Every finding on record at Weslaco Nursing and Rehabilitation Center

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 16 (Resident #39, # 84, #94, #45, #7, and #61) residents reviewed for infection control, 1. The facility failed to ensure that an Enhanced Barrier Precaution (EBP) sign was displayed outside the room of Resident #39. 2. The facility failed to ensure that CMA J performed hand hygiene for at least 20 seconds after medication administration for Resident #84. 3. The facility failed to ensure CNA K performed hand hygiene while assisting Resident #94 and Resident #45 with their lunch on 7/26/26. 4. The facility failed to ensure Resident #7's IV dressing was clean and clearly labeled on 7/27/26. 5. The facility failed to ensure CNA G and CNA H performed proper hand hygiene and proper incontinent care for Resident #61. These failures could place residents at risk for healthcare associated cross-contamination and the spread of infection. 1.Record review of Resident #39's face sheet, dated 07/28/2026, reflected a [AGE] year-old male readmitted on [DATE] with an original admission date of 03/01/2025. His pertinent diagnoses included Stage II Pressure Ulcer (open wound also called a bedsore) and Type 2 Diabetes Mellitus (high blood sugar levels). Record review of Resident #39's comprehensive MDS assessment, dated 05/26/2026, revealed a BIMS score of 09, indicating moderate impaired cognition. Record review of Resident #39's care plan not dated, reflected a stage II pressure ulcer to left sacral area (the lower back and the tailbone). Interventions were to follow wound care orders as directed. Monitor area for signs and symptoms of infection and notify MD. There was no care plan implemented to place resident on enhanced based precautions. Record review of Resident #39's Physician's Order Summary dated 07/26/2026 reflected Silvadene External Cream 1% apply to Left Sacral area topically every day shift for Stage II Pressure Ulcer, Apply to sacrum topically every day shift for Stage 2 pressure wound cleanse with wound cleanser spray pat dry with gauze, then apply Silvadene cream to wound bed followed by adaptic gauze, cover with dry dressing and secure with medfix retention tape start date 07/19/2026. There was no EBP order. Observation on 07/26/2026 at 2:55 p.m. revealed there was no EBP sign displayed outside Resident #39's room. During an interview on 07/26/2026 at 3:25 p.m. LVN L stated that she was Resident #39's nurse. She stated that residents requiring an EBP sign were identified if they have a wound, an indwelling catheter, and other open areas. She stated that the floor nurses were responsible for posting the EBP sign immediately once the need for EBP was identified. LVN L stated that it was important to have the EBP signs posted to alert all staff that the residents had an invasive device or an open wound requiring EBP. She stated Resident #39 had a new pressure ulcer wound in the sacral area. LVN L confirmed there was no EBP sign outside Resident #39's room. She stated that the negative outcome was the spread of infection. During an interview on 07/28/2026 at 2:12 p.m., ADON M, stated residents requiring an EBP sign were identified if they have a G-tube, an indwelling catheter, IV access, a midline catheter (a long, flexible IV tube put into a large vein in the upper arm) or a surgical incision. She stated Resident #39 should have a sign posted on the door. ADON M stated the purpose of the sign was to alert staff to wear the appropriate PPE when providing care or engaging in high resident care activities. ADON M stated any staff member could post the EBP sign but ultimately it was the nursing staff who received the order or in this case identified the wound. She stated that the appropriate PPE for EBP included gloves and a gown. ADON M stated the negative outcome of not having the EBP sign posted was that the spread of infection could be transmitted to the resident from another resident. During an interview on 07/28/2026 at 2:34 p.m., the DON stated that anyone could place the EBP sign on the door, but the responsibility ultimately rested with the nurse who received the order. She stated Resident #39 should have a sign posted on the door because he has a wound. The DON stated that the sign at the door alerts staff to gown up when providing care or taking an extensive amount of time at bedside. She stated that the negative outcome of failing to post the EBP sign was the spread of infection. 2.Record review of Resident #84's face sheet, dated 07/28/2026, reflected an [AGE] year-old female admitted on [DATE] with an original admission date of 02/02/2018. Her pertinent diagnoses included Type 2 Diabetes Mellitus (high blood sugar levels), Chronic Kidney Disease (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood), and Chronic Congestive Heart Failure (the heart muscle is too weak or stiff to pump blood well). Record review of Resident #84's quarterly MDS assessment, dated 06/09/2026, revealed a BIMS score of 15, indicating intact cognition. Section GG (functional abilities) indicated Resident #84 needed partial/moderate assistance with upper/lower body dressing, personal hygiene, and toileting hygiene. Record review of Resident #84's care plan not dated, reflected resident had Diabetes Mellitus. Goal: The resident would have no complications related to diabetes. Interventions were monitor/document/report as needed any symptoms of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). During an observation of medication administration on 07/27/2026 at 7:51 a.m., MA J performed hand hygiene for 11 seconds prior to Resident #84's medication administration. After medication administration, MA J performed hand hygiene for 9 seconds. During an interview on 07/27/2026 at 8:09 a.m., MA J stated that handwashing should be done for at least 20 seconds. MA J stated that it was important to properly wash the hands to prevent the spread of infections. She stated that an in-service for infection control was done last month. During an interview on 07/28/2026 at 2:12 p.m., ADON M stated the process for handwashing was to wash hands for at least 20 seconds. She stated that they frequently conduct in-services on proper handwashing. ADON M stated that it was important for staff to have washed their hands properly because it prevented the spread of infection. She stated that she monitored staff to ensure they were following infection control procedures by conducting random skill check offs to assess proper handwashing. During an interview on 07/28/2026 at 2:30 p.m., ADON/IP stated that she was the infection preventionist. She stated staff should have washed their hands for a minimum of 20 seconds. She stated she instructed them to wash for 30 seconds to be on the safe side. ADON/IP stated staff should have washed their hands as often as possible, including before and after medication administration, before and after resident contact, before and after handling food items, and whenever their hands were visibly soiled. ADON/IP stated the negative outcome of not properly washing hands would be the transmission of infection and contamination. During an interview on 07/28/2026 at 2:34 p.m., the DON stated staff should have washed their hands for 20-30 seconds, but for no less than 20 seconds. She stated they have monthly in services on hand hygiene and additional in services as needed. The DON stated it was important to wash hands thoroughly because it kept everyone safe. The DON stated the negative outcome of failing to properly wash hands would be cross contamination. She stated the staff were monitored through annual skill check offs. 3. Record review of Resident #94's face sheet, dated 7/27/2026, reflected an [AGE] year-old female with an admission date of 8/5/15. Her relevant diagnoses included Parkinsonism (group of brain conditions that cause core movement problems like shaking, muscle stiffness, and slowed motion), unspecified dementia (decline in memory and thinking skills that interferes with daily life, but underlying disease causing it has not yet been determined by doctors), and muscle wasting and atrophy (shrinking, thinning, and weakening of muscles caused by a lack of use, aging, or nerve damage). Record review of Resident #94's quarterly MDS assessment, dated 6/8/26, reflected a BIMS score left blank, which indicated the interview was not attempted. Section GG (functional abilities) indicated Resident #94 needed substantial/maximal assistance with eating. Section K (swallowing/nutritional status) indicated Resident #94 had a mechanically altered diet. Record review of Resident #94's care plan, date revised 6/11/26, indicated Resident #94 has an ADL self-care performance deficit r/t cognitive deficits and overall unsteadiness. Interventions: The resident requires substantial/maximal assistance for eating. Record review of Resident #45's face sheet, dated 7/27/26, reflected a [AGE] year-old female with an admission date of 2/24/26. Her relevant diagnoses included cerebral palsy (lifelong physical condition that affects movement, balance, and muscle control due to an early brain injury or unusual brain development), dysphagia (difficulty swallowing), and muscle wasting and atrophy (shrinking, thinning, and weakening of muscles caused by a lack of use, aging, or nerve damage). Record review of Resident #45's quarterly MDS assessment, dated 5/11/26, reflected a BIMS score of 9, which indicated moderate cognitive impairment. Section GG (functional abilities) indicated Resident #45 needed substantial/maximal assistance with eating. Section K (swallowing/nutritional status) indicated Resident #45 had a mechanically altered diet. Resident #45's care plan, date revised 2/27/26, indicated Resident #45 had an ADL self-care performance deficit r/t weakness, limited ROM, impaired balance/coordination. Interventions: The resident requires tray set up and total staff assist x 1 to assist with meals. During an observation on 07/26/26 12:38 p.m., CNA K was assisting two residents with their meals. CNA K was using her right hand to assist Resident #95 and Resident #45 and not performing hand hygiene in between feedings. During an interview on 7/26/26 at 12:52 p.m., LVN C said she oversaw dining for this week beginning Sunday (7/26/26) through Saturday (8/1/26). She said she supervised choking episodes or residents that were not eating and monitored for safety. She said she monitored CNAs aiding residents that needed assistance with their meals. LVN C said she monitored CNAs to ensure the residents were not being rushed and that CNAs were feeding residents one at a time. She said there could be a problem with infection control when assisting two residents at the same time without performing hand hygiene in between. She said her last in-service on infection control was last week. During an interview on 7/26/26 at 1:07 p.m., CNA K said she had her hand sanitizer in her pocket and was unaware she had not performed hand hygiene between feeding Resident #95 and Resident #45. She said the possibility of cross contamination between residents could have happened by not having performed hand hygiene. She said her last in-service on infection control was two weeks ago. CNA K said she was employed for 7 years and knew she had to perform hand hygiene when assisting two residents at the same time with their meals. During an interview on 7/27/26 at 4:06 p.m., the ADON/IP said she had told the CNAs to assist residents with their meals, one at a time. She said feeding a resident one at a time would reduce the risk of infection. The ADON/IP said she performed an in-service on infection control and hand hygiene on 7/26/26. During an interview on 7/28/26 at 1:55 p.m., the DON said she was aware of not feeding multiple residents at one time. She said if staff were feeding more than one resident, they had to perform hand hygiene between feeding the residents. The DON said CNA K had her hand sanitizer on her person but had forgotten to perform hand hygiene. She said CNA K knew she was supposed to perform hand hygiene when assisting more than one resident with their meals. The DON said hand hygiene was performed during mealtimes to prevent cross contamination. She said the last in-service on infection control and dining practices was in May 2026. 4. Record review of Resident #7's face sheet, dated 7/27/26, reflected an [AGE] year-old female with an admission date of 7/06/26. Her diagnoses included unspecified dementia (loss of memory, thinking, and reasoning skills that gets in the way of daily living), diabetes mellitus type 2 (condition where the body has too much sugar in the blood because it cannot use insulin properly or make enough of it to turn that sugar into energy), and venous insufficiency [chronic] [peripheral] (condition where the veins in the lower legs have trouble pumping blood back to the heart causing blood to pool in the lower legs and ankles).Record review of Resident #7's quarterly MDS assessment, dated 7/8/26, reflected a BIMS score of 13, which indicated cognitively intact. Section O (special treatments, procedures, and programs) indicated Resident #7 had IV medication while a resident. Record review of Resident #7's care plan, revised date 7/7/26, reflected Resident #7 has the need for Enhanced Barrier Precautions due to PIV/surgical wound/pressure ulcer is at risk for infection depression, and decline in physical activity. Interventions: Assess for signs and symptoms of infection such as increased white blood count, fever, redness, swelling. Asses the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, catheters). Record review of Resident #7's MAR, dated 7/27/26, reflected orders for ceftriaxone use 1 gram intravenously at bedtime for UTI until 7/13/2026. Start date: 7/6/26. Flush peripheral IV line (pushing a safe, clear saltwater liquid through the small plastic tube in the arm to clean it out and keep it from getting blocked) with 10 ML of NS before and after each medication administered every shift for IV patency (IV line is open clear and working correctly so that fluids and medicine can flow smoothly into the vein without any blockages). Start date: 7/06/26. D/C date: 7/16/26. Flush peripheral IV line with 10 ML of NS every shift for IV patency maintenance. Start date: 7/06/26. D/C date: 7/16/26. Monitor peripheral IV site for redness, tenderness, edema, excessive bleeding and any other abnormalities. Notify MD as needed every shift. Start date: 7/6/26. D/c date: 7/16/26. Change peripheral IV site and dressing as needed for infiltration (fluid or medication from an IV accidentally leaks into the tissue under the skin instead of flowing directly into the vein). Start date: 7/6/26. D/C date: 7/16/26. During an interview on 7/27/26 at 11:37 p.m., LVN I said he did not know the last time Resident #7's IV dressing was last changed. He said he could not read the date labeled on Resident #7's IV dressing. LVN I said not having a dressing clearly labeled could have caused a risk of infiltration and an infection to the IV site. He said he received an in-service by the ADON/IP in July 2026 on infection and control and IV medication. During an interview on 7/27/26 at 3:30 p.m., the DON said Resident #7's IV dressing was not legible and that it was the nurse's responsibility to monitor the resident's IV sites. She said the negative outcomes for Resident #7's IV site not being clearly labeled were increased risk of infection and loss of IV patency. The DON said she performed in-services on IV medication and medication administration monthly. During an interview on 7/27/26 at 4:06 p.m., the ADON/IP said she reviewed physician orders to see which residents were on antibiotic therapy and followed up to check the residents' IV sites. She said not having a legible date labeled on Resident #7's IV dressing could increase the risk of infection for the resident, and nurses would not know when it was last changed. The ADON/IP said IV sites were checked frequently, and all staff should have placed eyes on IV sites. She said the last infection control in-service she performed was on 7/26/26. 5.Record review of Resident #61's electronic face sheet dated 7/27/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and an original admission date of 12/6/24 with diagnoses to include: Alzheimer's (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), dementia (loss of cognitive functioning, such as thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), and muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). Record review of Resident #61's undated comprehensive person-centered care plan reflected Resident #61 had an ADL self-care performance deficit r/t HX of RT femur fx, cognitive deficits, and overall weakness Date Initiated: 12/09/2024 Revision on: 03/24/2025. PERSONAL HYGIENE: The resident requires extensive staff assist x 2 withpersonal hygiene and oral care. Date Initiated: 12/09/2024 Revision on: 06/04/2026. TOILET USE: The resident requires total staff assist x 2 with toileting/incontinent care routinely and PRN Date Initiated: 12/09/2024 Revision on: 06/04/2026 Record review of Resident #61's Quarterly MDS Assessment, dated 5/15/26, reflected Resident #61 had a BIMS of 02 which indicated a severe impairment of mental status. Resident #61 was dependent on self-care for toileting hygiene. During an incontinent care observation on 7/27/26 at 3:00 p.m., CNA G and CNA H performed incontinent care on Resident #61. CNA G grabbed a wipe, cleaned the urinary catheter tubing, and reused the same wipe, wiping up and down the urinary catheter two separate times. CNA G removed her gloves, sanitized her hands, and applied clean gloves. CNA G grabbed a wipe, cleaned the vaginal area, and reused the same wipe three separate times. CNA G removed her gloves, did not sanitize her hands, and applied clean gloves. CNA G grabbed a wipe, cleaned the buttocks area, and reused the same wipe three separate times. CNA G removed her gloves, did not sanitize her hands, and applied clean gloves. CNA H changed her gloves three times during incontinent care. She did not sanitize her hands between the last two glove changes. In an interview on 7/27/26 at 3:27 pm, CNA G said she received training for incontinent care and infection control and was checked off on her skills upon hire and annually. CNA G said she was supposed to wipe using a wipe only once then throw the wipe after using. CNA G said she reused the wipe because she was having difficulty removing the cream the resident had in her vaginal area and because she was nervous. CNA G said for the buttocks she accidentally reused the same wipe when trying to remove the BM from the resident's buttocks. CNA G said she should hand sanitize between glove changes. CNA G said maybe she was nervous when changing gloves so she could not recall if she did not use hand sanitizer. CNA G said it could cause contamination if she did not use hand sanitizer between glove changes or reused wipes. In an interview on 7/27/26 at 3:40 p.m., CNA H said the facility provided in-services on infection control and incontinent care about every 3 months. CNA H said when using wipes, she would use one wipe for each labia and one wipe in the center, disposing of each wipe after each use, using one wipe per swipe. CNA H said when she changed gloves, she should use sanitizer between glove changes. CNA H said she used hand sanitizer when she grabbed gloves on the other side of the bed, but when CNA G passed her gloves on two different occasions after that, she said she did not come around to the other side of the bed to get hand sanitizer and did not sanitize her hands at those times. CNA H said if she did not hand sanitize between glove changes, infection control could be compromised. In an interview on 7/28/26 at 7:00 p.m., the DON said incontinent care check-offs were done yearly. The DON said with newer staff it would be done a little more frequently until staff were comfortable with providing appropriate incontinent care. The DON said she also did incontinent care training and check-offs as needed as well as spot checks. The DON said CNAs must sanitize hands between glove changes using hand sanitizer. The DON said that was part of the check-off they did. The DON said wipes were used as one and done, swiped from front to back and not reuse a wipe and staff knew this. The DON said if hands were not sanitized between glove changes and wipes were reused, it could introduce bacteria and cause a UTI unnecessarily and unintentionally. Record review of the facility's policy titled Infection Prevention and Control Program, dated 5/13/23, stated Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Record review of the facility's Enhanced Barrier Precautions policy dated 4/5/24 reflected, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers). 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the residents room. 4. High contact resident care activities include: h. Wound care: any skin opening requiring a dressing. Record review of the facility's Medication Administration policy dated 10/24/22 reflected, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medication per facility protocol and product. Record review of the facility's Hand Hygiene policy dated 10/22/24 reflected, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations withing facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the Incontinent Care Skills Checklist for CNA G dated 2/13/26 and 7/27/26 indicated she was checked off as skills met on the following: Miscellaneous7 Remove gloves, sanitize hands and apply new gloves.Female Perineal Care .2. Wipe, across the base of the abdomen (just above the pubic area), going from one side to the other in one direction. Use new wipe or washcloth if wiping more than once. 3 Staring with the top/center of the vaginal area wipe from front towards rectum, front to back, using clean stroke. Never wipe back and forth from the back to the top. Using additional wipes or cloths as needed. 4 Separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back. 5 Wipe labia majora and skin folds. Use one stroke method to clean front to back. 6 Cleanse the inside of the first groin area downward from top to bottom, then get a new wipe or cloth and cleanse the other groin area.7 If catheter is present, gently wipe the catheter tubing with new wipe or cloth from the meatus outward for at least 4 inches of tubing.9 Wipe from vagina toward rectum with one stroke, front to back, repeat if necessary with a new wipe or cloth as all feces must be cleaned off. Record review of the Incontinent Care Skills Checklist for CNA H dated 2/13/26 and 7/27/26 indicated she was checked off as skills met on the following: Miscellaneous7 Remove gloves, sanitize hands and apply new gloves.Female Perineal Care .2. Wipe, across the base of the abdomen (just above the pubic area), going from one side to the other in one direction. Use new wipe or washcloth if wiping more than once. 3 Staring with the top/center of the vaginal area wipe from front towards rectum, front to back, using clean stroke. Never wipe back and forth from the back to the top. Using additional wipes or cloths as needed. 4 Separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back. 5 Wipe labia majora and skin folds. Use one stroke method to clean front to back. 6 Cleanse the inside of the first groin area downward from top to bottom, then get a new wipe or cloth and cleanse the other groin area.7 If catheter is present, gently wipe the catheter tubing with new wipe or cloth from the meatus outward for at least 4 inches of tubing.9 Wipe from vagina toward rectum with one stroke, front to back, repeat if necessary with a new wipe or cloth as all feces must be cleaned off. Record review of the facility's Hand Hygiene policy dated 10/22/24 reflected, Policy:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations withing facility.Definitions:Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR).Policy Explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of facility's Perineal Care policy dated 10/24/22 reflected,Policy:It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.Policy Explanation and Compliance Guidelines: .9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard:a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes.10. Re-position resident in supine positions. Change gloves if soiled and continue with perineal care.11. Females: .c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).d. Repeat on opposite side using separate section of washcloth or new disposable wipe. e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or a new disposable wipe with each stroke.16. Remove gloves and discard. Perform hand hygiene.

Based on observation, interviews, and record reviews, the facility failed to ensure the resident's right to personal personal medical records and to personal privacy during medical treatment for 4 (unknown resident, Residents #20, #111, and #84) of 8 residents reviewed for Privacy. 1.The facility failed to ensure the privacy of the unknown resident by not locking the computer screen on a medication cart, leaving the resident's personal and medical information exposed. 2. The facility failed to ensure MA J closed the door, the privacy curtain and the window during medication administration for Residents #20, #111, and #84 on 07/27/2026. These failures could place residents at risk of resident-identifiable information being accessed by unauthorized persons and of not having their personal privacy maintained during medical treatment. Findings included: 1. Observation and interview on 07/27/26 at 9:48 AM, revealed a computer screen on a medication cart in the 400 hallway was left unlocked. The screen displayed the unknown resident's medication information on the screen. Noted on the screen was unknown resident's photo, date of birth , and a medication log. The surveyor called LVN A, who was nearby and asked who the medication cart belonged to. LVN A informed the surveyor that it belonged to LVN C who was in a room providing care to a resident. LVN A quickly locked the screen and proceeded to locate LVN C. In an interview on 07/27/26 at 9:53 PM, LVN C stated she was called to assist a resident while she was at her computer. LVN C stated that she pressed the lock button on the screen and assumed the screen had locked. LVN C stated she walked away from her computer without verifying the screen had locked. LVN C stated it was important to lock the computer screen when not in use because the screen displayed unknown resident's private personal and medical information. LVN C stated exposing private personal and medical information was a HIPAA (a law that protects patient medical privacy) violation. LVN C stated she was aware not to leave any resident information exposed but had just failed to do it this time. In an interview on 07/28/2026 at 2:20 PM, the DON stated LVN stated there were a lot of things going on and LVN C did not verify that the computer screen was locked. The DON stated LVN C stated to her that she was in a hurry and had stepped away from the computer for just a moment. The DON stated staff had been in-serviced (teaching) frequently on HIPAA. The DON stated that it was important for the computer screen to be locked because it contained protective information, and it was not anyone's business what was on the screen. In an interview on 07/28/26 at 4:32 PM, the Administrator stated LVN C was a senior employee but might have gone too fast and did not verify the screen was indeed locked. The Administrator stated all staff were in-serviced on HIPAA several times throughout the year, such as upon hire, monthly in-services and as needed. The Administrator stated it was important to verify that computer screens were locked because computers contained resident information which could be seen by unauthorized people. The Administrator stated there was not a policy specifically for locking computer screens, but HIPAA regulations were enforced. 2. During an observation on 07/27/2026 at 7:32 a.m., MA J kept the door and the privacy curtain open while administering Resident #20's medications, including eye drops, while his roommate was seated between the two beds. During an observation on 07/27/2026 at 7:40 a.m., MA J kept the door and the privacy curtain open while checking Resident #111's blood pressure. She then proceeded to administer her medications including eye drops. During Resident #111 medication administration, several people walked past the room and looked inside. During an observation on 07/27/2026 at 7:51 a.m., MA J kept the door, the privacy curtain, and the window open while checking Resident #84's blood pressure. She then proceeded to administer her medications. In an interview on 07/27/2026 at 8:09 a.m., MA J stated that she was supposed to close the door, the privacy curtain, and window before checking blood pressures and administering medications. She stated that she forgot to do it. MA J stated that it was important because residents should not have to take their medications with other people watching. MA J stated that closing the door, the curtain, and the window was important to provide the residents with privacy during medication administration. During an interview on 07/28/2026 at 2:12 p.m., ADON M stated that staff should provide privacy while providing care and during medication administration. She stated that the staff had been trained quarterly and as needed. She stated that she conducts medication administration skill checkoffs. ADON M stated that during medication administration, staff should take patients to their room, close the door, pull the privacy curtain, and close the blinds to provide privacy. ADON M stated that these measures were important to provide the residents with dignity and privacy. During an interview on 07/28/2026 at 2:34 p.m., the DON stated that staff were expected to provide privacy while assisting with ADL care, performing invasive procedures, providing wound care, completing bed baths, and administering medications. She stated that staff were trained quarterly and as needed. The DON stated that it was important for staff to provide privacy because it was the residents right and preserved their dignity. Record review of the Facility's Manual revised on 07/14/2020 revealed, Statement of Resident Rights You have a right to: (8) have facility information about you maintained as confidential Our Responsibilities In addition to providing you your rights, as detailed above, the federal privacy standard requires us to: Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information. Record review of the Facility's Manual revised on 07/14/2020 revealed, Statement of Resident Rights You have a right to: (8) have facility information about you maintained as confidential Our Responsibilities In addition to providing you your rights, as detailed above, the federal privacy standard requires us to: Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information. Record review of the facility's Medication Administration policy dated 10/24/22 reflected, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 7. Provide privacy.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #7) of six residents reviewed for intravenous fluids. The facility failed to ensure physician orders were written for IV flush (rinsing an intravenous tube with sterile salt water to keep the line clean, clear, and free of blockages) on 7/16/2026 to 7/27/2026. This failure could place residents at risk for infection, catheter occlusion (blockage), and chemical vessel irritation (inflammation of a vein caused when a harsh medication or fluid passing through an IV irritates the lining of the blood vessel).Record review of Resident #7's face sheet, dated 7/27/26, reflected an [AGE] year-old female with an admission date of 7/06/26. Her diagnoses included unspecified dementia (loss of memory, thinking, and reasoning skills that gets in the way of daily living), diabetes mellitus type 2 (condition where the body has too much sugar in the blood because it cannot use insulin properly or make enough of it to turn that sugar into energy), and venous insufficiency [chronic] [peripheral] (condition where the veins in the lower legs have trouble pumping blood back to the heart causing blood to pool in the lower legs and ankles). Record review of Resident #7's quarterly MDS assessment, dated 7/8/26, reflected a BIMS score of 13, which indicated cognitively intact. Section O (special treatments, procedures, and programs) indicated Resident #7 had IV medication while a resident. Record review of Resident #7's care plan, revised date 7/7/26, reflected Resident #7 has the need for Enhanced Barrier Precautions due to PIV/surgical wound/pressure ulcer and is at risk for infection depression, and decline in physical activity. Interventions: Assess for signs and symptoms of infection such as increased white blood count, fever, redness, swelling. Asses the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, catheters). Record review of Resident #7's MAR, dated 7/27/26, reflected orders for ceftriaxone (a prescription-only antibiotic medicine) use 1 gram intravenously at bedtime for UTI until 7/13/2026. Start date: 7/6/26. Flush peripheral IV line (pushing a sterile salt-and-water solution through the IV tube in the arm to keep it clear and working properly) with 10 ML of NS before and after each medication administered every shift for IV patency (being open and unblocked). Start date: 7/06/26. D/C date: 7/16/26. Flush peripheral IV line with 10 ML of NS every shift for IV patency maintenance. Start date:7/06/26. D/C date: 7/16/26. Record review of Resident #7's order summary, dated 7/27/2026, reflected there were no orders to flush the IV catheter.During an observation and interview on 7/27/2026 at 10:04 a.m., Resident #7 was sitting up in her wheelchair with an IV catheter (a tiny, flexible plastic tube placed inside a vein to deliver fluids or medicine directly into the bloodstream) to her right hand. There was no redness and no swelling to the IV site. Resident #7 did not complain of pain or discomfort to the area. During an interview on 7/27/26 at 11:37 a.m., LVN I said there was no order to discontinue the IV catheter and there were no current orders for IV flushes. He said he did not flush the resident's IV catheter on 7/27/26 because there were no physician orders. He said the order to discontinue IV flushes was on 7/16/26. He said the resident received IV hydration on 7/18/26. LVN I said the negative outcomes for Resident #7 not having an order for IV flushes were infection to the IV site and IV infiltration (fluid or medicine from the IV line leaks out of the vein into the soft tissue under the skin). He said he received an in-service on IV medication in July 2026 from the ADON/IP. During an interview on 7/27/2026 at 3:30 p.m., the DON verified that the order for IV flushes were discontinued on 7/16/26 and the IV should have been discontinued at the same time. She said the floor nurses were responsible for ensuring physician orders were received to maintain IV patency. She said during the morning meeting she and the nurses discussed resident care and reviewed residents on IVs. She said an in-service on IV medication was given but could not remember the date. The DON said in-services on medication administration were given monthly. She said a negative outcome for Resident #7 from not having her IV flushed included loss of IV patency and infection to the IV site.Record review of facility policy, dated 10/01/19, titled Parenteral Administration, stated, Policy: To provide for the safe and accurate reconstitution of parenteral medication prior to administration, manufacturer information is reviewed and aseptic technique is observed.9. Administer medication or add to intravenous (IV) solution as directed and complete documentation.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #133) residents reviewed for respiratory care. The facility failed to ensure Resident #133's oxygen was administered on 07/26/26 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident # 133's admission record dated 07/26/26 revealed a [AGE] year-old female with an admission date of 07/22/24. The diagnoses for Resident #133 included: combined congestive heart failure (when the heart muscle both weakens (failing to pump properly) and stiffens (failing to relax and fill adequately)), acute (it can happen very fast) and chronic (build up slowly over a long period of time) respiratory failure (not enough oxygen passes from your lungs to your blood), dyspnea (shortness of breath), and essential hypertension (high blood pressure). Record review of Resident #133's admission BIMS assessment dated [DATE] revealed resident had a score of 15 which indicated resident was cognitively intact. Record review of Resident #133's admission MDS dated [DATE] revealed MDS was still in progress therefore not completed at the time of the record review. Record review of Resident #133's admission Care Plan dated 07/23/26 revealed Problem: [Resident #133] has oxygen therapy r/t respiratory failure. Interventions: OXYGEN SETTINGS O2 via nasal cannula (a thin plastic tube with two short prongs that delivers supplemental oxygen directly into the nostrils) as ordered per MD Date Initiated: 07/23/2026. Record review of Resident #133's active Physicians Order Summary Report dated 07/26/26, revealed an order dated 07/23/26 for Oxygen at 2 LPM via NC every shift for hypoxia (low levels of oxygen in your body tissues) related to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (having too much carbon dioxide in the blood). During an observation and interview of Resident #133 on 07/26/26 at 2:56 pm, revealed resident was on oxygen therapy. Resident #133 had a nasal cannula (a thin plastic tube with two short prongs that deliver supplemental oxygen directly into the nostrils). The oxygen concentrator machine (a medical device that filters ambient air to deliver oxygen) was at the level of 2.5 LPM. Resident #133 was in bed, with the head of the bed elevated. No signs of respiratory distress were noted. Resident #133 stated she had to be on oxygen therapy all the time; if she did not have oxygen, she would be short of breath. Resident #133 stated she knew the oxygen level had to be on 2 LPM. Resident #133 stated the nurses managed her oxygen therapy. Resident #133 stated she was not able to reach the concentrator. During an observation and interview on 07/26/26 at 3:17 pm, LVN B stated Resident #133 had an order for oxygen at 2 LPM. LVN B observed Resident #133's oxygen concentrator machine and stated that the current reading was just a little above the ordered setting. LVN B stated he checked on Resident #133 every 2-3 hours in which he also checked the setting of the oxygen concentrator. LVN B stated the last time he had checked on Resident #133 was around 12:00 pm and the oxygen setting was at 2 LPM. LVN B stated he did not know how the oxygen setting was moved but stated it could have been caused by the vibration of the oxygen concentrator itself. LVN B stated it was important to check the oxygen setting to make sure Resident #133 was getting the accurate amount of oxygen. LVN B stated that if Resident #133 did not receive the correct amount of oxygen, she would get hypoxia and go into respiratory distress. In an interview on 07/28/2026 at 2:20 pm, the DON stated the charge nurse was in charge of checking the oxygen settings. The DON stated LVN B checked on Resident #133 right after the observation and resident was satting (amount of oxygen being carried in the red blood cells) at 99% (representing optimal blood-oxygen levels between 95% and 100%). The DON stated it was important to check Resident #133 to ensure she was getting the correct oxygen amount. The DON stated that the facility did not have a policy regarding oxygen settings. In an interview on 07/28/26 at 4:32 pm, the Administrator stated that all the halls are rounded (walk throughs to check on the wellbeing of residents) frequently. The administrator stated that all staff had been in-serviced (teaching) on how to read the oxygen flow meter (device used to measure and adjust the flow rate of oxygen) on the oxygen concentrator. The Administrator stated that all oxygen concentrators have been serviced as a preventive measure to ensure all oxygen concentrators were working properly.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. On 07/26/26, the facility failed to ensure drink items in the refrigerator were labeled and dated. On 07/26/26, the facility failed to ensure a drink item in the refrigerator was covered and sealed to prevent exposure to air and cause cross contamination. These failures placed all residents who had drinks served by the kitchen at risk for food-borne illness. Findings included: Observation of the refrigerator on 07/26/26 at 10:15 AM revealed 3 juice pitchers not labeled or dated when made. One of the juice pitchers did not have a lid on it. In an interview on 07/26/26 at 10:17 AM, the [NAME] stated she did not know why the food items had not been labeled. The [NAME] stated it was important to label the juice pitchers because of the 1st in 1st out rule (a system that rotates food so that the oldest items are used first). The [NAME] stated that if the rule was not used, food that was not used could expire. The [NAME] stated if expired food was served to residents, they could get sick or get food poisoning. The [NAME] stated that it was important for items to be covered to prevent things from falling inside the container that could cause residents to get sick. In an interview on 07/27/26 at 9:45 AM, the DM stated it was the responsibility of the person that made the food or drink, to label it. The DM stated it was important for every food item to have a label because items could expire and if served to the residents, the residents would become sick. In an interview on 07/28/26 at 2:20pm, the DON stated that the DM was in charge of overseeing the kitchen therefore she did not get involved in the finding. The DON did not have further comments. In an interview on 07/28/26 at 4:32pm, the Administrator stated that as a dietitian, she had no concern with the pitchers of juice not being labeled or covered. The Administrator stated that as long as the pitchers were used for immediate service, she did not worry about it. Record review of the Food Storage Policy with a revised date of 06/01/19 revealed the following: 2. Refrigerators a. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for 1 (hall 300 med aide cart) of 4 medication carts reviewed for storage and labeling. The facility failed to ensure three boxes of eye drops were labeled with an open date on 7/26/26 at 2:10 p.m This failure could place residents at risk for adverse effects and not having received the therapeutic effects of the medication or treatment. Findings included: During an observation on 7/26/26 at 2:10 p.m. of the Hall 300 med aide medication cart, with CMA J, revealed there were two boxes of Brimonidine (used to treat elevated pressure in the eye) eye drops and one box of fluorometholone (steroid used to treat swelling redness and itching of the eye) eye dops that were not labeled with an open date. During an interview on 7/26/26 at 2:20 p.m., CMA J said medication aides labeled eye drops with an open date when they were first opened. She said the ADON and the pharmacy consultant checked eye drops to ensure they were labeled with an open date. She said it was the medication aide's responsibility to check and ensure eye drops were labeled. She said the eye drops expired 30 days after the day they were opened. CMA J said she would not know when the medication expired without the open date written on the eye drops. She said the last in-service she received was in June 2026 on medication administration. During an interview on 7/28/2026 at 2:15 p.m., the DON said they label OTC medications with an open date as well as insulin and eye drops. She said the charge nurses and the medication aides were responsible for checking and ensuring eye drops were labeled. She said she and the ADONs performed spot checks and checked for expired medication, medication labeled with an open date, checked for loose pills, and pulled out medication from the medication carts that were discontinued. She said it was important to know when eye drops were opened because then the nurse would know the life expectancy of the medication and when to discard the medication. The DON said in-services on medication administration were done every quarter and as needed. Record review of the facility policy titled, Expiration Dating and Expired Medication, dated 10/01/19, stated . 8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per facility policy. 9. A continuous monitoring system will be designated by the Director of Nursing to identify expired medications and remove the from the medication system.

Based on interview and record review, the facility failed to have services provided by qualified persons in accordance with each resident's written plan of care for 1 of 1 resident (Resident #26) reviewed for care plan in that: CNA D administered liquid cough medication to Resident #26 on 7/23/26, which was not in her scope of practice. This failure could place residents who received medication at risk for improper care. Findings included: Record review of Resident #26's face sheet, dated 7/28/26, reflected a [AGE] year-old male with an admission date of 11/14/26. His relevant diagnoses included dysphagia (difficulty swallowing), paraplegia (loss of movement and sensation in the lower half of the body), and fibromyalgia (long-term medical condition causing widespread body pain, extreme tiredness, and sleep problems). Record review of Resident #26's quarterly MDS assessment, dated 6/30/26, reflected a BIMS score of 15, which indicated intact cognition. Section GG (functional limitation in range of motion) indicated the resident had impairment on both sides to his lower and upper extremities (arms, legs, hands, and feet). Record review of Resident # 26's care plan, date revised on 12/31/25, reflected Resident #26 has c/o cough at times, PRN medication in place to treat. Interventions: Administer medication as ordered. Record review of Resident #26's physician orders, dated 7/27/26, reflected orders for guaifenesin oral liquid 200 MG/10 ML give 10 ML by mouth every 4 hours as needed for cough. Order date: 3/18/25. During an interview on 07/27/26 at 10:28 a.m., Resident #26 said CNA D had given him cough medicine last week. He said the nurse was supposed to bring it to him. Instead, the medication was brought by the CNA. During an interview on 7/27/26 at 1:34 p.m., CNA D said Resident #26 had told her that he wanted his cough medicine. She said she informed RN E that Resident #26 wanted his cough medicine. CNA D said she had told RN E that if he wanted, she could give the resident the medicine. She said RN E was supervising her as he stood by the resident's door. CNA D said CNAs were not authorized to give medication and that it was her error by giving it. She said the medication was in liquid form and was for his cough. CNA D said she gave him the medicine about one week ago but was not sure of the exact date. She said a negative outcome for the resident from her giving him the cough medicine was that he could have spilled it, or the resident could have had difficulty swallowing it. She said the last in-service she had was last week on ANE. During an interview on 7/28/26 at 1:55 p.m., the DON said she was informed by Resident #26 that CNA D had given him cough medicine. She said the resident filed a grievance, and she followed up with CNA D and RN E. She said she counseled both employees and provided further education and in-services on medication administration for RN E. During an interview on 7/28/26 at 2:46 p.m., RN E said Resident #26 was angry at him and had asked him for cough medicine. He said he poured the medication in a cup as ordered and handed the cup to CNA D while he stood at the resident's doorway to ensure safety. He said CNA D and Resident #26 were within his sight. He said the DON had given him an extensive lecture about medication administration and had an in-service on the five rights of medication administration. RN E said there was no negative outcome for Resident #26 from having the CNA administer the cough medicine. Record review of complaint/grievance follow-up report, dated 7/23/2026, indicated a grievance filled by Resident #26 regarding medication given by the CNA. The resolution to the grievance indicated there were no negative outcomes for Resident #26. Record review of facility policy titled Medication Administration, dated 10/24/22, stated, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Record review of CNA job description, undated, stated, Essential functions: Assist resident in customary daily requirements and tasks in care and treatment such as bathing, feeding, dressing, observing intake of food, care of hair, nails, moving residents from area to area, responding to calls. Carry out duties and responsibilities in accordance with resident care policy and procedures. Measure and record vital signs as assigned by Charge Nurse. Detect and report situations that may cause resident accidents or injuries. Contribute knowledge of resident's conditions/needs to resident care plans. Observe and report symptoms, reactions and changes of condition to residents to Charge Nurse.

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #39) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #39's Enhanced Based Precautions. These failures could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner. Record review of Resident #39's face sheet, dated 07/28/2026, reflected a [AGE] year-old male admitted on [DATE] with an original admission date of 03/01/2025. His pertinent diagnoses included Stage II Pressure Ulcer and Type 2 Diabetes Mellitus (high blood sugar levels). Record review of Resident #39's MDS assessment, dated 05/26/2026, revealed a BIMS score of 09, indicating moderate impaired cognition. Record review of Resident #39's care plan not dated, reflected resident had a stage II pressure ulcer to left sacral area. Interventions were to follow wound care orders as directed. Monitor area for signs and symptoms of infection and notify MD. There was no care plan implemented to place resident on enhanced based precautions. Record review of Resident #39's Physician's Order Summary dated 07/26/2026 reflected Silvadene External Cream 1% apply to Left Sacral area topically every day shift for Stage II Pressure Ulcer, Apply to sacrum topically every day shift for Stage 2 pressure wound cleanse with wound cleanser spray pat dry with gauze, then apply Silvadene cream to wound bed followed by adaptic gauze, cover with dry dressing and secure with medfix retention tape start date 07/19/2026. There was no EBP physician order. During an interview on 07/28/2026 at 10:01a.m. LVN A stated that she was one of the MDS nurses. She stated that she was responsible for developing the care plan for Resident #39. LVN A stated that enhanced based should have been care planned but there was no order. She stated that the negative outcome of not care planning would have been the spread of infection. During an interview on 07/28/2026 at 2:34 p.m., the DON stated that any nurse could develop the EBP care plan but ultimately the nurse who gets the order would enter it right away. She stated that enhanced based precautions should have been care planned but there was no physician order in place. The DON stated that it was important for it to be completed to make sure that the resident has a patient centered care plan. Record review of the facility's Comprehensive Care Plans policy, dated 10/24/22 revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment.Policy Explanation and Compliance Guidelines:1.The care planning process will include an assessment of the residents strengths and needs and will incorporate the residents personal, and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 6.The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the residents comprehensive assessments.

Based on interview, observation, and record review, the facility failed to ensure the right to be free from chemical restraint was provided for 1 (Resident #13) of 6 residents reviewed for unnecessary medications.The facility failed to ensure Resident #13 had an appropriate diagnosis for Zyprexa (used to treat schizophrenia and bipolar disorder).This failure could place residents at risk of receiving unnecessary psychotropic medications.The findings included:In an interview and observation on 7/27/26 at 12:30 pm Resident #13 was located in the dining area eating her lunch. Resident #13 was groomed and dressed appropriately. Resident #13 had no visible injury observed. Resident #13 did not appear to be in any distress. Resident #13 nodded yes that she was doing ok and nodded yes that she liked her food. Resident #13 shook her head no that she had no concerns or complaints about the facility. Resident #13 only answered simple yes or no questions with head nods and head shakes. Record review of Resident #13's electronic face sheet dated 7/28/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and an original admission date of 11/3/19 with diagnoses to include: dementia (a decline in mental ability severe enough to interfere with daily life), depression (a common and serious mood disorder that causes persistent feeling of sadness, loss of interest in activities and changes in how a person thinks, feels, and behaves), restlessness, and agitation.Record review of Resident #13's quarterly MDS assessment dated [DATE], reflected a BIMS score of 03 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #13 was receiving an antipsychotic and antianxiety medication.Record review of Resident #13's undated Comprehensive Care Plan reflected: Resident #13 had episodes of smearing her feces/playing with feces Date Initiated: 01/21/2025. Resident #13 had restlessness/agitation Date Initiated: 06/19/2026. Approach resident in a warm, calm, friendly manner Date Initiated: 06/19/2026 Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 06/19/2026 Notify MD/Hospice if medication was no longer effective or if s/s worsen in frequency/severity Date Initiated: 06/19/2026 Redirect and reassure resident as needed Date Initiated: 06/19/2026 Zyprexa.Resident #13 uses antipsychotic medications Date Initiated: 03/19/2025 Revision on: 03/24/2026 Monitor behaviors PRN, Notify MD/hospice of new or worsening behaviors asNecessary Date Initiated: 03/19/2025 Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 03/19/2025Resident #13 and her family had elected to receive Hospice services Date Initiated: 09/06/2024. Contact hospice to report changes in condition Date Initiated: 09/06/2024 Refer for Psychiatric/Psychogeriatric consult if indicated Date Initiated: 09/06/2024 Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Date Initiated: 09/06/2024Record review of Resident #13's progress notes from 7/24/26 to 7/27/26 reflect resident had been seen by facility staff, the NP, and hospice services. No new orders given. The hospice nurse reordered Zyprexa. Record review of Resident #13's July 2026 MAR reflected:Zyprexa Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth one time a day for anxiety/agitation and aggressive behavior related to restlessness and agitation -Start Date- 03/12/2026 - No missed doses.Behavior Monitoring -Antipsychotic Behavior Code: 0. None 1. Mania 2. Auditoryhallucinations 3. Visual hallucinations 4. Delusions 5. Paranoia 6. Grandiosity 7. Biting 8.Danger to self 9. Danger to others 10. Smearing feces 11. Kicking 12. Pinching 13. Extreme fear 14. Striking out/ hitting 15. Other (Document in PN) INTERVENTION(S): Document in PNevery shift for Zyprexa -Start Date- 03/12/2025 - No behaviors noted. Side Effect Monitoring - antipsychotic Side Effect Codes: 0. None 1. Stiff Neck 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbance 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation 13. Other (Document in PN) every shift for Zyprexa -Start Date- 03/12/2025 - No behaviors noted.Record review of Resident #13's order summary report reflected: Admit under . hospice . under Dr. Dx: atherosclerotic heart disease of native coronary artery without angina pectoris Active 08/01/2024.Behavior Monitoring - Antipsychotic Behavior Code: 0. None 1. Mania 2. Auditory hallucinations 3. Visual hallucinations 4. Delusions 5. Paranoia 6. Grandiosity 7. Biting 8. Danger to self 9. Danger to others 10. Smearing feces 11. Kicking 12. Pinching 13. Extreme fear 14. Striking out/ hitting 15. Other (Document in PN) Intervention(S): Document inPN every shift for Zyprexa Active 03/12/2025 Side Effect Monitoring - antipsychotic Side Effect Codes: 0. None 1. Stiff Neck 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbance 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation 13. Other (Document in PN) every shift for ZyprexaZyprexa Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth one time a day for anxiety/agitation and aggressive behavior related to restlessness and agitation. Review of manufacturers prescribing information for Zyprexa accessed on 7/20/26 at https://pi.lilly.com/us/zyprexa-pi.pdf revealed: ZYPREXA(R) (olanzapine) is an atypical antipsychotic indicated:As oral formulation for the: Treatment of schizophrenia. Acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder.Adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder.As ZYPREXA and Fluoxetine in Combination for the: Treatment of depressive episodes associated with bipolar I disorder.Treatment of treatment resistant depression.In an interview on 7/28/26 at 6:17 p.m., the NP said the diagnoses of anxiety/agitation and aggressive behavior related to restlessness and agitation were inappropriate diagnosis with an appropriate off-label use. The NP said Zyprexa was used more for a psychosis, schizophrenia and bipolar. He said symptoms of psychosis would include delusions, hallucinations, and origins of mood swings. The NP said restlessness and agitation would be behaviors during the manic phases of bipolar. The NP said he knew very little of Resident #13 due to taking over this case load at the facility as of August 1st. The NP said he would complete a thorough review of his patients at that time, but he did not see himself doing any abrupt medication changes right away since it could cause destabilization of the residents' mental health. In an interview on 7/28/26 at 6:45 p.m., LVN F said during his initial report about Resident #13, the medication Zyprexa helped her not become agitated, so she received care without harm to herself or others. LVN F said behaviors of Resident #13 included refusal of care and combativeness at times. LVN F said Zyprexa was an antipsychotic. LVN F said agitation and restlessness would be symptoms of a diagnosis versus schizophrenia which would be an appropriate diagnosis to prescribe Zyprexa. LVN F said not even anxiety would be an appropriate diagnosis for Zyprexa. LVN F said all prescribed medications must be prescribed for an appropriate diagnosis, especially antipsychotics. LVN F said Resident #13 had not experienced adverse side effects, such as drowsiness or inability to be aroused while on Zyprexa and participated in activities at times. LVN F said Resident #13 was a hospice patient and the hospice company regulated their own care plans and medications. LVN F said if there were special circumstances for Resident #13 to be given Zyprexa for off label-use, it should have been placed in the hospice care plan.In an interview on 7/28/26 at 7:00 p.m., the DON said Zyprexa was prescribed to Resident #13 by the hospice's medical director due to Resident #13 being combative when provided care by the CNAs. The DON said Resident #13 also scratched herself and played with her own feces. The DON said the facility asked hospice if they could use their own psychiatrist to treat Resident #13, and the hospice medical director said no he would manage her care. The DON said Resident #13 was not as combative as she used to be and her quality of care was better with the Zyprexa, so it helped. The DON said staff monitored Resident #13 for any adverse side effects, such she stayed asleep all the time, and there were none. The DON said Resident #13's hospice nurse checked on her weekly. The DON said Zyprexa should be prescribed for an appropriate diagnosis. The DON said she was not sure why the doctor went straight to prescribing Zyprexa, but since Resident #13 was hospice, the facility must follow their diagnoses. The DON said agitation and restlessness were considered more behavior rather than diagnoses, but the behaviors could be related to an actual diagnosis. The DON said Resident #13 did not have a diagnosis of psychosis, schizophrenia, or bipolar. Record review of the facility's Medication Monitoring policy dated 10/1/19 reflected: Policy:The facility employs a system to assure that medication usage is evaluated on an ongoing basis.Procedure:1. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis in accordance with the policy on Medication Management. 2. When a resident receives a new medication, the medication order is evaluated for the following: A. The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.B. A written diagnosis/indication support the use of the medication. G. The prescriber documents the clinical rationale in the resident's active record for using a medication outside these state guidelines.

Based on observation, interviews and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 16 residents (Resident #39) reviewed for resident records. The facility failed to ensure a physician order was written for enhanced barrier precautions for Resident #39 on 07/19/2026. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to inaccurate medical records. Record review of Resident #39's face sheet, dated 07/28/2026, reflected a [AGE] year-old male admitted on [DATE] with an original admission date of 03/01/2025. His pertinent diagnoses included Stage II Pressure Ulcer (open wound also called a bedsore) and Type 2 Diabetes Mellitus (high blood sugar levels). Record review of Resident #39's MDS assessment, dated 05/26/2026, revealed a BIMS score of 09, indicating moderate impaired cognition. Record review of Resident #39's care plan not dated, reflected a stage II pressure ulcer to left sacral area (the lower back and the tailbone). Interventions were to follow wound care orders as directed. Monitor area for signs and symptoms of infection and notify MD. There was no care plan implemented to place resident on enhanced barrier precautions. Record review of Resident #39's Physician's Order Summary dated 07/26/2026 reflected Silvadene External Cream 1% apply to Left Sacral area topically every day shift for Stage II Pressure Ulcer, Apply to sacrum topically every day shift for Stage 2 pressure wound cleanse with wound cleanser spray pat dry with gauze, then apply Silvadene cream to wound bed followed by adaptic gauze (a special medical mesh coated in petroleum jelly), cover with dry dressing and secure with retention tape start date 07/19/2026. There was no EBP order. During an interview on 07/26/2026 at 3:25 p.m., LVN L stated that the person who was responsible for entering the enhanced based precaution order was the nurse who found the wound. She did not know that there was no enhanced based precaution order for Resident #39. LVN L stated it was important to have a physician order in place to make sure that the order was followed through for safety. During an interview on 07/28/2026 at 2:12 p.m., ADON M stated that the nurses were responsible for entering physician orders. She stated the nursing staff who received the order should be the one who entered it. ADON M stated the physician order needed to be placed in the record as soon as the nurse got the order. She stated that she was not aware Resident #39 did not have a physician order for enhanced based precautions. ADON M stated that a physician order needed to be in place to implement necessary precautions for staff. During an interview on 07/28/2026 at 2:34 p.m., the DON stated the person responsible for entering the physician order were the nurses. She stated the order should be entered as soon as they get the orders. The DON stated it was important for the order to be in place to ensure the intervention was care planned, appropriate signage was posted, and the resident was protected from unnecessary bacteria that could have been transmitted from staff clothing when providing care. Record review of the facility's Enhanced Barrier Precautions policy dated 4/5/24 reflected, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms.Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: 2. Initiation of Enhanced Barrier Precautions:b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds. 4. High contact resident care activities include:

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 8 residents (Resident #10) reviewed for assessments: Resident #10's Quarterly MDS assessments dated 03/12/2026 and 06/08/2026, were not coded to include his diagnosis of Anxiety. This failure could place residents at risk for inadequate care due to inaccurate assessments. Record review of Resident #10's face sheet, dated 07/27/2026, reflected a [AGE] year-old male admitted on [DATE]. His pertinent diagnoses included Depression, Anemia, Muscle Wasting and Atrophy (a wasting away or progressive decline of the muscle), and Type 2 Diabetes Mellitus (high blood sugar levels). Record review of Resident #10's Quarterly MDS assessment, dated 06/08/2026, reflected a BIMS score of 07, indicating he was severely cognitively impaired. Section I - Active Diagnoses, Psychiatric/Mood Disorder: Did not have Anxiety Disorder checked off. Quarterly MDS dated [DATE], reflected a BIMS score of 05, indicating he was severely cognitively impaired. Section I - Active Diagnoses, Psychiatric/Mood Disorder: Did not have Anxiety Disorder checked off. Record review of Resident #10's care plan not dated, reflected resident had Anxiety. Interventions were to administer medication as ordered. Behavioral health consults as needed. Notify MD and RP if signs and symptoms of anxiety not relieved with medication or if signs or symptoms of anxiety increase in frequency and intensity. Record review of Resident #10's physician order summary, dated 07/28/2025, reflected the resident had medication order for Buspirone 10 mg tablet for Anxiety Disorder with start date of 02/25/2026. During an interview on 07/28/2026 at 10:01a.m. LVN A stated that she was one of the MDS nurses. She stated that she was responsible for completing the MDS assessments for Resident #10. She confirmed that the diagnosis for Anxiety had not been coded on quarterly MDS assessments dated 03/12/2026 and 06/08/2026. LVN A stated that the diagnosis of Anxiety should have been included in both MDS assessments for Resident #10 but had been omitted. She stated that there was no negative outcome related to the accuracy of the MDS assessment. During an interview on 07/28/2026 at 2:34 p.m., the DON stated that the MDS nurse was responsible for completing the MDS assessments. She stated the regional MDS reviewed the assessments for accuracy but was unsure why the diagnosis was missed on both quarterly assessments. The DON confirmed that Resident #10 had a diagnosis of Anxiety. She stated that it was important for the MDS assessments to be completed accurately to ensure compliance. Record review of the CMS's RAI Version 3.0 Manual dated October 2025, revealed Section I: Active Diagnoses. Intent: the items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. I0100-I8000: Active Diagnoses in the Last 7 Days-Check all that applyPsychiatric/Mood DisorderI5700. Anxiety Disorder Record review of the facility policy, titled Documentation in Medical Record, dated 10/24/22, revealed: Policy: Each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for use of a BiPAP device.This failure could place residents at risk of receiving care and services to meet their needs. The findings included:Record review of Resident #1's face sheet dated 4/23/26 reflected Resident #1 was admitted on [DATE] with an initial admission of 7/10/24. Resident #1 had a diagnosis of obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial collapse of the upper airway, causing oxygen desaturation (decrease in oxygen level in the blood that falls below 90%) or sleep arousal) and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS dated [DATE] indicated the following:, *Section C - Cognitive Patterns reflected Resident #1 had a BIMS of 14 which indicated a mental status of cognitively intact. *Section J - Health Conditions reveal Resident #1 had shortness of breath or trouble breathing when lying flat. *Section O - Special Treatments, Procedures, and Programs, G1. Non-invasive Mechanical Ventilator BiPAP was not checked off.Record review of Resident #1's undated comprehensive care plan reflected: Resident #1 required the use of BiPAP to treat sleep apnea. Date Initiated: 02/19/2026. Interventions included: Apply/remove BiPAP as ordered Date Initiated: 02/19/2026 Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive sweating unrelated to heat or exercises), Headaches, Lethargy (severe tiredness, sluggishness, and reduced mental alertness), Confusion, Atelectasis (collapse of lung), Hemoptysis (coughing up of blood or blood-tinged mucous), Cough, Pleuritic (membranes surrounding the lungs) pain, Accessory (muscles recruited for breathing during high effort, such as neck) muscle usage, Skin color. Date Initiated: 02/19/2026 Prevent abdomen compression and respiratory embarrassment by routinely checking the resident's position so that he or she does not slide down in bed. Date Initiated: 02/19/2026 Promote lung expansion and improve air exchange by positioning with proper bodyAlignment. Date Initiated: 02/19/2026 Schedule follow up with specialist as necessary/ordered (Dr. [NAME]) Date Initiated: 02/19/2026Record Review of Resident #1's order summary reflected BiPAP settings: 14/9, place on at night and off in a.m. every evening shift related to obstructive sleep apnea Active Date: 5/07/2025 Start Date: 05/07/2025. Record Review of Resident #1's MAR dated 4/23/2026 reflected BiPAP was used from 4/1/2026 to 4/23/2026. In an interview on 4/24/26 at 2:10 p.m. the DON said normally they care planned everything. She said she had no idea if the BiPAP should be captured on the MDS assessment. She said MDS was responsible for ensuring it was completed. She said the BiPAP not selected on the MDS would not affect the care plan because Resident #1's BiPAP was care planned, so it would not have had a negative effect. In an interview on 4/24/26 at 3:00 p.m., LVN/MDS A said a BiPAP device was on a 7-day lookback period and gets checked off on the MDS if it had been used withing the 7 days prior to completing the assessment. She said that Resident #1 had a history of refusing and removing her BiPAP device. She checked the MAR, and said it reflected Resident #1 used the BiPAP device daily for the month of April. LVN/MDS A said, the BiPAP device should have been reflected on Resident #1's most recent quarterly MDS assessment. LVN/MDS A said she must complete a correction for that quarterly MDS assessment. LVN/MDS A said it would not have had a negative effect on Resident #1's care if the BiPAP device was not checked off on the MDS quarterly assessment, because the BiPAP device was care planned, so it would not change the care she received. LVN/MDS A said the BiPAP device was checked off on the MDS assessment to show what types of nursing services Resident #1 was receiving. LVN/MDS A said if Resident #1 goes to the hospital, the receiving hospital would get a copy of the MAR, so they would know Resident #1 was on a BiPAP device. LVN/MDS A said the same goes for if Resident #1 was transferred to another nursing facility.Record review of CMS's RAI Version 3.0 Manual, CH 3: MDS Items [O] dated October 2025 reflected section:O0110 Special Treatments, Procedures, and Programs. O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through at mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device. - O0110G2, BiPAPCheck if the non-invasive mechanical ventilator support was a BiPAP.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plans.1. The facility failed to ensure Resident #1's most current undated care plan reflected the use of grab bars.2. The facility failed to follow Resident #1's care plan when she was identified with scabbed over scratches on left wrist and did not report findings to MD/NP. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included:Record review of Resident #1's face sheet dated 4/23/26 reflected Resident #1 was admitted on [DATE] with an initial admission of 7/10/24. Resident #1 had diagnoses of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Parkinsonism (neurodegenerative disease (cells of the central nervous system stop working or die) which manifest with motor symptoms such as rigidity, tremors, bradykinesia, and unstable posture), and hemiplegia (severe or complete loss of strength leading to paralysis (loss of muscle function) on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction affecting left dominant side. Record review of Resident #1's quarterly MDS dated [DATE] indicated the following: *Section C - Cognitive Patterns reflected Resident #1 had a BIMS of 14 which indicated a mental status of cognitively intact. *Section GG - Functional Abilities - GG0130 Self-Care reflected Resident #1 was dependent on lower body dressing and putting on/taking off footwear. *Resident #1 required substantial/maximal assistance with personal hygiene, upper body dressing, shower/bathe self, and toileting hygiene.Record review of Resident #1's most recent undated comprehensive care plan indicated the following:*Did not include Resident #1's use of grab bars. *Resident #1 was at risk for impaired skin integrity r/t decreased mobility, friction/shear, and incontinence Date Initiated: 07/12/2023 Revision on: 02/25/2024. Encourage resident to avoid scratching and keep hands and body parts from excessive moisture as much as possible. Keep fingernails short/trimmed Date Initiated: 03/13/2024. SKIN inspection with care and PRN, Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Date Initiated: 03/13/2024*Resident #1 had c/o DRY SKIN Date Initiated: 04/23/2026. Notify MD/NP of changes in skin condition Date Initiated: 04/23/2026 SKIN inspection with care and PRN, Observe for redness, open areas, scratches,cuts, bruises, and report changes to the Nurse Date Initiated: 04/23/2026.*Resident #1 had c/o ITCHING/PRURITUS (itchy skin) Date Initiated: 02/25/2024 Revision on: 08/08/2024. Notify MD of changes to skin condition or if medication/treatment was no longer effectiveDate Initiated: 02/25/2024 SKIN inspection with care and PRN, Observe for redness, open areas, scratches,cuts, bruises, and report changes to the Nurse. Date Initiated: 02/25/2024Record review of Resident #1's quarterly MDS dated [DATE], Section C - Cognitive Patterns reflected Resident #1 had a BIMS of 14 which indicated a mental status of cognitively intact. Section GG - Functional Abilities - GG0130 Self-Care reflected Resident #1 was dependent on lower body dressing and putting on/taking off footwear. Resident #1 required substantial/maximal assistance with personal hygiene, upper body dressing, shower/bathe self, and toileting hygiene. Record Review of Resident #1's order summary did not include orders for use of grab bars.Record review of Resident #1's skin assessment dated [DATE] at 07:19 a.m. reflected no new skin issues found this evaluation by LVN/Treatment Nurse. In an interview on 4/23/26 at 2:30 p.m. the LVN/Treatment Nurse said Resident #1 was seen by a Dermatologist due to skin related issues. LVN/Treatment Nurse said Resident #1 had medications prescribed by the Dermatologist that the floor nurses applied due to skin related issues. The LVN/Treatment Nurse states she did head-to-toes weekly skin assessments on Resident #1 to rule out any bruises, skin breakdown, and DTIs. She said her last skin assessment on Resident #1 was on 4/21/26 early in the morning and she did not notice any scratches to resident's left wrist area. The LVN/Treatment Nurse also said no one had reported any scratches to her prior. The LVN/Treatment Nurse said Resident #1 was also good at informing staff if she sustained any injury. She said if she noted scratches on Resident #1, she would report them to the floor nurse and MD immediately, even if the scratches were not big or healed so they can be monitored because they can get infected and get cellulitis. The LVN/Treatment Nurse went to check on the resident's scratches, returned, and said she had not noticed them before. She said Resident #1 told her she was scratching herself. The LVN/Treatment Nurse said she informed the charge nurse and that the charge nurse said it was reported to MD already. In an interview on 4/24/26 at 9:38 a.m. LVN B said Resident #1 was a 2-person Hoyer lift with transfers and did not assist with transfers. LVN B said Resident #1 did not help much with any care completed in bed. LVN B said grab bars were for bed mobility for residents who can grab and were there for Resident #1 when she needed them to reach for something on her own. LVN B said Resident #1 was unable to grab them to assist with turning or repositioning and she cannot turn or reposition on her own. LVN B said she believed grab bars should be care planned. LVN B said she was not aware of any negative outcomes if they were not because the grab bars were in place for Resident #1 if needed. LVN B said the last time she worked with Resident #1 was on Tuesday, 4/21/26 during her scheduled 6:00 a.m. to 2:00 pm shift. LVN B said she noted some dry, scabbed over, and healed scratches that were already blending into Resident # 1's skin. LVN B said there was no redness or swelling to the area, and Resident #1 did not have any open areas to other areas. She said Resident #1 was known for scratching herself and complained of itching. LVN B said even though it was care planned to report scratches, she did not report since the scratches were healed and scabbed over. LVN B said the scratches were not open and she only needed to report open wounds or scratches that were at risk for infection. LVN B said there was not a risk of any worsening since the scratches were scabbed and dried over.In an interview on 4/24/26 at 2:10 p.m. the DON said normally they care planned everything. The DON said she knew LVN/MDS A worked on them. The DON did not know if the grab bars were added to the care plan or not. The DON said Resident #1 was able to use the grab bars. The DON said Resident #1 assisted when repositioned to help remain on her side. The DON was not sure if Resident #1 could use the grab bars on her own, but probably not. The DON said no adverse outcome would happen if the grab bars were not care planned. The DON said if Resident #1 requested the bed to go with her during a room change it would. The DON said they would make modifications to another bed. The DON said grab bars do not need orders because they were considered a nursing intervention. The DON said there was no assessment completed for grab bars or halos because they were aids for turning and repositioning. The DON said if staff were not familiar with the resident, they would not know if she needed the grab bars. The DON said she was made aware of Resident #1's scratches. The DON said Resident #1 had cream prescribed for itching. The DON said if a resident were seen with scratches, staff would call the doctor or the NP to inform and see if it were an actual skin tear for treatment, and staff would enter a progress note. The DON said she called the NP and since the scratches were very superficial, the NP told her to continue with the creams she was currently on. The DON said if staff noted the scratches on Tuesday, 4/21/26, they should have reported the scratches. If a CNA saw the scratches they must report it to the nurse. If a nurse saw the scratches, they must call the MD and RP just so everyone was on the same page with treatment. The DON said even if the scratches were dried and scabbed over, staff must always report since we did not know how she got the scratches. The DON said maybe staff who initially noticed the scratches thought the scratches were reported before. The DON said the scratches were superficial, but if they were larger and not reported, it could have caused an infection. In an interview on 4/24/26 at 3:00 p.m. the LVN/MDS said Resident #1 used the grab bars to hold on. The LVN/MDS said grab bars had usually cared planned, but it depended on how long they had been in use. The LVN/MDS said if grab bars were not care planned for Resident #1, it could have been the grab bars were placed after the last care plan was reviewed, so they would be showing up after the next care plan review. The LVN/MDS said she was not aware of any negative outcomes since the grab bars were in place.Record review of facility's Comprehensive Care Plans policy dated 10/24/22 reflected:Policy:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Policy Explanation and Compliance Guidelines:6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.8. Qualified staff responsible for carrying out interventions specified in the are plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. In an interview on 4/24/26 at 2:10 p.m. the DON stated the facility did not have a policy addressing assessment of grab bars.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold administration of Resident #1's nifedipine (blood pressure medication) when Resident #2's blood pressure was outside parameters on 10/01/25. This failure could place residents at risk for complications due to discomfort or their health being jeopardized.The findings include: Record review of Resident #1's face sheet, dated 10/13/25, reflected a [AGE] year-old female with an initial admission date of 07/10/23 and current admission date of 03/21/24. Resident #1's pertinent diagnosis included Essential Hypertension (high blood pressure with no known specific cause). Record review of Resident #1's Quarterly MDS assessment, dated 09/01/25, reflected a BIMS score of 12 which indicated moderate impairment. Record review of Resident #1's comprehensive care plan, dated 11/13/25, reflected the problem [Resident #1] has hypertension initiated on 07/12/23 and revised on 02/25/24. An intervention listed for the problem included Give anti hypertensive medications as ordered. initiated on 07/12/23 and revised on 02/25/24. Record review of Resident #1's order summary reflected an active order for Nifedipine Extended Release 90 mg Give 1 tablet by mouth one time a day for hypertension hold if SBP <100 or HR <60, notify nurse initiated on 03/21/24. Record review of Resident #1's MAR from October 2025 reflected on 10/01/25 Resident #1's blood pressure was measured at 155/66 while her HR was measured at 56. Further review reflected nifedipine ER 90 mg was administered on 10/01/25 by LVN A after the heart rate was measured to be outside of ordered parameters. In an interview with LVN A at 11:48 AM on 11/13/25, LVN A stated before administering blood pressure medications she always measured the resident's blood pressure and heart rate. LVN A stated if the resident's heart rate or blood pressure was outside of the ordered parameters on the medication she would hold the medication and inform the charge nurse. LVN A stated it was important to follow the doctor's orders because administering medication outside of the parameters may harm the resident. LVN A stated she did not remember specifically if she notified the nurse and got the okay to administer the nifedipine to Resident #1 on 10/01/25. In an interview with the DON at 12:06 PM on 11/13/25, the DON stated a resident's blood pressure and heart rate were measured before administering blood pressure medication. The DON stated if a resident's heart rate or blood pressure was outside parameters for a medication the nurse should hold the medication and notify the nurse or physician depending on the order. The DON stated the nifedipine should not have been administered to Resident #1 on 10/01/25 unless LVN A had been given the go ahead by the nurse or physician. The DON stated there was no documentation that LVN A had talked to the nurse or physician about nifedipine on 10/01/25. The DON stated it was important to follow doctor's orders on blood pressure medications to protect residents from negative effects like weakness, lethargy, and dizziness. Record review of the facility's policy Medication Administration, dated 10/24/22, reflected the following policies: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.14. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for quality of care. The facility failed to perform a head-to-toe skin assessment immediately after finding a new skin tear on Resident #2 on 10/22/25. The failure could affect residents currently residing in the facility, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included:Record review of Resident #2's face sheet, dated 11/13/25, reflected a [AGE] year-old female with an admission date of 12/06/24. Resident #2's pertinent diagnosis included Alzheimer's Disease (a progressive brain disorder that affects thinking, memory, and language, leading to a decline in the ability to perform daily activities). Record review of Resident #2's Quarterly MDS assessment, dated 10/02/25, reflected a BIMS score of 5 which indicated severe impairment. Record review of Resident #2's comprehensive care plan, dated 11/13/25, reflected the problem [Resident #2] is at risk for impaired skin integrity [related to] incontinence, friction/shear, and decreased mobility initiated on 12/26/24 and revised on 03/24/25. An intervention listed for the problem included Conduct skin inspections / examinations weekly and as needed. Document findings initiated on 12/26/24. Record review of Resident #2's order summary reflected a current order for cleanse skin tear to left outer forearm with [normal saline], pat dry with 4X4 gauze, apply steri strips X1. Monitor [every day] for signs and symptoms of infection until healed initiated on 10/24/25. Record review of Resident #2's Progress Notes reflected a note written by the MDSN at 5:07 PM on 10/22/25. The note stated MDSN was called into Resident #2's room to remove a sleeve over her left arm. After removing the sleeve, MDSN noted a skin tear to her left forearm was found. MDSN noted she notified the charge nurse of skin tear to left forearm. Record review of Resident #2's assessments reflected a skin assessment was not conducted on 10/22/25. During an observation of Resident #2 at 2:01 PM on 11/13/25, the skin tear to her left forearm was almost completely healed. The area still had a little redness. An interview was attempted at that time but Resident #2 was not able to be interviewed. In an interview with the WCN at 2:51 PM on 11/13/25, the WCN stated Resident #2 sustained a skin tear on her left forearm, but there was no drainage or blood. The WCN stated she was not informed of the skin tear until 10/24/25 when the order to clean the wound was input. The WCN stated she had treated the skin tear and it had improved since it was first brought to her attention. The WCN stated after a skin tear was found on the resident, a head-to-toe assessment should have been performed by either the nurse that found the skin tear or the charge nurse. The WCN stated it was important to perform a skin assessment after finding a new wound to ensure no other new wounds or skin tears were also present. In an interview with the MDSN at 3:56 PM on 11/13/25, the MDSN stated she found out about the skin tear on Resident #2 on 10/22/25. The MDSN stated she told the LVN B who was the charge nurse at that time about the skin tear. The MDSN stated she filed an incident report about the skin tear, but she did not conduct a full head-to-toe assessment on the resident. The MDSN stated she thought the charge nurse was going to conduct a full head-to-toe assessment on the resident. The MDSN stated it was important to do a full head-to-toe assessment on a resident after a new skin tear or wound was found to ensure there was not any other damage to the resident. In an interview with LVN B at 4:28 PM on 11/18/25, LVN B stated she was the charge nurse for Resident #2 on 10/22/25. LVN B stated she remembered the MDSN told her about the skin tear on Resident #2 on 10/22/25. LVN B stated she thought the MDSN was just informing her about the skin tear, and not that it had just been found. LVN B stated she thought the skin tear had been found on a previous shift. LVN B stated she did not perform a full head-to-toe skin assessment on Resident #2 on 10/22/25. LVN B stated it was important to do a full head-to-toe assessment on a resident after a new skin tear was found to ensure there were no other new wounds. In an interview with the DON at 5:28 PM on 11/18/25, the DON stated Resident #2 should have had a full head-to-toe skin assessment on 10/22/25 immediately after the new skin tear was found. The DON stated Resident #2 did receive treatment for her skin tear and it looked a lot better now than it did before. The DON stated it was important to conduct the assessment to see if new orders were needed and to examine the extent of the damage. Record review of the facility's policy Skin Assessment, dated 4/24/25, reflected the following policies: .7. Documentation of skin assessment:a. Include date and time of the assessment, your name, and position title.b. Documents observations.c. Document type of wound.d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).e. Documents if resident refused assessment and why.f. Document other information as indicated or appropriate.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (200 hallway cart) of 4 medication carts. The facility failed to ensure expired supplies and medications were removed from the nurses' medication cart for 200 hall. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on 05/13/2025 at 02:48 PM of the 200 hall nurse's medication cart with LVN A revealed 1 box of famotidine 10milligrams with an expiration date of 4/2025. During an interview on 5/13/25 at 8:00 a.m. LVN A stated all of the nurses were responsible for checking for expiration dates on the medications and supplies in the medication carts. LVN A stated using the expired medications and supplies could lead to the medications and topical treatments not being as effective. During an interview on 5/13/25 at 12:10 p.m. ADON C stated taking the medication past the expirations date could lead to decreased effectiveness or ad verse effects including sickness. ADON C stated that nurses were responsible for checking the medication cart. During an interview on 5/13/25 at 4:45 p.m. the DON stated nurses, were responsible for ensuring expired medications were pulled from the medication carts. The DON stated that the negative outcome could be the medication was not as potent and resident would not receive the full benefit of the medication. The DON said that inservices were done quarterly on expired medications. DON said that she did routine rounds and checking the medication carts. Record review of facility policy Medication Administration dated 10/24/22 revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Identify expiration date. If expired, notify nurse manager.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #40) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #40 was coded in the MDS for a fall on 3/30/25. This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and was [AGE] years old. Resident #40 had diagnoses of muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination, abnormalities of gait (pattern walking or moving on foot) and mobility, dementia (major neurocognitive disorder which causes a progressive decline in cognitive function, such as memory, thinking, reasoning, and judgment), and Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior). Record review of Incident Log reflected Resident #40 had a witnessed fall on 3/30/25. Record review of Resident #40's undated comprehensive care plan reflected: Resident #40 had an actual fall. Educated resident on importance of using call light and waiting for assistance with tall transfers and assistance with ADL on 3/30/35. Labs: UA/C&S on 3/30/25. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation on 3/30/25. NP/RP/DON notified on 3/30/25. Record review of Resident #40's progress notes dated 3/30/35 at 6:00 pm, written by LVN H indicated a change of condition due to resident stated had a witnessed fall. It also reflected a mental status change, vitals/assessment completed, and notifications made to RP and NP. Labs and medications were ordered. Record review of Resident #40's Discharge MDS dated [DATE] revealed: Section GG130 revealed Resident #40 required partial/moderate assistance for showering/bathing and supervision or touch/setup for all other self-care and Section J1800 and J1900 revealed no falls since Admission/Entry or Reentry or Prior Assessment. In an interview on 5/14/25 at 8:54 am the DON said falls were captured on the care plan by the floor nurse. She said if falls were not captured on the care plan, it could cause a lack of communication with the MDS department. They would not get the information of a resident's fall. She said they also had meetings every day to discuss any incidents, and the MDS department also obtained information on any falls at these meetings. She said the MDS department was responsible for capturing and documenting falls on the MDS assessment. The DON said it would not have any negative outcome on the resident who had a fall, because the floor nurses, ADONs, and DON will edit the care plan upon the fall and add any interventions right away and update as needed. In an interview on 5/14/25 at 3:00 pm MDS G said falls should be captured between MDS assessments. She said for Resident #40, the fall should have been captured on the discharge MDS dated [DATE] and it was not. She said the negative outcomes could be the hospital he was discharged to would not know he had a recent fall and plan interventions for the fall. She said if it had been a fall with a serious injury, they would not know what precautions to take. She said Resident #40 had a no serious injuries from his fall. Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section: J1800: Any falls since admission/entry or reentry or prior to assessment . Coding instructions: Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment . item (J1900), . J1900: Number of falls since admission/entry or reentry or prior assessment . Coding instructions for J1900A, No Injury: Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry or prior assessment .

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #262) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #262's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #262's electronic face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included Syncope (fainting) and Collapse, Hypertensive urgency (high blood pressure), Nonrheumatic Mitral Valve Disorder (mitral valve does not close properly, allowing blood to flow backwards into the heart), Atrioventricular Block first degree (a condition where the hearts wiring was slow to send electrical signals), Paroxysmal Atrial Fibrillation (episodes of irregular heartbeat), and Somnolence (a state of drowsiness or strong desire to fall asleep). Record review of Resident #262's BIMS dated [DATE],5 revealed she scored a 15, which indicated she was cognitively intact. Record review of Resident #262's care plan revealed, Resident #262 was a DNR. Interventions: Ensure signed DNR was in medical record. If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Keep resident as comfortable as possible at all times. [NAME] chart and all pertinent documents with DNR status. Send copy of DNR paperwork upon transfer from facility. Social services consult if resident/family want to change code status. Record review of Resident #262's physician order dated [DATE] revealed, DNR (Do Not Resuscitate). Record review of Resident #262's OOH-DNR form dated [DATE] revealed the form was signed in section A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardia pacing, defibrillation, advanced airway management, artificial ventilation. The OOH-DNR revealed the form was not signed by the attending physician in section: Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician did not sign below in the last section All persons who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 10:44 a.m. with SS, she stated upon admission when doing the initial social history, she informed the resident and/or family of their rights regarding the DNR. She explained the difference between DNR and full code. She explained the risks involved when receiving CPR. If it were requested for the resident to be a DNR, she provided them with the form, and obtained their signatures. SS stated that she has been trained to have DNR form completed within 24 hours. She stated the DNR form was placed in a binder at the nurse's station, even if form was incomplete, missing MD signature. She puts the original DNR form in the MD binder and shares it with medical records. Medical Records, who was responsible to get the form signed by the physician. SS stated the form was not complete until the physician signs it. In an interview on [DATE] at 11:02 a.m. with MR, she stated that she scans the DNR form sand emails them to the physician to get it signed. She stated that she tries to get it signed within 24 hours. She stated if the resident was a new admit, she would not leave without uploading the form and sending it to the physician. MR stated she will then take the form to social services, and she puts it in the binder. She stated the DNR form was not complete until the physician signs. MR stated that it was important for the physician to sign the DNR form because if staff does not know that they were DNR and they do CPR, the family would be upset. She verified that the DNR form for Resident #262 was missing the physician signature. She checked her email and did not find anything. MR stated that she was out on [DATE] and the social worker put it in the binder, uploaded it and sent it out to the physician. MR stated she will email the physician right now. In an interview on [DATE] at 11:20 a.m. LVN F, stated that he was Resident #262's nurse. He stated that he could not remember at the top of his head what her code status was, but he would check in PCC. He located Resident #262's in PCC and stated that she was a DNR. He stated that the person responsible for the DNR form to be completed was the social worker. She takes care of asking the families and patients. He stated the DNR form was considered complete when the following signatures were on the form- the patient, the family member, 2 witnesses, and the MD. He stated if the DNR was not signed by the MD that, they can call and get a verbal order. He stated the purpose of the DNR form was to make sure what codes status or whishes the patient chooses in case they code. He stated the DNR code status was located in PCC and in the DNR binder. He stated if the patient does not have a DNR in place, then they were considered a full code. In an interview on [DATE] at 11:30 a.m. with the DON, she stated the DNR form was done upon admission and the social worker also completes the form. The patient and the family will decide if full code or DNR. She stated if the patient was nonverbal then we do full code until the patient's family tells us otherwise. The facility obtains the patient or RP to signature, witnesses and we contact MD. She stated that if DNR form was not signed by MD then it was considered incomplete, but they do honor the patient's wishes since they have the MD order. The DON stated that the MD does not come in daily, and it was impossible to get for signed the same day. She stated that they try to get the MD signature on the DNR form as soon as possible in case the patient goes out to the hospital. If they don't have an MD signature on the DNR form, then the staff will have to call the hospital nurse and inform them that it has not been signed. She stated that there was no timeframe to get the MD signature on the DNR form. She stated that the nurse puts the code status in PCC. The DON stated that as soon as the RP or patient signs form that they change code status in the PCC even if MD has not signed. They get a verbal order; he just hasn't signed the DNR form. Medical records have been told not to take too long to get them signed. The DON provided me with a copy of the DNR at 1:56 p.m., and it revealed the MD signed it today, [DATE]. In an interview on [DATE] at 5:50 p.m. with the ADM, stated that the DNR forms were discussed in their morning meetings. She stated that this was the first thing social services tries to get in motion during new admissions. They also conduct self-audits. She stated that as soon as the DNR forms come in, they get MD signature, or they get a verbal order. They try to have medical records run to their medical office to obtain signatures. She stated that in order for the DNR form to be completed it would have to have all three signatures. ADM stated she was not familiar with the DNR form policy, but social services would be better with the DNR form policy questions. She stated that between medical records and social services, they work on getting MD signatures on the DNR forms. Record review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy dated [DATE], revealed the following: Policy: It is the policy of this facility to support and facilitate a residents right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for heal care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the induvial is incapacitated. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed and advance directive, and if not, determine whether the resident would like to formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart . Record review of the OOH DNR Order instructions for issuing and OOH-DNR Order revealed the Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

50487 Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #40 and Resident #23) of 8 residents reviewed for care plans, in that: 1.The facility failed to ensure Resident #40's most current undated care plan reflected his diagnosis of dementia. 2.The facility failed to develop a comprehensive person-centered care plan to address Resident #23's antibiotics for pneumonia. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and was [AGE] years old. Resident #40 had diagnoses of muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination, abnormalities of gait (pattern walking or moving on foot) and mobility, dementia (major neurocognitive disorder which causes a progressive decline in cognitive function, such as memory, thinking, reasoning, and judgment), and Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior). Record review of Resident #40's most recent undated comprehensive care plan did not include dementia as a diagnosis. Record review of Resident #40's quarterly MDS dated [DATE] revealed: Section I - Active Diagnoses Neurological: Non-Alzheimer's Dementia Other: Unsp Dementia, Unsp severity, without beh/psych/mood/anx In an interview on 5/14/25 at 8:54 am the DON said she knew the MDS department had up to 14 days to complete the assessment. She said the MDS department updated the initial care plans from the MDS assessment, such as for dementia, smoking, etc. She said the floor nurses, ADONs, and DON will update care plans as needed for anything new that had not been addressed in the initial care plan, such as upon a fall. The floor nurses would edit the care plan with interventions right away even if there is no injury because an intervention needs to be done. She said if not on the care plan, there would be a lack of communication and interventions not done. In an interview on 5/14/25 at 3:00 pm MDS G said she was the MDS for the facility's long term care residents. She said the comprehensive care plan will be completed with active diagnosis that were on the MD note and were being treated/provided interventions. She said they usually must care plan for a diagnosis such as Dementia, unless it was not an active diagnosis - not receiving any treatments/interventions for the past 30 to 60 days and the MD did not list the diagnosis as an active diagnosis prior to the most recent MDS Assessment. She said there were no specific diagnosis that were automatically care planned. She said they would capture the active diagnosis on the MDS under active diagnosis. She said for Resident #40, the MD did not include dementia in the most recent progress notes dated 5/13/25. Surveyor asked MDS, since the most recent MDS dated [DATE] show Dementia as an active diagnosis, should dementia have been care planned at that time? MDS said dementia was only included on the MDS because as best practice, we were instructed to place all hospital discharge diagnosis on the MDS assessments. She said Resident #40 was only here for wound care and antibiotics and had a BIMS of 14, so dementia should not have been care planned as an active diagnosis. She said there was no MD support for Dementia as an active diagnosis. She said it could be looked as an oversight on the MDS department, but when they complete the next review in 60 to 90 days, they will get with the MD/NP to see which diagnosis were considered active and which could be resolved/removed. She said there would be no negative outcomes because the resident was still receiving care/interventions for his active diagnosis and his BIMS was high. She said Resident #40's MD also made frequent rounds and picked up changes right away. Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section: I: Active Diagnoses in the last 7 days Active Diagnoses in the last 7 days - Check all that apply . Item Rationale Health-related Quality of Life Planning for Care This section identifies active diseases and infections that drive the current plan of care. Steps for Assessment . 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. 2.Review of Resident #23's Admission Record dated 05/12/2025 revealed an admitted [DATE] and originally admitted on [DATE]. The Resident's diagnoses included Pneumonia (a serious lung infection where the air sacs (alveoli) fill with fluid or pus, causing inflammation and difficulty breathing.), Alzheimer's disease (a progressive, neurodegenerative brain disorder that primarily affects memory and thinking skills). Review of the Resident #23's Care Plan, dated 02/13/2023, revealed the care plan did not identify the resident's treatment for pneumonia. Review of Resident #23's most recent comprehensive MDS assessment dated [DATE], revealed the resident was taking an antibiotic for the last 7 days. Review of the Resident #23's physician orders dated 05/12/2025 revealed Resident #23 received Ceftriaxone sodium intravenous solution reconstituted 1 gram, administer 1 gram via intravenously one time a day for pneumonia for 5 days with a start day on 5/9/2025 and end date 5/14/2025. During an interview on 05/5/25 at 9:44 a.m. MDS G nurse stated the care plan should have been updated when and by whomever received the order for the antibiotic. MDS nurse stated if the care plan was not updated it could affect the nurses by not being able to give the care that Resident #23 needed. During an interview on 5/13/25 at 10:00 a.m. ADON C stated nurses and ADONs were responsible to update the care plan for Resident #23. ADON C stated care plan had to be updated as soon as possible when the order for the antibiotic was received. ADON C stated Resident #23 was at risk of not receiving the care that he needed. ADON said that they monitor any new orders during the morning meetings. During an interview on 05/13/25 at 4:27 p.m. the DON stated the care plan had to be updated to give the resident the best care and to verify if the interventions were effective. The DON stated the care plan had to be updated as soon as possible to give the best care to Resident #23. The DON stated Resident #23 was at risk of not receiving the proper care that he required. Record review of facility's Comprehensive Care Plans policy dated 10/24/22 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed withing 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interview and record review the facility failed to ensure Seroquel had a proper diagnosis for 1 (Resident #50) of 1 residents reviewed for drug regimen review, in that: The facility failed to address Seroquel (antipsychotic) being given to a resident with diagnosis of dementia. This deficient practice could place residents at risk of receiving unnecessary medications and dosages. The findings were: Record review of Resident #50's face sheet dated 05/13/25 revealed an [AGE] year-old male initially admitted to the facility on [DATE] with the diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a diagnosis of dementia where the type and severity are unknown, and there are no significant psychological or behavioral symptoms like aggressiveness, agitation, or psychosis), Hallucinations (a perception that someone experiences as real, but that has no actual external stimulus). Record review of Resident #12's care plan dated 05/10/21 revealed Resident #50 had impaired cognitive function and impaired processes related to lewy body dementia(a progressive neurodegenerative disorder characterized by the buildup of abnormal protein clumps called lewy bodies in the brain), black box warning: elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine (Seroquel) is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #50's MDS dated [DATE] revealed he had a BIMS score of 12, indicating he had moderate cognitive impairment. Resident #50's MDS section N-Medications, he had received antipsychotics on a routine basis only. Record review of Resident #50's Order Summary Report, dated 05/13/25 revealed, Seroquel Tablet 100 MG (Quetiapine Fumarate) Give 4 tablet by mouth two times a day related to lewy body dementia with behavioral disturbance. Start date of 1/10/25. During an interview on 5/13/25 at 10:50 a.m. LVN B stated Seroquel was an antipsychotic medication given for anxiety or insomnia. LVN B stated if an antipsychotic medication was given to a resident with dementia, Resident #50 could be drowsy. LVN B stated dementia was not a diagnosis for an antipsychotic medication. During an interview on 5/13/25 at 1:30 p.m. LVN E stated that she knew that lewy body dementia was not an appropriate diagnosis for an antipsychotic and that she called the Veterans office to clarify and was told that lewy body dementia was an appropriate diagnosis for the Seroquel. LVN E stated that a negative outcome could be resident declining, increase fall risk, and the resident could worsen his medical condition. LVN E stated that resident did not have any side effect to this medication. During an interview on 5/13/25 at 12:10 p.m. ADON C stated Seroquel was an antipsychotic used for depression. ADON C stated lewy body dementia was not an appropriate diagnosis for Seroquel because it could cause the opposite effect on the patient, increase lethargy, or an adverse reaction. ADON C stated that resident did not have any side effect to this medication. During an interview on 5/13/25 at 4:00 p.m. DON stated Physicians were the ones who orders antipsychotics and gave the diagnosis. The DON stated the negative outcome of giving a resident who has the diagnosis of dementia or Alzheimer's an antipsychotic for dementia or Alzheimer's could be adverse side effects. DON stated that resident did not have any side effect to this medication. DON said that the physician was called and stated that this diagnosis was for this medication. Record review of facility's policy on Use psychotropic Medication (s) dated 3/5/25 (implemented date 3/5/25), revealed: Policy Statement: it is the intent f this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent promote healing, prevent infection, and prevent new ulcers from developing, for one Resident (R#6) of 24 residents reviewed for pressure ulcers, in that: Facility staff did not reposition R#6's sacrum area to promote healing of R#6's unstageable pressure ulcer. Nursing staff did not monitor to ensure R#6 air mattress was at the manufacturer's recommended setting for the weight of R#6. These failures could place residents with pressure ulcers at risk for worsening of current pressure ulcers and/or the development of new pressure ulcers. The findings were: Record review of R#6's Admission Record, dated 12/12/19, revealed R#6 was 81-years-old and was admitted to the facility on [DATE]. R#6's [DIAGNOSES REDACTED]. Record review of R#6's Medication Review Sheet (physician's orders [REDACTED]. - R#6 had additional [DIAGNOSES REDACTED]. - There was no order for an Air Mattress. Record review of R#6's Minimum Data Set (MDS) assessment, dated 11/25/19, revealed R#6: -had moderate difficulty hearing -had unclear speech -had moderately impaired cognition, -required extensive assistance by two plus staff for bed mobility, transfers, dressing, toilet use and personal hygiene, -was under hospice care, -had a pain intensity score of 6 (Moderate on the NRS - Numeric Rating Scale), - weighed 143 pounds, -had weight loss of five percent in the last month or loss of 10% or more in the last 6 months, -had one unstageable pressure injury presenting as a deep tissue injury, -had a pressure reducing device for chair, -had pressure reducing device for bed, and -received pressure ulcer/injury care, application of nonsurgical dressings, application of dressings to feet. Record review of R#6's Care Plan, initiated 10/06/19, revealed: The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) weakness and pain. Interventions included: Bed Mobility: The resident requires extensive staff assist to turn side to side and CNA reposition while in bed. Record review of R#6's Care Plan, initiated 10/06/19, revealed: The resident has potential for pressure ulcer development r/t decreased mobility, incontinence and friction/shear. Interventions included: The resident needs assistance and encouragement with repositioning routinely or more often as needed or requested. Use of wheelchair cushion and pressure reduction mattress as necessary. Record review of R#6's Care Plan, initiated 11/25/19 and revised on 12/02/19, revealed: The resident has (Deep Tissue Pressure Injury) pressure ulcer (Right Heel) or potential for pressure ulcer development r/t disease process Malignant Neoplasm, CA, Immobility. Interventions included: The resident needs: monitoring/reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. The resident requires Air Mattress/ Gel Cushion: Pressure relieving/reducing device on (bed/chair). Record review of R#6's Care Plan, initiated 11/25/19, and revised on 12/02/19 revealed: The resident has (Unstageable) pressure ulcer (Sacrum) or potential for pressure ulcer development r/t disease process Malignant Neoplasm, CA, Hx (history) of ulcers, Immobility. Interventions included: The resident needs: monitoring/reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. The resident requires Air Mattress/ Gel Cushion: Pressure relieving/reducing device on (bed/chair). Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 11/25/19, revealed: Date Area Developed 11/25/19: Sacrum, Excoriation, Treatment apply [MEDICATION NAME] cream QD (daily). Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 11/25/19, revealed: Date Wound Developed 11/25/19: Right Heel, In-House Developed - Pressure, Suspected Deep Tissue Injury, 2.0 X 2.0 X 0 centimeters, normal wound bed, surrounding skin color Dark Red/Purple. Current Treatment started 11/25/19 [MEDICATION NAME] Solution 10% QD and PRN. Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 12/02/19, revealed: Date Wound Developed 12/02/19: Sacrum, In-House Developed - Pressure, Unstageable 1.0X 1.0 X 0.0 centimeters, slough wound bed, no change current treatment started 12/02/19 Therahoney Gel QD and PRN (as needed). Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 12/02/19, revealed: Date Wound Developed 11/25/19: Right Heel, In-House Developed - Pressure, Suspected Deep Tissue Injury, 2.0 X 2.0 X 0 centimeters, normal wound bed, surrounding skin color Dark Red/Purple. Continue with Treatment started 11/25/19 [MEDICATION NAME] Solution 10% QD and PRN. Observation on 12/09/19 at 8:55 a.m. revealed R#6 was positioned on his back in bed, with his eyes closed and his hands laying to the sides of his body. Observation on 12/09/19 at 10:28 a.m. revealed R#6 was positioned on his back in bed, with his eyes closed and his hands together near his chest. Observation on 12/09/19 at 11:14 a.m., revealed R#6 was positioned on his back in bed, with his eyes closed and his arms laying to the sides of his body. In an interview on 12/09/19 at 11:30 a.m., R#6's Family Member (FM) P said R#6 had developed pressure ulcers because he was bed bound, and being on his back did not help. FM P said R#6 received an air mattress a little over a week ago. FM P said R#6 had a reddened area on his back and his heel started developing a darker red area. Surveyor observed R#6, with his eyes closed, positioned on his back in bed. The dial on R#6's air mattress control indicated the air mattress was set at inflation for an individual who weighed 320 pounds. In an interview on 12/09/19 at 11:40 a.m., R#6's FM P said that, on Friday 12/06/19, she noticed upon arriving that R#6's mattress felt harder and had inquired about it. FM P said she was informed it had become deflated, but was not informed how that occurred. In an interview on 12/09/19 at 12:05 p.m., surveyor, accompanied by Licensed Vocational Nurse (LVN) F, entered R#6's room. R#6 was positioned on his back. LVN F said she checked to see that R#6's air mattress was on, but did not set or adjust the settings. LVN F said whoever set the air mattress up would set the dial for inflation. LVN F said she did not know who set up R#6's air mattress. When asked if anyone checked the setting, LVN F said, If setting is off, the mattress would deflate. LVN F acknowledged R#6's air mattress setting was at 320 pounds at this time. When asked if R#6 weight was 320 pounds, LVN F said she would need to check. LVN F said Maintenance set up the air mattresses. LVN F acknowledged R#6 was positioned on his back and that R#6's pressure ulcers to the sacrum and right heel had deteriorated. LVN F said, The air mattress was ordered for the skin breakdown that had started on the sacrum and heel. LVN F exited R#6's room without adjusting the air mattress setting and without repositioning R#6. Observation on 12/09/19 at 1:05 p.m. revealed R#6 was positioned on his back in bed, with eyes closed and his left hand on his chest and his right arm laying close to his side. R#6's air mattress was set at inflation for an individual who weighed 320 pounds. Observation on 12/10/19 at 8:35 a.m. revealed R#6 was positioned on his back in bed, with his eyes closed and his arms laying at the sides of his body. R#6's air mattress was set at inflation for an individual who weighed 320 pounds. Observation on 12/10/19 at 9:25 a.m. revealed R#6 was positioned on his back, with his eyes closed and his hands on his chest. R#6's air mattress was set at inflation for an individual who weighed 320 pounds. In an interview on 12/10/19 at 9:30 a.m., Maintenance Director R said he did not have a written policy or manufacturer's information on the air mattresses. Maintenance Director R said his department did not order or set up the air mattresses and did not handle the settings. Maintenance Director R said Central Supply handled getting the air mattresses. In an interview on 12/10/19 at 9:40 a.m., Central Supply Q said nurses set the air mattresses to the proper settings, her department only ordered or bought the air mattresses, with the exception of hospice residents. In an interview on 12/10/10 at 10:30 a.m., Assistant Director of Nursing (ADON) G acknowledged R#6 had pressure ulcers to the sacrum and right heel. ADON G said the air mattress was ordered when the reddened area was found on R#6, to promote healing. ADON G said nurses were to monitor the setting of the air mattress throughout their shift. ADON G said there was no specific documentation for air mattresses. At this time, ADON G accompanied surveyor to R#6's room. ADON G said R#6's air mattress was set at 320 pounds. ADON G acknowledged that R#6 did not weigh 320 pounds. ADON G exited R#6's room without adjusting R#6's air mattress setting and without repositioning R#6. Observation on 12/10/19 at 10:42 a.m. revealed R#6 was positioned on his back in bed, with his eyes closed and his right arm at the side of his body, his left-hand holding FM P hand. R#6's air mattress was set at inflation for an individual who weighed 320 pounds. On 12/10/19 at 11:23 a.m., surveyor accompanied Certified Wound Care Nurse/LVN H and Certified Nurse Aide (CNA) T to R#6's room to observe wound care of R#6's right heel and sacrum. R#6 was positioned on his back in bed. Certified Wound Care Nurse/LVN H acknowledged R#6 had a pressure ulcer on his sacrum and on his right heel. The wound on the edge of R#6's heel was open red/pink, with a white area and darker area noted around that. R#6's sacrum wound bed had redness and open area with a blackened area in the middle, with redness around the blackened area. Certified Wound Care Nurse/LVN H said both pressure ulcer sites had developed in-house and had deteriorated. Certified Wound Care Nurse/LVN H said positioning R#6 on his back put pressure on his wound. Certified Wound Care Nurse/LVN H said R#6's air mattress was set at 320 pounds. Certified Wound Care Nurse/LVN H said she only checked that the air mattress was on and not deflated. Certified Wound Care Nurse/LVN H said on 12/06/19, when coming to do wound care for R#6, she had found that R#6's air mattress had been deflated. Certified Wound Care Nurse/LVN H said R#6's air mattress was ordered after there was a reddened area found on his sacrum. Certified Wound Care Nurse/LVN H exited room without adjusting air mattress setting and without repositioning R#6. Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 12/10/19, revealed: Date Wound Developed 12/10/19: Right Heel, In-House Developed - Pressure, Stage Two, 1.50 X 1.2 X 0.1 centimeters, pink/beefy red wound bed, surrounding skin color pink. Treatment started 12/10/19 Hydrogel/non-adherent dressing QD and PRN. Comments: Resident DTI to RT heel, now with stage two pressure wound with wound measurement of 1.5cmx1.2cmx0.1cm. New wound care tx (treatment) obtained, RN/DON aware. Record review of R#6's Weekly Pressure Ulcer Evaluation, dated 12/11/19, revealed: Date Wound Developed 12/02/19: Sacrum, In-House Developed - Pressure, Unstageable, 1.6 X 1.2 X 0.01 centimeters, slough wound bed, serous: thin watery, clear drainage, no odor, Deteriorated, to continue with current treatment Therahoney gel QD and PRN. Comments: Pt (patient) con't (continues) w (with) unstageable wound to sacrum, increased in size, 95% slough noted to wound bed area. Observation on 12/11/19 at 8:45 a.m. revealed R#6's air mattress setting was set at inflation for an individual who weighed 160 pounds. R#6 was positioned on his back. On 12/11/19 at 9:55 a.m., LVN F accompanied surveyor to R#6's room. R#6 was positioned on his back in bed, with his arms at the sides of his body. LVN F said R#6's air mattress was set at 160 pounds. LVN F said she did not know who changed the setting on R#6's air mattress. LVN F exited the room without repositioning R#6. On 12/11/19 at 10:48 a.m., ADON G accompanied surveyor to R#6's room. R#6 was on back in bed. ADON G said R#6's air mattress setting was changed by self and LVN F, to meet the needs for R#6's weight of 143 pounds. ADON G said that weight was from the beginning of (MONTH) 2019. ADON G placed the air mattress setting near 140 pounds. R#6's FM P said, I wondered why the air mattress was at a different setting. The air mattress has been turned all the way to the 320 mark since (R#6) received the mattress. ADON G said it was changed to assist in the healing and comfort of R#6. ADON 'G exited the room without repositioning R#6. In an interview on 12/11/19 at 4:36 p.m., the Director of Nurses (DON) said R#6 being positioned on his back would not promote healing due to the location of R#6's wound. The DON said R#6's air mattress was to be set to his weight, and that nurses were supposed to check the air mattress settings every shift. The DON said there was not a written facility policy on air mattresses. The DON said air mattress had to be ordered by a physician. In an interview on 12/11/19 at 4:48 p.m., Hospice Registered Nurse (RN) S said, The DME (Durable Medical Equipment company) set up the air mattress. I do not have access to the facility electronic medical record. The communication on 11/25/19 in the hospice binder read follow facility wound care policy/protocol. In an interview on 12/13/19 at 9:15 a.m., ADON G said there was an order for [REDACTED]. ADON G acknowledged the Hospice note said to follow the facility's wound care policy/protocol. In an interview on 12/13/19 at 9:50 a.m., the DON said R#6 had an air mattress since (MONTH) 2019. Record review of facility policy entitled, Repositioning, revised (MONTH) (YEAR), revealed: The purpose of this procedure is to evaluate the resident's need for repositioning, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed and/or chairbound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Record review of facility policy entitled, Hospice Policy, revised (MONTH) (YEAR), revealed: When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency is developed. The resident's care plan should be revised and updated with changes. Record review of the National Pressure Ulcer Advisory Panel website (https://www.npuap.org), researched on 12/10/19, revealed: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.