loosely woven, almost translucent fabric used to bandage wounds) every day (QD) and as needed (PRN) until further orders. 2. Cleanse right medial (middle) malleolus (a bony projection with a shape likened to a hammer head especially each of those on either side of the ankle) s/p surgical wound with NS, pat dry, gently pack with Medihoney, collagen powder and Ca Alg, apply nonadherent pad and roll gauze QD and PRN until further orders. 3. Cleanse coccyx (a small triangular bone at the base of the spine) stage 3 pressure injury (second to last stage of pressure sore progression where the sore has gone through all layers of skin into the fat tissue) with NS, pat dry, apply Medihoney and collagen powder, skin barrier cream (a product applied directly to the skin surface to help maintain the skin's physical barrier and providing protection from irritants and drying out) to periwound (tissue surrounding a wound), cover with dry dressing QD and PRN until further orders. 4. Apply betadine (used on the skin to treat or prevent skin infection in minor cuts, scrapes or burns) to left anterior (front) lower leg laceration (a wound that is produced by the tearing of soft body tissue), cover with nonadherent and roll gauze QD and PRN until further orders. 5. Cleanse right forearm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. 6. Cleanse right upper arm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. 7. Cleanse left upper arm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. During a concurrent interview and record review on 1/31/24 at 2:40 PM with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR) for January 2024 was reviewed. The TAR indicated that no wound treatment was provided for Resident 1's left dorsal foot s/p surgical wound, right medial malleolus s/p surgical wound, coccyx, left anterior lower leg laceration, right posterior forearm skin tear, left upper arm skin tear, left posterior forearm skin tear, and right upper arm skin tear on 1/22/24. DON stated that the treatment nurse who was working that day did the resident's treatment for everything except for the areas that needed medical honey ointment which included both her feet because they ran out of the ointment that day. The DON stated she told the family that she, herself would provide the treatment for the areas that needed medical honey ointment once it arrived but stated that it arrived at that facility late in the evening from the pharmacy and she had already gone home. The DON also stated the daytime treatment nurse should have signed off on the treatments performed that day. The DON further stated if the nurse did not document treatment being performed, then it would be considered not being done. During an interview on 1/31/24 at 3:19 PM with Treatment Nurse 1 (TXN 1), TXN 1 stated on 1/22/24 he provided wound care treatment to Resident 1's upper arms but did not provide treatment for any of the areas that required medical honey ointment since they were out of the medication (Medihoney). TXN 1 stated he did not sign the TAR on 1/22/24 for the areas her performed treatment on because he forgot. During an interview on 1/31/24 at 3:45 PM with the DON, the DON stated the facility was not policy driven and that they have no specific policy regarding providing treatment as ordered by the physician. During a review of the facility's policy and procedure (P&P) titled, Charting Guidelines, revised November 2019, the P&P indicated charting should be done as soon as possible after a given event.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from accident hazards by failing to secure a keyboard that was placed on top of a music equipment cart on 12/31/23 at 3:30 PM while an entertainer (a person such as a singer, musician, [NAME], or comedian whose job is to entertain others) was setting up their equipment for a performance. This failure resulted in the keyboard slipping off the cart and falling onto Resident 1's feet and caused her to sustain blood blisters that needed surgical intervention. Findings: During a review of Resident 1's Admission Record, Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's History and Physical Examination (H&P), dated 11/10/23, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1'S Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/15/23, MDS indicated the resident was moderately impaired with cognition (ability to think, remember, and reason), but needed partial/moderate assistance (helper does less than half the effort) with transfers (how a resident moves to and from bed, chair, wheelchair, standing position), was dependent with dressing (how a resident puts on, fastens and takes off all items of clothing), toileting hygiene and needed setup or clean-up assistance with eating and personal hygiene. During a concurrent observation and interview on 1/31/24 at 10:47 AM with Resident 1's Family Member in Resident 1's room, Resident 1 was observed lying down in bed with both of her feet wrapped in gauze (a loosely woven, almost translucent fabric that is used to bandage wounds). Resident 1's Family Member stated that on 12/31/23 a keyboard fell on both of Resident 1's feet and now has two surgical wounds (a cut or incision in the skin that is usually made by a scalpel during surgery and can vary greatly in size. They are usually closed with sutures but are sometimes left open to heal) on her feet. During an interview on 1/31/24 at 3:30 PM with Activities Specialist (AS), AS stated on 12/31/23 at 3:30 PM an entertainer was setting up their music equipment in the activities room and the music equipment cart was placed in front of Resident 1's wheelchair. AS stated, she was repositioning the resident's wheelchair and locked the wheelchair brake. AS then stated, the keyboard that was placed on top of the equipment cart slid off the cart and fell on to both of Resident 1's feet. During a review of Resident 1's Complete Interdisciplinary Note dated 12/31/23 at 5:30 PM, the Completed Interdisciplinary Note indicated Resident 1 was involved in an incident where a piano keyboard fell on to her feet while an entertainer was trying to set up their instruments in the activities room. Resident 1 complained of pain in both her feet with the right inner ankle swollen and discolored. Resident 1's doctor (MD) was notified and a STAT (immediately) order for both lower extremities x-ray (use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) was obtained as well as an order to medicate the resident with pain medication when needed. During a review of Resident 1's Radiology Report dated 12/31/23 at 8:47 PM, the Radiology Report indicated that both the right and left ankle were found to be intact with soft tissue swelling but no fracture. During a review of Resident 1's Complete Interdisciplinary Note dated 1/1/24 at 3:58 AM, the Complete Interdisciplinary Note indicated that Resident 1's right foot was swollen and discolored purplish, and no heavy linens were to be placed on top of the right foot. During a review of Resident 1's Complete Interdisciplinary Note dated 1/1/24 at 10:49 PM, the Complete Interdisciplinary Note indicated Resident 1's right foot near her ankle was noted with a bump and discoloration while her left foot was noted to have a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) on the top of it. During a review of Resident 1's Complete Interdisciplinary Note dated 1/8/24 at 12:20 PM, the Complete Interdisciplinary Note indicated Resident 1, incurred hematoma on both lower extremities during the weekend due to incident. The form also indicated, Resident 1's left dorsal (relating to the back of a structure) foot blood blister (a bump on the skin filled with blood) and right medial (middle) aspect of malleolus (a bony projection with a shape likened to a hammer head especially each of those on either sided the ankle) had blood blister, intact. During a review of Resident 1's Complete Interdisciplinary Note dated 1/11/24 at 10:30 AM, the Complete Interdisciplinary Note indicated that Resident 1 was seen by the wound care MD. Per MD, the left dorsal foot blood blister was 2.5 centimeters (cm) by 3 cm by unstageable (pressure ulcer stage is not clear) with 100% eschar (dead tissue that forms over healthy skin and then over time, falls off or sheds) noted with redness around area and treatment with betadine (an antiseptic used for skin disinfection) to be continued. The right medial malleolus blood blister measuring 3.5 cm by 3 cm by unstageable with 100% eschar with redness around area was to continue with betadine treatment until further orders. During a review of Resident 1's Complete Interdisciplinary Note dated 1/12/24 at 11:18 PM, the Complete Interdisciplinary Note indicated that Resident 1 was transferred to General Acute Care Hospital (GACH) accompanied by her family and MD was notified. The GACH H&P indicated skin assessment showed bilateral lower circumferential erythema (a skin lesion presenting redness in a ring form that spreads from the center) of both feet with exquisite thrombotic thrombocytopenic purpura (TTP; a blood disorder in which platelet [a small colorless cell fragment in our blood that form clots and stop or prevent bleeding] clumps form in small blood vessels and leads to a low platelet count), eschar on the left ankle without purulence (the condition of containing or forming pus) appreciated (not found on exam). The GACH H&P also indicated, plan included a vascular (relating to blood vessels) surgery consult and for Resident 1 to start on a blood thinning medication for prophylaxis (ppx; action taken to prevent disease). During a review of Resident 1's GACH Consultation Note dated 1/16/24 at 7:55 PM, the GACH Consultation Note indicated Resident 1's right ankle and left foot were found to have acute signs of localized infection of hematoma which required the sites to undergo an incision and drainage (I&D) for the evacuation of the hematoma. After the I&D of both the infected hematomas, undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) approximately three centimeters circumferentially were noted. During a review of the facility's policy and procedure titled, Resident Safety Plan, revised 07/2010, the Resident Safety Plan indicated its purpose, to improve the health and safety of residents and reduce preventable safety occurrences.