Every finding on record at West Haven Healthcare

Based on interview and record review, the facility failed to ensure one of four sampled nursing staff's (Certified Nursing Assistant [CNA] 6's) competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) evaluation was completed annually.This deficient practice resulted in incomplete competency evaluation for CNA 6 and had the potential for CNA 6 to provide inadequate care and services to assure resident safety and physical, mental, and psychosocial well-being of residents.During a concurrent interview and record review on 5/5/2026 at 3:53 PM with the Director of Staff Development (DSD), CNA 6's Competency Evaluation Worksheets (CEWs) in CNA 6's employee file were reviewed. The DSD stated the last CEW in CNA 6's file was dated 7/17/2019. The DSD stated it was important to complete staff's CEW every year.During an interview on 5/5/2026 at 4:01 PM with the administrator, the administrator stated that the facility should ensure every employee completes the CEW annually and keep a record in employee's file.During an interview on 5/5/2026 at 4:30 PM with the Director of Nursing (DON), the DON stated every staff should have competency evaluation annually and it was important to complete competency evaluation annually to make sure staff provided good patient care.During a review of the facility's policy and procedure (P&P) titled, Competency Evaluation, dated 1/1/2025, the P&P indicated it is the facility's policy to complete a performance competency evaluation for employees. The P&P indicated that skills competency evaluation will be performed upon hire, annually, and as needed and a record of the competency evaluations will be filed in the employee file.

Based on interview and record review the facility failed to obtain written informed consent for two out of two sampled residents (Residents 30 and 3) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 30 and 3 not receiving adequate or sufficient information regarding psychotropic drugs necessary to make an informed health care decision.Findings: a. During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted Resident 30 on 6/19/2025 with diagnoses including major depressive disorder (a feeling of severe sadness or hopelessness) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). During a review of Resident 30's OSR dated 6/19/2025, the OSR indicated for licensed staff to administer Wellbutrin (a medication that change the way your brain uses certain chemicals to regulate mood and behavior) Extended Release (designed to release slowly into the body) 150 milligrams one tablet by mouth one time a day related to major depressive disorder manifested by persistent verbalization of feeling sad. During a review of Resident 30's History and Physical (H&P) dated 6/22/2025, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 12/23/2025, the MDS indicated Resident 30's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 30 required moderate physical assistance with toileting, shower, lower body dressing and putting on/taking off footwear. During a review of Resident 30's Order Summary Report (OSR) dated 1/14/2026, the OSR indicated for licensed staff to administer Olanzapine ( medication to treat serious mental disorder) 5 milligrams (mg, unit of measurement) one tablet by mouth at bedtime for schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems) bipolar type (mental disorder with periods of depression and periods of elevated mood) manifested by episodes of paranoia (irrational distrust and suspicion) hearing voices that are not there. During a concurrent record review and interview on 3/11/2026 at 1:15 pm with Registered Nurse 2 (RN 2), Resident 30's medical record was reviewed. RN 2 stated, Resident 30's Psychotherapeutic Drug Informed Consent for Olanzapine and Wellbutrin were not dated when signed by the physician. RN 2 stated, it was the RN who obtained informed consent from the Responsible Party (RP) or the resident and not the physician. RN 2 stated, informed consent needed to be signed and dated by the physician to determine when the consent was obtained. During a concurrent record review and interview on 3/12/2026 at 2:30 pm with the Director of Nursing (DON), the DON stated Psychotherapeutic Drug Informed Consent needed to be dated when the physician obtained the informed consent from the resident or RP. The DON stated, licensed nurses needed to verify the informed consent obtained by the physician from the resident or RP. The DON stated it was important to have a valid informed consent for residents receiving psychotropic medications because the risks and benefits needed to be discussed with the resident or resident's RP by the physician. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 1/23/2026, the P&P indicated, The facility will have the Attending Physician/Licensed Healthcare Practitioner (LHP) determine when material circumstances have changed so that an informed consent is required from the resident before providing treatment. The Attending Physician/LHP will then obtain informed consent from the resident or authorized representative before administration of a therapy or procedure that requires an informed consent. The use of an informed consent will be done for but not limited to the following: Psychotherapeutic Drugs. b.During a review of Resident 3's admission Record (AR) dated 3/13/2026, the AR indicated Resident 3, a [AGE] year-old female, admitted on [DATE], with the diagnosis that included but not limit to: senile degeneration of brain (a condition age-related, progressive, and irreversible loss of nerve cell, causing significant cognitive decline beyond normal aging), diabetes (a condition where a person's body has trouble controlling the amount of sugar in their blood), hypertension (high blood pressure) and anxiety disorder (a condition when a person feels constant or overwhelming worry or fear.) During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2026, MDS indicated Resident 3 had an anxiety and psychotic disorder (a person has trouble telling what is real because their brain is sending confusing signals, causing hallucinations or false beliefs.) During a review of Resident 3's psychotherapeutic drug informed consent (PTDIC- a document that explains the essential information a patient must understand before starting treatment) for lorazepam (an anti-anxiety medication), dated 2/20/2026, the PTDIC did not indicate the date the physician signed the form to treat Resident 3 with lorazepam. During a review of Resident 3's PTDIC for olanzapine (an anti-psychotic medication that helps with agitation, to calm the brain when someone has serious mood, behavior, or thinking problem), dated 2/20/2026, the PTDIC did not indicate the date the physician signed the form to treat Resident 3 with olanzapine. During a review of Resident 3's PTDIC for quetiapine fumarate (an anti-psychotic medication that helps calm the brain when someone has serious mood, behavior, or thinking problems), dated 2/20/2026, the PTDIC did not indicate the date the physician signed the form to treat Resident 3 with quetiapine fumarate. During an interview on 3/12/2026 at 2:30 PM with Director of Nursing (DON), DON stated that PTDIC must be signed and dated by the physician. The DON explained that without a date, the consent form is incomplete because the facility cannot verify when it was obtained or became effective. A valid, dated PTDIC is essential for residents receiving psychotropic medications so the physician can document that risks and benefits were discussed with the resident or representative. During a record review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 1/23/2026, the P&P indicated, The Facility will have the Attending Physician/Licensed Healthcare Practitioner (LHP) determine when material circumstances have changed so that an informed consent is required from the resident before providing treatment. The Attending Physician/LHP will then obtain an informed consent from the resident or authorized representative before administration of a therapy or procedure that requires an informed consent. The use of an informed consent will be done for but not limited to the following: Psychotherapeutic Drugs.

Based on observation, interview, and record review the facility failed to ensure the call light (an alerting device to assist a resident when needed) was within reach and appropriate to the patient's physical ability for two of two sampled residents (Residents 25 and 62). These failures had the potential to delay meeting Resident 25 and 62's needs or result in a fall or accident/injury. Findings: a. During a review of Resident 62's admission Record (AR), the AR indicated the facility re-admitted Resident 62 on 2/11/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, abnormal gait and mobility (irregular walk and movement). During a review of Resident 62's History & Physical (H&P) dated 2/12/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 62's Minimum Data Set (MDS, a resident assessment tool) dated 2/16/2026, the MDS indicated Resident 62 had moderately impaired cognition (ability to understand) and required partial/moderate assistance (helper does less than half the effort) to roll left and right (ability to roll from lying on back to left and right side, and return to lying on back on bed) and walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space). During a review of Resident 62's Care Plan (CP), the CP indicated Resident 62 had: 1. An unsteady gait, recent fall in the last 30 days and was risk for further falls and injury related to dementia or Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The CP was dated 2/12/2026, with an intervention to place most needed personal belongings within the resident's reach, including the call light. 2. Impaired urinary elimination (incontinence)-occasionally incontinent with bladder related to dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), impaired mobility and required ADL assistance for toileting hygiene or toileting transfers. The CP was dated 3/2/2026 with an intervention to place the call light within reach and answer the call light promptly. During a concurrent observation and interview on 3/10/2026 at 9:43 am with Resident 62 in Resident 62's room, Resident 62 was lying in bed that had a large yellow star on the footboard, and the call light was hanging off the resident's left side of the bed and touching the floor. Resident 62 stated Resident 62 was unable to locate the call light and could not call for help. During a concurrent observation and interview on 3/10/2026 at 9:44 am with the Assistant Director of Nursing in Resident 62's room, Resident 62 was lying in bed that had a large yellow star on the footboard and the call light was hanging off the resident's left side of the bed and touching the floor. The ADON stated, Resident 62 was a fall risk and the yellow star indicated Resident 62 was in the fall risk program. The ADON stated Resident 62's call light should be within reach to allow Resident 62 to press it and ask for help, including obtaining assistance to go to the bathroom because Resident 62 was at risk for falling. During a review of the facility's Policy and Procedure (P&P) titled, Communication-Call System, dated 2/9/2024, the P&P indicated the purpose of the call system was providing a mechanism for residents to promptly communicate with nursing staff. The P&P indicated, call cords would be placed within the resident's reach in the resident's room. b. During a review of Resident 25's AR, the AR indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (disease that affects the function or structure of the brain), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear). During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 had intact cognition for daily decision making. The MDS indicated Resident 25 needed setup or clean-up assistance (helper sets up or cleans up) assistance from staff for eating, oral hygiene, and showering/bathing self. During a review of Resident 25's CP dated 1/4/2026, the CP indicated Resident 25 had impaired bowel elimination related to impaired mobility (the ability to move) and required assistance with care. The CP intervention indicated for staff to place Resident 25's call light within reach and answer promptly. During a concurrent observation and interview on 3/11/2026 at 10:02 am, Resident 25 was awake, lying in bed with call light on the floor below Resident 25's bed. Resident 25 stated I do not know where it is (referring to call light). It should be there. During a concurrent observation and interview on 3/11/2026 at 10:08 am, with Registered Nurse 1 (RN 1), RN 1 stated Resident 25's call light was on the floor, below the resident's bed. RN 1 stated the call light should be within resident's reach at all times so they can place a call for assistance or help in the case of an emergency. During an interview on 3/12/2026 at 2:32 pm with the Director of Nursing (DON), the DON stated the call light needed to be within reach of the residents at all times so they can ask for assistance when needed. During a review of the facility's P&P titled, Communication-Call System, dated 2/9/2024, the P&P indicated Call cords will be placed within the resident's reach in the resident's room.

Based on observation, interview, and record review, the facility failed to provide care and services to promote healing for residents with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 65) by failing to:a. Ensure Resident 65's Low Air Loss Mattress (LAL - a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) pressure was set consistent with the resident's weight. b. Ensure to turn and reposition Resident 65 every two hours in accordance with Resident 65's care plan. These failures had the potential to result in worsening of Resident 65's existing pressure ulcer/injury and developing new skin breakdown.Findings: a. During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 11/10/2025 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently) and chronic kidney disease (CKD - irreversible, and gradual loss of kidney function). During a review of Resident 65's untitled Care Plan (CP) dated 2/26/2026, the CP indicated Resident 65 had a wound decline. The CP interventions included the use of LAL mattress to reduce or relieve pressure on bony prominences. During a review of Resident 65's Order Summary Report (OSR) dated 2/28/2026, the OSR indicated Resident 65 had an order for LAL mattress and for staff to check the setting of LAL mattress every shift, for wound management. During a review of Resident 65's Minimum Data Set (MDS - a resident assessment tool) dated 3/2/2026, the MDS indicated Resident 65 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 65 was dependent (helper did all the effort) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. The MDS indicated Resident 65 had a stage 3 pressure ulcer (ulcer that extends into the underlying subcutaneous tissue layer, but not all the way to the bone). The MDS indicated Resident 65 was on hospice care (compassionate care for people near the end of life). During a review of Resident 65's Skin Weekly Assessment (SWA) dated 3/5/2026, the SWA indicated Resident 65 had a stage 3 pressure ulcer on the sacrococcyx region (refers to the area at the base of the vertebral column). During a concurrent observation inside Resident 65's room and interview on 3/11/2026 at 1:57 pm with the Treatment Nurse (TN), Resident 65 was lying in bed, on Resident 65's back, on a LAL bed mattress. The TN stated the LAL mattress pressure was set up at 150. The TN stated Resident 65's weight was 131 pounds (lbs.). The TN stated the LAL mattress pressure was too firm for Resident 65. The TN stated the LAL mattress pressure needed to be set based on the resident's weight for equal distribution of pressure to relieve pressure on bony prominences and to prevent worsening of Resident 65's pressure ulcer. During an interview on 3/11/2026 at 2:02 pm with the Assistant Director of Nursing (ADON), the ADON stated the LAL mattress should be set according to the resident's weight for equal pressure distribution on the back of the resident and to aid with pressure ulcer/injury healing. During a review of the undated LAL mattress Operation Manual (OM), the OM indicated, Determine the patient's weight and set the control knob to that weight setting on the control unit. During a review of the facility's Policy and Procedure (P&P) titled, Wound Management, dated February 9, 2024, the P&P indicated, A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. An assessment of care needs for pressure ulcer and wound management will be made with emphasis on but not limited to: mechanical offloading and pressure reducing devices. Reducing skin friction, sheer, and moisture. Evaluating and modifying interventions for a resident with existing pressure ulcers/pressure injuries Pus/PIs). b. During a review of Resident 65's untitled CP dated 2/18/2026, the CP indicated Resident 65 had an impaired skin integrity. The CP interventions included turning and repositioning the resident every 2 hours and as needed while in bed. During an observation inside Resident 65's room on 3/11/2026 at 9:29 am, Resident 65 was lying in bed, on Resident 65's back. During an observation inside Resident 65's room on 3/11/2026 at 10:55 am, Resident 65 was lying in bed, on Resident 65's back. During an observation inside Resident 65's room on 3/11/2026 at 11:56 am, Resident 65 was lying in bed, on Resident 65's back. During an observation inside Resident 65's room on 3/11/2026 at 12:36 pm, Resident 65 was lying in bed, on Resident 65's back. During a concurrent observation inside Resident 65's room and interview on 3/11/2026 at 1:57 pm with the TN, Resident 65 was lying in bed, on Resident 65's back. The TN stated the facility had a turning schedule program. The TN stated, at this time (1:57 pm), Resident 65 should have been facing the door. The TN stated Resident 65 had a stage 3 pressure ulcer on the sacrococcyx area. The TN stated Resident 65 should be turned and repositioned every 2 hours to relieve and reduce pressure on bony prominences and prevent worsening of Resident 65's pressure ulcer. During an interview on 3/11/2026 at 2:02 pm with the ADON, the ADON stated residents with pressure ulcers and at risk of developing pressure ulcers should be turned and repositioned every 2 hours to reduce pressure and prevent pressure injuries on vulnerable areas like the sacrum, hips, and heels. During a review of the facility's P&P titled, Support Surface Guidelines, dated February 9, 2024, the P&P indicated, The facility would implement measures to reduce tissue pressure that includes frequent repositioning, protective devices and the use of support surfaces.

Based on observation, interview, and record review, the facility failed to ensure the resident was administered oxygen therapy (treatment that provides supplemental oxygen) at the rate ordered by the physician and the resident's care plan (CP) for the use of oxygen was revised for one of one sampled resident (Resident 2). This deficient practice placed Resident 2 at risk for respiratory distress (difficulty breathing).Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility 12/5/2025 with diagnoses including respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and muscle weakness (a reduced ability to exert force). During a review of Resident 2's History and Physical (H&P) dated 12/8/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment and care planning tool) dated 12/10/2025, the MDS indicated Resident 2's cognition was intact and Resident 2 was dependent on toileting hygiene, bowel and bladder incontinence (involuntary loss of urine or stool), shower/bathe self, and lower body dressing. The MDS indicated Resident 2 was receiving oxygen therapy. During an observation in Resident 2's room on 3/10/26 at 9:40 a.m., Resident 2 was receiving 2 liters per minute (LPM) of oxygen via nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) while lying in bed. During a review of Resident 2's Physician's Order (PO) dated 2/28/26, the PO indicated for licensed staff to provide oxygen at 3L/minute (3 LPM) via nasal cannula continuously every shift. During a review of Resident 2's Ineffective Breathing Pattern Care Plan (CP) with last revision date of 12/7/25, the CP indicated for licensed staff to administer supplemental oxygen as prescribed: O2 at 2 LPM via nasal cannula continuously. During a concurrent interview and record review on 3/12/26 at 11:21 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 2's PO was reviewed. LVN 4 stated the current PO indicated for Resident 2 to receive oxygen at 3LPM via nasal cannula continuously every shift. LVN 4 stated the oxygen setting was checked once in a shift or usually during medication administration. LVN 4 stated it was important to revise the resident's CP based on the current PO to provide appropriate/necessary care to the resident. LVN 4 stated it was important to follow the PO to provide accurate care to the resident. During a phone interview on 3/13/2026 at 4:55 p.m., with Registered Nurse 3 (RN 3), RN 3 stated it was important that Resident 2's oxygen setting was accurate as ordered because if the treatment was not followed, it could negatively affect the resident. RN 3 stated if Resident 2 was not getting 3 LPM oxygen as ordered, the resident is not getting enough oxygen. During a review of the facility's Policy and Procedure (P&P), titled, Oxygen Administration, dated February 9, 2024, the P&P indicated to check the physician's order and turn on the oxygen at prescribed rate.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage for one of two resident refrigerators.This deficient practice had the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness. Findings: During an observation of the Nursing Station 3's resident refrigerator in the presence of the Assistant Director of Nursing (ADON) on 3/11/2026 at 9:35 AM, the following were observed:1. Resident 50's opened salad dressing bottle with best-used-by date of 11/13/2025 inside the refrigerator.2. Resident 27's bag of lemons did not have a received date.3. There was a puddle of water at the bottom of Resident 27's bag of lemons. During an interview with the ADON on 3/11/2026 at 9:35 AM, the ADON stated Resident 50's salad dressing that was beyond the best-used-by date should not be inside the resident's refrigerator due to the risk of food poisoning such as stomachache, diarrhea, nausea, and vomiting. The ADON stated the licensed nurse should have checked the resident's refrigerator for any food beyond the best-used-by date and threw it away. The ADON stated the nursing staff did not label the received date for Resident 27's bag of lemons. The ADON stated the nursing staff who received Resident 27's bag of lemons should have labeled the bag of lemons with the resident's name and the date of refrigeration. The ADON stated labeling the food with the resident's name prevented other residents from touching and contaminating the food. The ADON stated there should not be any puddle of water inside the refrigerator because it could cause mold and infection. During an interview with the Dietary Supervisor (DS) on 3/11/2026 at 1:23 PM, the DS stated the dietary department was responsible for the resident's refrigerator by providing the temperature log and labels. The DS stated nursing staff was responsible for ensuring proper food labeling. The DS stated the salad dressing was considered perishable and should not be inside the refrigerator after the best-used-by date because of the risk of infection. The DS stated the food's flavor would not be the best and optimal after the best-used-by date. During a review of the facility's Policy and Procedure (P&P) titled Food: Safe Handling for Foods from Visitor, dated 2/2023, the P&P indicated that staff would properly maintain the refrigerator for storage of foods brought in by visitors. The P&P indicated staff would label food with the resident name and the current date. The P&P indicated staff would daily monitor for refrigerated storage duration and discard of any food items that had been stored for more than 7 days.

Based on interview and record review, the facility staff failed to accurately document the nursing interventions and medication indication on the residents' medical record for four of four sampled residents (Residents 2, 3, 33, and 40) when: a. The facility did not complete Adult Daily Living (ADL, the basic self care tasks an adult performed each day, such as bathing, dressing, eating, toileting, and mobility) documentation for Resident 2 and completed in a timely manner. b 1. Resident 3 was placed on NPO as ordered by MD, on MAR resident was receiving a regular diet from 3/5/2026 to 3/11/2026. b 2. Resident 33 did not have a history or diagnosis of depression but resident was receiving Trazadone for depression. c. The facility did not complete ADL documentation for Resident 2 and completed in a timely manner. These deficient practices had the potential to result in lack of communication between staff and delay and interruption of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 40's admission Record (AR), the AR indicated the facility admitted Resident 40 on 1/22/2026 with diagnoses including sepsis (a life-threatening blood infection [when germs entered the body and caused illness]) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 40's History and Physical (H&P) dated 1/24/2026, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 40 had intact cognition (ability to understand). The MDS indicated Resident 40 required maximal assistance (helper did more than half the effort) from staff with eating and oral hygiene. The MDS indicated Resident 40 was dependent on staff with toileting hygiene, showering/ bathing, personal hygiene, and mobility. During a concurrent record review and interview with Certified Nurse Assistant 1 (CNA 1) on 3/13/2026 at 9:26 AM, Resident 40's Documentation Survey Report (DSR) for February and March 2026 were reviewed. The DSR indicated the CNAs (in general) documented Resident 40's bathing for 81 out of 84 shifts from 2/1/2026 to 2/28/2026. The DSR indicated the CNAs (in general) documented Resident 40's bathing for 34 out of 36 shifts from 3/1/2026 to 3/12/2026. CNA 1 stated the CNAs (in general) should have documented on the resident's medical record after bathing the resident to validate the bathing was done. CNA 1 stated the CNAs needed to document on the resident's medical record if the resident refused bathing. CNA 1 stated it was important to complete the documentation on the resident's medical record before the end of the shift because it was the standard of practice. CNA 1 stated if there was no staff initial on the DSR, it indicated bathing was not done for the residents. CNA 1 stated the CNAs (in general) should provide bathing to the residents to keep the residents clean for infection control. During an interview with the Assistant Director of Nursing (ADON) on 3/13/2026 at 9:54 AM, the ADON stated incomplete medical record documentation would affect the continuity of residents' care. The ADON stated, without accurate documentation, nursing staff would not know what happened previously to the residents. The ADON stated it was important for staff to complete documentation before the end of the shift to demonstrate that care was provided for the residents. During a review of the facility's policy and procedure (P&P) titled Documentation-Nursing, dated 2/9/2024, the P&P indicated the CNA would sign each entry on the Adult Daily Living (ADL) Flow Sheet in the appropriate area of the record according to the date and shift that services were performed. The P&P further indicates that documentation would be completed by the end of the assigned shift. b1.During a review of Resident 3's admission Record (AR) dated 3/13/2026, the AR indicated Resident 3, a [AGE] year-old female, admitted on [DATE], with the diagnosis that included but not limited to: senile degeneration of brain ( a condition age-related, progressive, and irreversible loss of nerve cell, causing significant cognitive decline beyond normal aging), diabetes (a condition where a person's body has trouble controlling the amount of sugar in their blood), and high blood pressure. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2026, MDS indicated Resident 3 is on hospice care (a special care for people who are very sick and near the end of their life). During a review of Resident 3's physician's orders dated 2/24/2026, the order indicated Resident 3 is under hospice care. During a review of Resident 3's physician's orders dated 2/28/2026, the order indicated Resident 3 had an active regular diet (a meal with normal foods without dietary restrictions) since 2/28/2026. During a review of Resident 3's physician's orders dated 3/5/2026, the order indicated Resident 3 was placed on nothing by mouth (NPO, a strict medical instruction to consume no food, drinks, liquids, or sometimes medications) since 3/5/2026. During a concurrent interview and record review on 3/12/2026 at 2:00 PM with Licensed Vocational Nurse (LVN) 3, Resident 3's medication administration record (MAR) dated 3/2026 was reviewed. The MAR indicated Resident 3 received a regular diet from 3/5/2026 to 3/11/2026. LVN 3 stated Resident 3's meal was documented given on MAR from 3/5/2026 to 3/11/2026; however, she did not give any meals to Resident 3 because Resident 3 could not swallow, and she knew Resident 3 was on NPO. LVN 3 also stated her documentation for Resident 3's meals on MAR were wrong, it should be documented as not given with a progress note to indicate the reason why the meal was not given. During an interview on 3/12/2026 at 2:20 PM with the Assistant Director of Nursing (ADON), ADON stated Resident 3's MAR for 3/2026 indicated a discrepancy regarding Resident 3's diet and NPO orders. The nurse who received the NPO order should have discontinued Resident 3's regular diet order at the same time. This failure caused miscommunication and incorrect MAR documentation. Resident 3 cannot swallow and giving a meal could lead to aspiration (any food, liquid, saliva accidentally goes into the lungs instead of the stomach). During a review of the facility's policy and procedure (P&P) titled, Documentation – Nursing, dated 2/9/2024, the P&P indicated documentation should be concise, clear, pertinent and accurate. b2.During a review of Resident 33's admission Record (AR) dated 3/13/2to, the AR indicated Resident 33, a [AGE] year-old female, initial admitted on [DATE] and re-admitted on [DATE], with the diagnosis that included but not limited to: fracture of left femur (a condition the left thigh bone is broken), high blood pressure), and epilepsy (a condition that cause a person to have seizures [a sudden uncontrolled involuntary movement, such as shaking, stiffening or jerking]) . During a review of Resident 33's MDS dated [DATE], the MDS did not indicate Resident 33 had a diagnosis of depression. During a review of Resident 33's physician's orders dated 1/6/2026, the order indicated Resident 33 is taking trazodone for depression. During a review of Resident 33's psychotherapeutic drug informed consent (PTDIC- a document that explains the essential information a patient must understand before starting treatment) dated 1/6/2026, the PTDIC indicated trazodone was being used to improve Resident 33's overall sleep quality. During a review of Resident 33's MAR dated 3/2026, the MAR indicated Resident 33 had been taking trazodone every day at bedtime for depression. During a review of Resident 33's psychiatric evaluation (psych eval) dated 1/16/2026, the psych eval did not indicate Resident 33 had depression and recommended Resident 33 to continue taking trazodone for insomnia (the inability to sleep). During an interview on 3/11/2026 at 2:00 PM with Assistant Director of Nursing (ADON), ADON stated Resident 33 did not have a diagnosis of depression. The nurse who got the order should have clarified the correct indication for the use of trazodone with the physician. ADON also stated it is the nurse's responsibility to verify unclear orders. An unclear medication order increases the risk of a medication error and may expose Resident 33 to unnecessary side effects from continued use of an antidepressant. During an interview on 3/12/2026 at 3:53 PM with Registered Nurse (RN) 2, RN 2 stated she entered the trazodone order for Resident 33 exactly as the physician dictated. She said she did not know the resident had no diagnosis of depression and had not reviewed Resident 33's psych eval. RN 2 stated that if she had read the psych eval, she would have clarified the correct indication for use of trazodone order with the physician. During an interview on 3/13/2026 at 8:46 AM with Pharmacy Consultant (PC), PC stated Resident 33's trazodone's order was for depression; however, as he reviewed Resident 33's medical record, he did not find any diagnosis for depression. PC stated the indication of Resident 33's trazodone order should not be for depression, but insomnia. There is a transcription issue for Resident 33's trazodone order, and it should have been clarified with the physician. During a review of the facility's policy and procedure (P&P) titled, Documentation – Nursing, dated 2/9/2024, the P&P indicated documentation should be concise, clear, pertinent and accurate. c. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 12/5/2025 with diagnoses including unspecified fracture of the lower end of the right femur (a broken bone), morbid obesity (excessive body fat that poses a risk of severe health complications), and muscle weakness (a reduced ability to exert force). During a review of Resident 2's H&P dated 12/8/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact and Resident 2 was dependent on toileting hygiene, bowel and bladder incontinence (involuntary loss of urine or stool), shower/bathe self, and lower body dressing. During an interview on 3/13/26 at 9:45 a.m., with CNA 3, CNA 3 stated oral care was documented in the computer to specify if oral care was provided by staff or if the residents did it themselves. CNA 1 stated the CNAs needed to document on the resident's medical record if the resident refused bathing. CNA 1 stated it was important to complete the documentation on the resident's medical record before the end of the shift because it was the standard of practice. CNA 1 stated if there was no staff initial on the DSR, it indicated bathing was not done for the residents. During a review of the February and March 2026 DSR for Resident 2, there was no oral care documented for the following dates: Night Shift: 2/11/26, 2/12/26, 2/14/26, 2/15/26, 2/20/26-2/25/26 and 2/28/26. Night Shift: 3/1/26, 3/3/26, 3/6/26-3/9/26 and 3/12/26. Evening Shift :3/2/26. During an interview with the Assistant Director of Nursing (ADON) on 3/13/2026 at 9:54 AM, the ADON stated incomplete medical record documentation would affect the continuity of residents' care. The ADON stated, without accurate documentation, nursing staff would not know what happened previously to the residents. The ADON stated it was important for staff to complete documentation before the end of the shift to demonstrate that care was provided for the residents. During a review of the facility's policy and procedure (P&P) titled Documentation-Nursing, dated 2/9/2024, the P&P indicated the CNA would sign each entry on the Adult Daily Living (ADL) Flow Sheet in the appropriate area of the record according to the date and shift that services were performed. The P&P further indicates that documentation would be completed by the end of the assigned shift.

Based on interview and record review, the facility failed to ensure hospice (compassionate care for people near the end of life) residents received the necessary care and services for one of one sampled resident (Resident 65) by failing to:a. Ensure Resident 65 received two skilled nursing visits every week in accordance with the hospice plan of care order.b. Ensure Resident 65 received two hospice aide visits every week in accordance with the hospice plan of care order. These failures had the potential not to meet Resident 65's hospice needs affecting the resident's quality of life. Findings: a. During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 11/10/2025 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently), and chronic kidney disease (CKD - irreversible, and gradual loss of kidney function). During a review of Resident 65's Order Summary Report (OSR) dated 2/28/2026, the OSR indicated the attending physician ordered Resident 65's admission to hospice care. During a review of Resident 65's Hospice Plan of Care Order (HPOC), dated 2/28/2026, the HPOC indicated the facility's contracted hospice would provide two visits every week of skilled nursing services for pain and symptom management. During a review of Resident 65's Minimum Data Set (MDS - a resident assessment tool), dated 3/2/2026, the MDS indicated Resident 65 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 65 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. The MDS indicated Resident 65 was in hospice care. During a concurrent interview and record on 3/11/2026 at 10:59 am with the Case Manager (CM), the Hospice and Palliative Care Patient Calendar for March 2026 and In Home Visit and Coordination Care log for March 2026 were reviewed. The CM stated the hospice provider admitted Resident 65 to hospice care on 2/28/2026. The CM stated the patient calendar, and the coordination care log indicated the hospice licensed vocational nurse (LVN) visited Resident 65 one time on 3/2/2026 for Week 1, covering March 1-7, 2026. The CM stated the patient calendar, and the coordination care log indicated the hospice LVN visited Resident 65 one time on 3/10/2026 for Week 2, covering March 8-14, 2026. The CM stated the contracted hospice should provide Resident 65 of the skilled nursing visits specified in the plan of care to promote comfort and supportive care to the resident. b. During a review of Resident 65's HPOC dated 2/28/2026, the HPOC indicated the facility's contracted hospice would provide two visits every week of hospice aide (HA) services for personal care and activity of daily living (ADL) support. During a concurrent interview and record on 3/11/2026 at 10:59 am with the Case Manager (CM), the Hospice and Palliative Care Patient Calendar for March 2026 and In Home Visit and Coordination Care log for March 2026 were reviewed. The CM stated the patient calendar and the coordination care log indicated the HA visited Resident 65 one time on 3/2/2026 for Week 1, covering March 1-7, 2026. The CM stated the patient calendar and the coordination care log indicated the HA did not visit Resident 65 for Week 2, covering March 8-14, 2026. The CM stated the contracted hospice should provide Resident 65 of the HA visits specified in the plan of care. The CM stated any missed visits should be communicated to the nursing staff of the facility to ensure there would be no interruptions and delay in providing and meeting the Resident 65's needs. During an interview on 3/11/2026 at 11:24 am with the Assistant Director of Nursing (ADON), the ADON stated the contracted hospice should provide services and frequency of visits as specified in the plan of care and collaborated with the facility to ensure the hospice residents were provided with comfort and quality of life during the residents' end-of-life process. During an interview on 3/12/2026 at 11:27 am with Hospice Registered Nurse (HRN), the HRN stated the hospice agency should provide the services and frequency of visits as specified in the resident's plan of care to ensure the resident's needs were taken care of and addressed. During a review of the facility's Hospice-Skilled Nursing Facility Agreement with effective date of February 1, 2026, the agreement indicated, Hospice Plan of Care - the hospice interdisciplinary group (IDG) shall prepare an individualized written hospice plan of care for each hospice patient in the nursing home. The hospice plan of care shall specify the hospice care and services necessary to meet the needs of the hospice patient and his/her family as identified in the initial, comprehensive, and updated assessments. During a review of the facility's Policy and Procedure (P&P) titled, End of Life Care, dated February 9, 2024, the P&P indicated, If hospice care is ordered by the attending physician and elected by the resident or his/her representative, the resident's care plan will reflect hospice interventions. Social services and nursing staff will coordinate with the hospice team to ensure that the resident needs were addressed.

Based on observation, interview, and record review, the facility failed to ensure oral care was provided to one of one sampled resident (Resident 2). This deficient practice did not maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 12/5/2025 with diagnoses including unspecified fracture of the lower end of the right femur (a broken bone), morbid obesity (excessive body fat that poses a risk of severe health complications), and muscle weakness (a reduced ability to exert force). During a review of Resident 2's History and Physical (H&P) dated 12/8/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment and care planning tool) dated 12/10/2025, the MDS indicated Resident 2's cognition was intact and Resident 2 was dependent on toileting hygiene, bowel and bladder incontinence (involuntary loss of urine or stool), shower/bathe self, and lower body dressing. During a review of the February and March 2026 DSR for Resident 2, there was no oral care documented for the following dates: Night Shift: 2/11/26, 2/12/26, 2/14/26, 2/15/26, 2/20/26-2/25/26 and 2/28/26.Night Shift: 3/1/26, 3/3/26, 3/6/26-3/9/26 and 3/12/26. Evening Shift : 3/2/26. During a concurrent observation and interview on 3/10/26 at 9:40 a.m., with Resident 2, Resident 2 stated Resident 2 was not provided with oral care inside Resident 2's mouth. Resident 2 stated staff did not provide oral care to Resident 2. Resident 2 did not have teeth. During a subsequent interview on 3/12/26 at 1:50 p.m., Resident 2 stated Resident 2 was not assisted with oral care. Resident 2 who was a dependent resident stated, staff had not assisted Resident 2 with gargling or mouth swabbing. During an interview on 3/13/26 at 9:45 a.m., with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated for dependent residents, staff had to do everything with feeding, bathing, all the ADLs including oral care, brushing/combing the resident's hair and trimming nails. CNA 3 stated oral care included rinsing the mouth with mouthwash and brushing the teeth and for residents with no teeth staff use swabs with mouthwash with water. CNA 3 stated oral care needed to be done before and after breakfast and before lunch time daily. CNA 3 stated it was important to provide daily oral care to prevent infection in the gums and for oral hygiene. During an interview on 3/13/26 at 10:01 a.m. with CNA 4, CNA 4 stated oral care was provided in the morning before and after breakfast and then after lunch daily. CNA 4 stated that for a resident with no teeth, staff should swab the inside of the resident's mouth with water. CNA 4 stated all residents should be receiving oral care daily to prevent cavities, tartar, and oral infections. During a review of the facility's Policy and Procedure (P&P), titled, Activities of Daily Living (ADLs), Supporting, dated, revised July 2024, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure the resident had a complete and accurate Advance Directive Acknowledgement Form (a signed form provided to acknowledge that information regarding an Advance Directive [AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitate]) for one of six sampled residents (Resident 2). This deficient practice had the potential for Residents 2 to receive life-sustaining care and/or treatment not desired.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 12/5/2025 with diagnoses including unspecified fracture of the lower end of the right femur (a broken bone), morbid obesity (excessive body fat that poses a risk of severe health complications), and muscle weakness (a reduced ability to exert force). The AR indicated Resident 2 was the responsible party (person legally accountable for the patient's medical decisions and/or financial obligations). During a review of Resident 2's History and Physical (H&P) dated 12/8/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment and care planning tool) dated 12/10/2025, the MDS indicated Resident 2's cognition was intact and Resident 2 was dependent on toileting hygiene, bowel and bladder incontinence (involuntary loss of urine or stool), shower/bathe self, and lower body dressing. During a review of Resident 2's clinical record, the AD Acknowledgment Form dated 12/13/24 was not signed by the resident. Resident 2 was self- responsible. During a concurrent interview on 3/12/2026 at 11:28 a.m. and review of Resident 2's AD Acknowledgement Form dated 12/13/2024 with the Social Services Director (SSD), the SSD stated licensed nurses complete the AD Acknowledgement Form upon admission and Social Services follows up. The AD Acknowledgement Form did not have Resident 2's signature. The AD Acknowledgement Form indicated the SSD signed with the SSD's initials in the representative portion of the AD Acknowledgement Form. The SSD stated the AD Acknowledgement Form should have a signature from the self-responsible resident or a representative. The SSD stated it was the facility's policy to have the signature on the AD Acknowledgement Form. The SSD stated it was important to obtain a signature because it was proof that staff provided information for an AD if residents did not have AD and that the staff had collected the necessary information. During a review of the facility's Policy and Procedure (P&P), titled, Advance Directives, dated February 2024, the P&P indicated upon admission, the Admissions Staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. The Interdisciplinary Team will annually review the advance directive with the resident or responsible party, to ensure that the directive still reflects the wishes of the resident.

Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 50), Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was accurately coded regarding the use of insulin (a hormone that removes excess sugar from the blood). This failure had the potential to result in delays of necessary care and services and inaccurate plan of care and interventions for Resident 50. Findings: During a review of Resident 50's admission Record (AR), the AR indicated the facility re-admitted Resident 50 on 8/18/2024 with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the abdominal wall, severe sepsis (a life-threatening blood infection), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control) with other specified complication. During a review of Resident 50's History & Physical (H&P) dated 8/6/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 was cognitively intact (ability to understand) and received an insulin injection during the last seven days.During a review of Resident 50's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/1/2025 to 12/31/2025 and 1/1/2026 to 1/31/2026, the MARs did not indicate insulin was administered to Resident 50. During an interview on 3/10/2026 at 10:10 am with Resident 50, Resident 50 stated Resident 50 was not on insulin. During an interview on 3/12/2026 at 2:58 pm with the Assistant Director of Nursing (ADON), the ADON stated Resident 50 was initially admitted on [DATE] and had never received insulin. During an interview on 3/13/2026 at 10:45 am with the MDS Nurse (MDSN), the MDSN stated Resident 50 did not have an order for insulin but had an order for Ozempic (medication used to improve blood sugar), which was not classified as an insulin. The MDSN stated insulin use should not have been documented in the MDS dated [DATE]. The MDSN stated it was important to accurately document Resident 50's assessment to provide the Centers for Medicare and Medicaid Services (CMS) the correct resident data, including the medications the resident was taking. During an interview on 3/13/2026 at 11:06 am with the Assistant Director of Nursing (ADON), the ADON stated the MDS was a complete assessment of a resident. The ADON stated MDS assessments needed to be accurate for billing purposes and to reflect all the care provided for the residents. During a review of the facility's Policy and Procedure (P&P) titled, RAI Process, revised 5/19/2024, the P&P indicated each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed. The P&P indicated, all information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD). During a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, dated October 2025, the manual indicated the RAI process had multiple regulatory requirements. The manual indicated, federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) required that the assessment accurately reflect the resident's status.

Based on interview and record review, the facility failed to provide care and services to prevent a fall (unintentional coming to the ground) for one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance (help from two persons) when turning Resident 2 in bed while changing Resident 2's adult brief. This deficient practice resulted in Resident 2's fall on 11/24/2025 and Resident 2 sustained a right femur fracture (broken thigh bone).Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/13/2024 and readmitted on [DATE] with diagnoses including unspecified fracture of the lower end of the right femur, morbid (severe) obesity (excessive body fat that poses a risk of severe health complications), and muscle weakness (a reduced ability to exert force). During a review of Resident 2's Care Plan (CP) for at risk for falls related to bowel/bladder incontinence (loss of ability to control bowel/bladder) dated 7/30/2025, the CP indicated a goal to minimize falls and injury. The CP interventions included staff to provide assistance with Resident 2's activities of daily living (ADL- basic self-care activities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment and care planning tool) dated 9/14/2025, the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 was dependent (helper does all effort) to staff on toileting hygiene, lower body dressing, lying to sitting on side of bed and chair to bed transfer. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) to roll left and right. During a review of Resident 2's Situation Background Assessment Request (SBAR) Communication Form dated 11/24/2025, the SBAR indicated on 11/24/2025 at 9:20 pm, CNA 5 attended Resident 2 for adult brief change. The SBAR indicated, upon turning Resident 2 to the left side, Resident 2 slid off the bed. During a review of Resident 2's Post Fall Assessment (PFA) dated 11/24/2025, the PFA indicated upon turning Resident 2 to the left side by CNA 5 during adult brief change, Resident 2 slowly slid off the bed. The PFA indicated CNA 5 held onto Resident 2, with Resident 2 half kneeling on the floor. During a review of Resident 2's General Acute Care Hospital 1(GACH 1) record dated 11/25/2025, GACH 1 record indicated Resident 2 was diagnosed at the emergency room (ER) with a right femur fracture. During a review of Resident 2's GACH 1 femur and knee X-ray report dated 11/25/2025, the report indicated Resident 2 had a nondisplaced distal femoral fracture with moderate suprapatellar (a stable break near the knee). During a review of Resident 2's Nursing admission Assessment (NAA) dated 12/5/2025 at 11:00 p.m., the NAA indicated Resident 2 was readmitted back to the facility from GACH 1. During a review of Resident 2's History and Physical (H&P) dated 12/8/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During an interview on 3/10/2026 at 9:40 a.m. with Resident 2, Resident 2 stated Resident 2 had a history of fall on 11/24/2025. During an interview on 3/12/2026, at 1:52 p.m. with Resident 2, Resident 2 stated Resident 2 remembered Resident 2 slipped from the bed while being changed. Resident 2 stated there was one female CNA who assisted Resident 2 with changing Resident 2's adult brief. Resident 2 stated Resident 2 fell to the right side of Resident 2's bed and Resident 2 fell face down. Resident 2 stated Resident 2 felt pain (not rated) in Resident 2's right leg and injured Resident 2's right knee on the same right leg from the fall. During an interview on 3/13/2026 at 9:45 a.m., with CNA 3, CNA 3 stated when changing a dependent resident (total assistance with activities of daily living), the resident would require two people assisting the resident regardless of the resident's weight. CNA 3 stated that when the resident was morbidly obese, two staff were required to assist the resident to prevent the resident from rolling out of bed while being turned for changing the adult brief. CNA 3 stated for Resident 2, two people were required while changing Resident 2's adult brief. CNA 3 stated Resident 2 needed two people working with Resident 2 because Resident 2 was dependent and morbidly obese. CNA 3 stated Resident 2 could not control Resident 2's weight while being turned by staff and Resident 2 could fall over the bed and get hurt. CNA 3 stated Resident 2 required two people assisting Resident 2 at all times. CNA 3 stated having only one staff working with Resident 2 was against the facility policy. During an interview on 3/13/2026 at 10:01 a.m., with CNA 4, CNA 4 stated Resident 2 was a dependent and bed bound (confined to bed). CNA 4 stated dependent residents could not do anything for themselves. CNA 4 stated two staff were required to change and turn a dependent resident. CNA 4 stated it was important to change Resident 2 with two people assistance for safety. During an interview on 3/13/2026 at 10:40 a.m., with the Director of Nursing (DON), the DON stated on 11/24/25, Resident 2 fell and sustained a fracture. The DON stated when changing Resident 2, Resident 2 would need 2-4 staff, depending on Resident 2's strength. The DON stated when changing or turning Resident 2, it would not be beneficial for less than two staff present. The DON stated having at least two staff when turning or changing Resident 2 was important to prevent the staff from hurting themselves and for Resident 2's safety. During an interview on 3/13/2026 at 11:22 a.m. with the DON, the DON stated it was the DON's understanding that CNA 5 was the only staff present while changing Resident 2 on 11/24/2025 that resulted in Resident 2's fall. During an interview on 3/13/2026 at 11:32 a.m., with the DON, the DON stated CNA 5 made a bad judgement and CNA 5 should have asked for help for additional staff. The DON stated CNA 5 was by herself while changing Resident 2 on 11/24/2025 that resulted in Resident 2's fall. During an interview on 3/13/26 at 12:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 2 was a dependent resident who had bladder and bowel incontinence. The ADON stated Resident 2 wore an adult brief and had to be changed by staff. The ADON stated there had to be one staff on each side of the bed for repositioning, changing, and transferring Resident 2. The ADON stated Resident 2 needed two staff assistants for safety because of Resident 2's weight and Resident 2 was dependent on staff. The ADON stated it was ADON's understanding that CNA 5 was changing Resident 2's adult brief and Resident 2's fall and fracture could have been avoided if there were two staff changing Resident 2. During a review of the facility's Policy and Procedure (P&P), titled, Fall Management Program, revised November 21, 2024, the P&P indicated it was the policy of the facility to provide the highest quality care in the safest environment for the residents residing in the facility.

Based on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order for one of two sampled residents (Resident 11). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 11. Findings: During a review of Resident 11's admission Record, the AR indicated the facility initially admitted Resident 11 on 10/3/2023 and readmitted on [DATE] with diagnoses including gastroesophageal reflux disease (GERD- the stomach acid or contents leak back into the esophagus) without esophagitis (irritation or inflammation of the esophagus [tube that carries food from throat to the stomach]) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/3/2026, the MDS indicated Resident 11 cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 11 was dependent (full staff performance) with oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 11's Order Summary Report (OSR) dated 1/10/2026, the OSR indicated for staff to elevate Resident 11's head of bed at 30 to 45 degrees at all times during feeding and at least one hour after feeding every shift. During a review of Resident 11's OSR dated 1/10/2026, the OSR indicated Resident 11 was on continuous GT feeding of Glucerna 1.5 (formula) at 50 millimeter (ml, unit of measurement) per hour (hr.) via enteral feeding pump for 20 hours in 24 hours, on at 11 am and off at 7 am or until the dose was completed. During a review of Resident 11's untitled Care Plan (CP) dated 1/13/2026, the CP indicated Resident 11 required tube feeding related to dysphagia (difficulty swallowing). The care plan interventions indicated for nursing staff to administer enteral feeding as prescribed and keep Resident 11's head of bed elevated at 30 to 45 degrees at all times during feeding and at least one hour after feeding. During a concurrent observation and interview on 3/11/2026 at 2:04 pm, together with Licensed Vocational Nurse 2 (LVN 2), Resident 11 was awake, lying in bed, in supine position with the head of the bed not elevated to 30 to 45 degrees and was connected to a GT feeding formula. LVN 2 turned on the GT feeding and started leaving Resident 11. LVN 2 stated Resident 11 was lying almost flat in bed and the CNA forgot to elevate the HOB to 30 to 45 degrees after assisting Resident 11 with activities of daily living (ADL). LVN 2 stated Resident 11's HOB should have been elevated to 30 to 45 degrees while the feeding is ongoing for aspiration precaution. During a concurrent interview and record review on 3/11/2026, at 2:18 pm, with the Assistant Director of Nursing (ADON) of Resident 11's medical records (PointClickCare - PCC, a cloud-based software) the ADON stated Resident 11's head of bed needed to be elevated to 30 to 45 degrees while receiving GT feeding and at least one hour after feeding to prevent aspiration. During a review of the facility's Policy and Procedure titled, Gastrostomy Placement, revised 2/9/2024, the P&P indicated To limit the risk for aspiration and reflux, raise the head of the bed 30-45 degrees prior to checking placement of the gastrostomy tube.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought in by Visitors, by failing to label outside food for Resident 88 and ensure outside food adhered to Resident 88's prescribed diet. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 88 that could lead to serious medical complications and hospitalization. Findings: During a review of Resident 88's admission Record (AR), the AR indicated the facility admitted Resident 88 on 3/3/2026 with diagnoses including pneumonia (an infection in the lungs) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 88's Care Plan (CP) dated 3/3/2026, the CP indicated Resident 88 was at risk for aspiration. The CP intervention indicated for the staff to educate the resident and family about the importance of adhering to the prescribed diet and the risks of eating food outside of the prescribed diet. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool) dated 3/8/2026, the MDS indicated Resident 88 had intact cognition (ability to understand). The MDS indicated it was very important for Resident 88 to have snacks available between meals. The MDS indicated Resident 88 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 88 required supervision from staff with personal hygiene. The MDS indicated Resident 88 required moderate assistance (helper did less than half the effort) from staff with showering/ bathing and bed-to-chair transferring. The MDS indicated Resident 88 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene. During a review of Resident 88's Order Summary Report (OSR) as of 3/12/2026, the OSR indicated an active physician order for Level 6 soft and bite sized texture diet (food was soft and cut into small pieces that were easy to chew) for Resident 88, ordered on 3/11/2026. During an observation on 3/10/2026 at 9:41 AM in Resident 88's room, the following were observed at Resident 88's bedside:1. Two sealed containers of food with no label.2. One jar of roasted cashew nuts halves with no label. 3. One jar of peanuts halves with no label. During an observation on 3/10/2026 at 11:45 AM, in Resident 88's room, the following were observed at Resident 88's bedside: 1. One jar of roasted cashew nuts halves with no label. 2. One jar of peanuts halves with no label. During a concurrent observation and interview with Resident 88 on 3/11/2026 at 12:52 PM in Resident 88's room, the following were observed at Resident 88's bedside:1. One jar of roasted cashew nuts halves with no label. 2. One jar of peanuts halves with no label.Resident 88 stated Resident 88's family brought the food yesterday (3/10/26) and Resident 88 ate it. During an interview with Certified Nurse Assistant 2 (CNA 2) on 3/11/2026 at 12:52 PM, CNA 2 stated CNA 2 did not have time to label the food brought in by family on 3/10/2026 for Resident 88. CNA 2 stated nursing staff should label Resident 88's food with room number and name, so the nursing staff would know who the food belonged to and not give it to other residents. During a concurrent pictures review and interview with Licensed Vocational Nurse 3 (LVN 3) on 3/12/2026 at 10:22 AM, the pictures dated 3/10/2026 at 9:42 AM and 11:45 AM, and 3/11/2026 at 12:52 PM, were reviewed. LVN 3 stated the pictures indicated Resident 88's outside food did not have labels of resident's name or date. LVN 3 stated it was the standard of practice and for infection control to label outside food. LVN 3 stated the receiving nurse should label the food with the resident's name and the date received and place it in the refrigerator. LVN 3 stated it was important to label the outside food to prevent foodborne illness. LVN 3 stated the licensed nurse should check the resident's diet order to ensure food brought in from the outside was in accordance with the ordered diet texture for the resident. LVN 3 stated the licensed nurse should document the resident's non compliance with prescribed diet in the resident's progress notes. LVN 3 stated Level 6 soft and bite sized foods were soft like mashed potatoes, while peanuts and cashews were dry and hard and did not meet Level 6 diet requirements. During a concurrent pictures review and interview with the Dietary Supervisor (DS) on 3/12/2026 at 1:42 PM, the picture dated 3/11/2026 at 12:52 PM was reviewed. The DS stated the cashew nuts halves and peanuts halves were not appropriate for Level 6 soft bite diet texture for Resident 88. The DS stated outside food should be in accordance with the resident's prescribed diet. The DS stated speech therapy should evaluate the resident to avoid choking for safety. The DS stated the purpose of Level 6 soft and bite size diet for Resident 88 was to avoid difficulty swallowing. During a concurrent record review and interview with the Assistant Director of Nursing (ADON) on 3/12/2026 at 1:54 PM, Resident 88's Nursing Progress Notes (NPN) for 3/2026 were reviewed. The ADON stated the NPN did not indicate documentation that Resident 88's physician was notified regarding Resident 88's outside food that did not adhere to the prescribed/ordered diet. The ADON stated the licensed nurse should have notified Resident 88's physician if Resident 88 insisted on wanting the cashew nuts and peanuts. The ADON stated following the prescribed diet was for the safety of Resident 88. During a review of the facility's P&P titled, Foods Brought in by Visitors, dated 2/9/2024, the P&P indicated the dietary staff would review the resident's diet with the visitor, and provide education regarding the resident's diet orders and safe food handling practices when the resident desired to have food brought in by visitors. The P&P indicated outside food should be stored in a sealable container with the resident's name and date it was bought to the facility. The P&P indicated residents who were not compliant with prescribed diets would receive education from the registered dietician, attending physician or licensed nurse regarding risks and benefits. The P&P further indicated that such education would be documented.

Based on observation, interview, and record review, the facility failed to ensure staffing information on the Nurse Staffing Information Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors. This failure resulted in nursing staffing information not accessible to residents and visitors and had the potential to negatively affect the quality of care for the residents. Findings: During a review of the facility's map, the map indicated there were two nursing stations, Station 1 and Station 2. During observations on 3/10/2026 at 10:44 am, 3/11/2026 at 10:53 am, and 3/12/2026 9:10 am the Nurse Staffing Information Sheet was only posted on the wall across from Nursing Station 1. During a concurrent observation and interview on 3/12/2026 at 2:29 pm with the Assistant Director of Nursing (ADON), the Nurse Staffing Information Sheet was posted across from Nursing Station 1. The ADON stated, the ADON was responsible for staffing postings and the nursing staffing information was only posted across from Station 1. The ADON stated the Nurse Staffing Information was not readily accessible to residents and visitors. The ADON stated, the residents in part of Nursing Station 2 and residents in Station 3 (Station 2 on the facility map) who resided behind the closed double doors were unable to easily access the Nurse Staffing Information posting. The ADON stated visitors needed to go to Nursing Station 1 and 2 (Station 1) to be able to view the Nurse Staffing Information. The ADON stated the Nurse Staffing Information was important for transparency and to allow residents or visitors to determine if the facility staff was adequate. During an interview on 3/13/2026 at 10:17 am with the Director of Nursing (DON), the DON stated the Nurse Staffing Information Sheet was posted in front of Nursing Station 1 and 2 (Station 1) and for residents and visitors to review it, they would need to go to Nursing Stations 1 and 2. During an interview on 3/16/2026 at 11:32 am with the Administrator (ADM), the ADM stated the Nurse Staffing Information Sheet had always been posted at Nursing Station 1 and 2 (Station 1) and should be posted somewhere where it was accessible. The ADM stated accessible means an area that residents or visitors would go to without restrictions. The ADM stated the purpose of posting the Nurse Staffing Information was for residents and visitors to be able to see the current staffing of the facility with the current census. The ADM stated residents and visitors had the right to view the Nurse Staffing Information, know what the staffing was, and if there were enough staff to provide resident care. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Department-Staffing, Scheduling & Postings, dated 2/9/2024, the P&P indicated as a posting requirement that data must be posted in a prominent place readily accessible to residents and visitors.

Based on interview and record review, the facility failed to develop and implement care plans (CP- a personalized document that outlines a resident's medical and social care needs and the actions required to address them) for four of seven sampled residents (Residents 1, 2, 6, and 7) according to the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Ensure Residents 1 and 6 had CPs developed for the administration of intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) antibiotics (abx- medication that inhibits the growth of or destroys bacteria in the body). 2. Ensure Resident 7 had a CP developed and implemented for the use of peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). 3. Ensure Resident 2's CP for IV indicated the location of the IV. These failures resulted in Residents 1, 2, 6, and 7 not having an appropriate CP developed or implemented. These failures had the potential for Residents 1, 2, 6, and 7 to not receive the care and services needed for IV services and to treat the residents' medical conditions.Findings: a1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 was readmitted on [DATE] with diagnoses that included urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract) acute kidney failure (when the kidneys suddenly stop working due to complication of another serious illness), and unspecified hydronephrosis (a condition where urine backs up into the kidneys, causing them to swell, generally caused by infection or obstruction). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had an active UTI. The MDS indicated Resident 1 was taking an abx. During a review of Resident 1's Order Summary Report (OSR) date range [DATE] to [DATE], the OSR indicated Resident 1 had an order for Cefepime HCl Intravenous Solution (type of abx), two grams (gm- unit of measurement) per 100 milliliters (mL- unit of measurement). The OSR indicated to give Resident 1 one dose daily intravenously every 12 hours for UTI for five days. The OSR indicated to start Cefepime on [DATE]. During a review of Resident 1's untitled Care Plan Report (CPR), the CPR did not indicate Resident 1 had a CP initiated for use of IV abx therapy, Cefepime. a2. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on [DATE] with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's OSR, date range from [DATE] to [DATE], the OSR indicated Resident 6 had an IV order for Caspofungin (an antifungal medication, used to treat serious fungal infections), 50 milligrams (mg- unit of measurement)) IV every 24 hours for 12 days for fungal infection to the upper right chest dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) catheter (line used for dialysis). The OSR indicated the order date was [DATE]. During a review of Resident 6's untitled CPR, the CPR did not indicate Resident 1 had a CP initiated for use of IV antifungal therapy, Caspofungin. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. b. During a review of Resident 7's AR, the AR indicated the facility admitted Resident 7 on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia (bacterial infection in the bloodstream), and unspecified respiratory failure (serious condition that makes it breathe on one's own). During a review of Resident 7's OSR, date range from [DATE] to [DATE], the OSR indicated Resident 7 had an IV medication order for Zosyn (type of abx), four and a half (4.5) gm IV via PICC line, every eight hours for five days for sepsis. The order date was [DATE]. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had pneumonia (an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) and was on abx. During a review of Resident 7's untitled CPR, the CPR did not indicate Resident 7 had a CP initiated for use of PICC. c. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on [DATE] and was readmitted on [DATE] with diagnoses that included sepsis due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), UTI, and bacteremia. During a review of Resident 2's OSR, date range [DATE] to [DATE], the OSR indicated Resident 2 had an IV order for Meropenem (type of abx) one gm, every 12 hours for seven days for (treatment of) extended-spectrum beta-lactamase (ESBL- enzymes produced by certain bacteria that make them resistant to many beta-lactam antibiotics) E. coli bacteremia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS indicated Resident 2 had a UTI in the last 30 days and was on abx therapy. The MDS indicated Resident 2 had an IV upon admission for abx use. During a review of Resident 2's untitled CPR, the CPR indicated Resident 2 had a CP initiated on [DATE] for at risk for infection and complications related to PIV line. The CP did not indicate the location or site of the PIV. The CP goals indicated Resident 2 would be free form signs and symptoms of infection related to IV line through the review date. The CP goals indicated to check the IV site for patency (openness) and dislodgment (not in the vein), flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)] IV line with 10 mL of NS before and after IV medications and to flush IV line with 10 mL NS every 12 hours when IV is not in use. During a concurrent interview and record review on [DATE] at 10:19 am, with the MDS Coordinator (MDSC), Residents 1, 2, 6, and 7's CPRs were reviewed. The MDSC stated Resident 7 did not have a CP for (use of) PICC. The MDSC stated Resident 7 should have a CP for use of PICC because staff needed to know what interventions to follow regarding the use. The MDSC stated MDSC could not find the location of Resident 2's PIV in the CPR or in any of Resident 2's records. The MDSC stated Resident 2's CP for PIV needed to indicate the location of the PIV so staff would know where to monitor and assess for complications. The MDSC Residents 1 and 6's CPR did not include a CP for (use of) abx therapy. The MDSC stated all residents on abx therapy needed a CP initiated because residents on abx therapy for being monitored for complications and adverse side effects. During an interview on [DATE] at 2:13 pm, with the Director of Nursing (DON), the DON stated (in general) all residents on IV medications, such as abx, and the IV access needed to be incorporated into the residents' plan of care because there were supposed to be interventions in place to prevent complications. The DON stated all IV CPs needed to indicate the site so staff know where to look and apply the interventions. The DON stated without CPs, the licensed nurses did not have a roadmap to the residents. During a review of the facility's P&P titled, Care Planning, implemented [DATE], the P&P indicated the purpose was to ensure that a comprehensive, person-centered CP was developed for each resident based on individual assessed needs. The P&P indicated the facility would develop a person-centered baseline CP for each resident within 48 hours of admission and would include at least the following information: physician orders, dietary services, therapy services, and social services. The P&P indicated once the baseline CP was completed, the facility must provide the resident and/or the resident's representative with a written summary of the baseline CP that included: initial goals of the resident, summary of medications and dietary instructions, services or treatments to be administered, and updated information on completion of the comprehensive CP, as indicated.

Based on interview and record review, the facility failed to provide clear, complete and signed intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) medication orders, and IV flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) orders according to the facility's policies and procedures (P&P) titled, Medication Orders, Peripheral Catheter (IV) Flushing, and, Continuous Infusion of Medications and Solutions, for seven of seven sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7) by failing to: 1. Ensure Resident 1's Physician Order for Infusion (IV) Therapy (POFIT) dated 6/30/2025, and IV medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 6/2025 to 7/2025 indicated peripheral (away from the heart) IV flush orders and that licensed nurses (LN) Resident 1's IV was being flushed with 10 milliliters (mL- unit of measurement) NS every 12 hours as indicated. 2. Ensure Resident 2's IV MAR dated 6/2025 indicated when to flush Resident 2's IV according to the POFIT, dated 6/19/2025, and that LNs were flushing Resident 2's IV with 10 mL NS every 12 hours as indicated in the POFIT. 3. Ensure Resident 3's LNs were flushing Resident 3's IV with 10 mL NS every 12 hours as indicated in Resident 3's IV MAR dated 7/2025 and ensure Resident 3's POFIT, dated 7/7/2025 was signed by the physician, indicated peripheral IV flush orders, and indicated an accurate dose of IV medication. 4. Ensure Resident 4's POFIT dated 7/7/2025 was signed by Resident 4's physician. 5. Ensure Resident 5's POFIT dated 5/9/2025 indicated the dose, frequency, and diagnosis for use of IV vancomycin (type of antibiotic [abx- medication that inhibits the growth of or destroys bacteria in the body]), and ensure Resident 5's peripherally inserted central venous catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart) was flushed every 12 hours as ordered in Resident 5's POFIT. 6. Ensure Resident 6's IV MAR for 7/2025 indicated to flush Resident 6's IV every 12 hours as ordered by Resident 6's physician in the POFIT dated 7/1/2025. 7. Ensure Resident 7's IV MAR dated 7/2025 indicated the frequency, start and stop dates for use of Zosyn (type of abx). As a result of these failures, Residents 1, 2, 3 and 5, 6's IV or PICC were not flushed every 12 hours as ordered. Residents 3 and 4's POFIT were not signed by their physicians. Resident 7's order for Zosyn did not have a start and stop dates. These failures put Residents 1, 2, 3, 4, 5, 6, and 7 at risk for complications with IV use and medication errors.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility was readmitted Resident 1 on 6/30/2025 with diagnoses that included urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract) acute kidney failure (when the kidneys suddenly stop working due to complication of another serious illness), and unspecified hydronephrosis (a condition where urine backs up into the kidneys, causing them to swell, generally caused by infection or obstruction). During a review of Resident 1's IV MAR dated 6/30/2025 to 7/2025, the IV MAR indicated Resident 1 received one maintenance flush per day from 6/30/2025 to 7/5/2025. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/5/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had an active UTI. The MDS indicated Resident 1 was taking an abx. b. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/7/2023 and was readmitted on [DATE] with diagnoses that included sepsis (the body's extreme response to infection and a life-threatening medical emergency) due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), UTI, and bacteremia (bacterial infection in the bloodstream). During a review of Resident 2's IV MAR dated 6/2025, the IV MAR indicated Resident 2 received Meropenem (type of abx) from 6/19/2025 to 6/25/2025. The IV MAR indicated Resident 2 received one maintenance (IV) flush between 3 pm and 11 pm between 6/19/2025 and 6/25/2025. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 2 had a UTI in the last 30 days and was on abx. The MDS indicated Resident 2 had an IV present on admission for abx use. c. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 7/7/2025 with diagnoses that included pneumonia (PNA- an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) due Mycoplasma pneumoniae (type of bacteria), unspecified respiratory failure (serious condition that makes it breathe on one's own) and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 3's IV MAR dated 7/2025, the IV MAR indicated Resident 3 received IV medication from 7/8/2025 to 7/13/2025. d. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should) stage three, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 4 had active PNA, was on abx therapy, and had an IV present on admission. During a review of Resident 4's POFIT dated 7/7/2025, the POFIT indicated Resident 3 was ordered to receive ceftriaxone (type of abx) for treatment of UTI. During a review of Resident 4's IV MAR dated 7/2025, the IV MAR indicated Resident 4 received IV medication from 7/7/2025 to 7/11/2025. e. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 5/9/2025 with diagnoses that included acute (sudden onset) osteomyelitis (serious infection of the bone that be either be acute or chronic) of the left ankle and foot, type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and gangrene (dangerous and potentially fatal condition that happens when blood flow to a large area of tissue is cut off, breaks down then dies). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition. The MDS indicated Resident 5 had acute osteomyelitis of the left ankle and foot, was taking abx and had IV access. During a review of Resident 5's IV MAR dated 6/2025, the IV MAR indicated Resident 5 received IV cefepime (type of abx) from 6/5/2025 to 6/19/2025. f. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 7/1/2025 with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's IV MAR dated 7/2025, the IV MAR indicated Resident 6 was on IV medication from 7/1/2025 to 7/12/2025. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. g. During a review of Resident 7's AR, the AR indicated the facility admitted [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia, and unspecified respiratory failure. During a review of Resident 7's IV MAR dated 7/2025, the IV MAR indicated Resident 7 was on Zosyn (type of abx) from 7/12/2025 to 7/16/2025. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had PNA and was on abx. During a concurrent interview and record review on 7/17/2025 at 10:19 am, with the MDS Coordinator (MDSC), Residents 1, 2, 3, 4, 5, 6, and 7's IV MAR and POFIT were reviewed. The MDSC stated Resident 1's POFIT dated 6/30/2025 did not indicate peripheral IV flush orders. The MDSC stated the orders were supposed to be filled out by the registered nurse (RN). The MDSC stated according to Resident 1's IV MAR dated 6/2025 to 7/2025, Resident 1 was only receiving one maintenance flush per day. The MDSC stated Resident 1 was supposed to be receive one maintenance flush every 12 hours. The MDSC stated the physician did not sign Resident 1's POFIT dated 6/30/2025. The MDSC stated according to Resident 2's POFIT dated 6/19/2025, LNs were to maintenance flush Resident 2's IV every 12 hours with 10 mL NS. The MDSC stated the physician's signature was missing from the POFIT. The MDSC stated according to the IV MAR dated 6/2025, LNs only maintenance flushed Resident 2's IV with 10 mL NS once a day not every 12 hours as ordered by Resident 2's physician. The MDSC stated Resident 3's POFIT dated 7/7/2025 was missing the physician's signature and did not indicate peripheral IV flush orders. The MDSC stated flush orders should be indicated in the POFIT. The MDSC stated dose of ceftriaxone (type of abx) was written as 29 but the ordered dose was supposed to be for two (2) grams (gm- unit of measurement). The MDSC stated according to Resident 3's IV MAR dated 7/2025 indicated to maintenance flush Resident 3's IV every 12 hours. The MDSC stated LNs were only maintenance flushing Resident 3's IV once a day. The MDSC stated the physician's signature was missing from Resident 4's POFIT dated 7/7/2025. The MDSC stated Resident 5's POFIT dated 5/9/2025 did not indicate what dose and at what frequency Resident 5 was to receive IV vancomycin. The MDSC stated the indicating diagnosis was missing from Resident 5's POFIT. The MDSC stated the physician ordered Resident 5's PICC to be flushed every 12 hours with 10 mL NS. The MDSC stated according to Resident 5's MAR dated 6/2025, LNs were only maintenance flushing Resident 5's PICC once a day. The MDSC stated Resident 6's IV MAR dated 7/2025 was supposed to indicate what maintenance flushes Resident 6 was to receive but was not indicated. The MDSC stated Resident 7's IV MAR dated 7/2025 was supposed to indicate the frequency, start and stop dates for Resident 7's Zosyn order, but were not indicated. The MDSC stated the IV needed to be complete because it was the official medical record. During an interview on 7/17/2025 at 2:13 pm, with the Director of Nursing (DON), the DON stated (in general) the IV MAR was filled out by RNs and needed to indicate the name of the IV medication, dose, frequency, start and stop dates. The DON stated the IV MAR needed to indicate what type of maintenance flush a resident was to received. The DON stated (in general) the POFIT needed to include the facility's name, order date and time, resident name and room/bed number and if the resident has DM or hypertension (condition where the force of blood against artery walls is consistently too high and blood pressure [BP- the pressure circulating blood against the walls of blood vessels; abnormal BP was less than 120/80 millimeters of mercury [mmHg- unit of measurement] and above 140/90 mmHg considered high blood pressure] is consistently high), the physician's name and signature, the LNs signature who obtained the order, resident's allergies, height, weight, laboratory values, and if they receive dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to). The DON stated the IV MAR and POFIT needed to be filled out accurately and completely so all staff know what the IV medication was to avoid medication errors, otherwise it could affect the resident's safety and could lead to complications like hospitalization or even death. The DON stated the POFIT needed to be signed by the physician because they are the ones ordering IV medications and their signatures verifies that what LNs write on the POFIT is correct. The DON stated there should always be maintenance flushes ordered with IVs to ensure patency (openness of IV line). The DON stated the standard of practice was for LNs to flush IVs (peripheral and PICC) every 12 hours and before and after medication administration. The DON stated IVs were not being flushed, the IV lines could become occluded (clogged) and could lead to blood clots and the inability to give medications to the residents, which could delay care or treatment. The DON stated the IV could need to be removed and replaced with a new line that could cause a resident pain or discomfort. The DON stated if there was a delay in care, it could affect the efficacy of the IV medication or complications to the resident's illness. During a review of the facility's P&P titled, Medication Orders, revised 1/2025, the P&P indicated medications were administered only upon clear, complete, and signed order of the person lawfully authorized to prescribe (write medication orders). The P&P indicated medication orders specified the name of the medication, strength (where indicated), dose and dosage form, time or frequency of administration, route of medication, quantity or duration of therapy, and diagnosis or indicated for use. During a review of the facility's P&P titled, Peripheral Catheter Flushing, dated 3/2023, the P&P indicated that RNs and IV certified licensed vocational nurses (LVN) according to state law and facility policy were to perform IV flushing. The P&P indicated flushing was performed to ensure and maintain catheter (IV) patency and to prevent the mixing of incompatible medications/solutions. The P&P indicated a physician's order was required to flush a peripheral catheter. The P&P indicated to verify the physician order (before flushing). The P&P indicated the order must include the flushing agent, volume and frequency. The P&P indicated documentation in the medical record must include the date and time (of the flush), prescribed flushing agents, site assessment, resident response to procedure and/or medication, and resident teaching. During a review of the facility's P&P titled, Continuous Infusion of Medications and Solutions, dated 3/2023, the P&P indicated to verify the physician's order for administering IV medications. The P&P indicated documentation in the medical record included, but was not limited to the date and time, prescribed flushing agents, medication/solution, rate of infusion site assessment, complications and interventions, resident response to procedure and/or medication, and resident teaching

Based on interview, and record review, the facility failed to provide concise and clear documentation for six of seven sampled residents (Residents 2, 3, 4, 5, 6, and 7) according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to ensure: 1. Ensure Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream flush (to insert normal saline [NS- a sterile solution of water and sodium chloride (table salt)]) in the IV Therapy medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) (IV MAR) were legible (able to clearly read). 2. Ensure Resident 3's medication name and diagnosis in the IVMAR were legible. Ensure Resident 3's medication dose and diagnosis were on the Physician Order for Infusion (IV) Therapy (POFIT) were legible. 3. Ensure Resident 4's allergies, medication dose, and flush times were legible in the IV MAR. 4. Ensure Resident 5's allergies were documented on the IV MAR. 5. Ensure Resident 6's medication name and allergies in the IV MAR were legible. 6. Ensure Resident 7's allergies, IV flush times, and medication order were legible in the IV MAR. As a result of these failures, Residents 2, 3, 4, 5, 6, and 7's medical records were not legible. These failures had the potential for Residents 2, 3, 4, 5, 6, and 7 to receive inaccurate medications and/or doses, experience an allergic reaction to medications, and not receive IV flushes at the appropriate times. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/7/2023 and was readmitted on [DATE] with diagnoses that included sepsis due to Escherichia coli (E. coli- a type of bacteria commonly found in the intestines [gut] and urinary tract), urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract), and bacteremia (bacterial infection in the bloodstream). During a review of Resident 2's IV MAR dated 6/2025, the IV MAR indicated Resident 2 received Meropenem (type of antibiotic) from 6/19/2025 to 6/25/2025. The IV MAR indicated Resident 2 received one maintenance (IV) flush (type of IV flush that it given at set times) between 3 pm and 11 pm between 6/19/2025 and 6/25/2025. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment too) dated 6/24/2025, the MDS indicated Resident 2 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 2 had a UTI in the last 30 days and was on antibiotic (abx- medication that inhibits the growth of or destroys bacteria in the body) therapy. The MDS indicated Resident 2 had an IV present on admission for abx use. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 7/7/2025 with diagnoses that included pneumonia (PNA- an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus) due Mycoplasma pneumoniae (type of bacteria), unspecified respiratory failure (serious condition that makes it breathe on one's own) and chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 3's IV MAR dated 7/2025, the IV MAR indicated Resident 3 received IV medication from 7/8/2025 to 7/13/2025. c. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should) stage three, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 4 had active PNA, was on abx therapy, and had an IV present on admission. During a review of Resident 4's POFIT dated 7/7/2025, the POFIT indicated Resident 3 was to receive ceftriaxone (type of abx) for treatment of UTI. During a review of Resident 4's IV MAR dated 7/2025, the IV MAR indicated Resident 4 received IV medication from 7/7/2025 to 7/11/2025. d. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 5/9/2025 with diagnoses that included acute (sudden onset) osteomyelitis (serious infection of the bone that be either be acute or chronic) of the left ankle and foot, type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and gangrene (dangerous and potentially fatal condition that happens when blood flow to a large area of tissue is cut off, breaks down then dies). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition. The MDS indicated Resident 5 had acute osteomyelitis of the left ankle and foot, was taking abx and had IV access. During a review of Resident 5's IV MAR dated 6/2025, the IV MAR indicated Resident 5 received IV cefepime (type of abx) from 6/5/2025 to 6/19/2025. e. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 7/1/2025 with diagnoses that included candidal sepsis (a severe bloodstream infection caused by Candida [type of fungus], which can lead to organ damage and even death), asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 6's IV MAR dated 7/2025, the IV MAR indicated Resident 6 was on IV medication from 7/1/2025 to 7/12/2025. During a review of Resident 6's MDS dated [DATE], the MDS indicated that Resident 6 had intact cognition. The MDS indicated Resident 6 was on IV medication and had IV access. f. During a review of Resident 7's AR, the AR indicated the facility admitted [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sepsis, bacteremia (bacterial infection in the bloodstream), and unspecified respiratory failure. During a review of Resident 7's IV MAR dated 7/2025, the IV MAR indicated Resident 7 was on Zosyn (type of abx) from 7/12/2025 to 7/16/2025. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. The MDS indicated Resident 7 had PNA and was on abx. During a concurrent interview and record review on 7/17/2025 at 10:19 am, with the MDS Coordinator (MDSC), Resident 2, 3, 4, 5, 6, and 7's IV MAR and POFIT were reviewed. The MDSC stated, when filling out the time date on the IV MAR, the treatment time was to be documented on top, and the licensed nurse's initials to be documented below the time. The MDSC stated on Resident 2's IV MAR dated 6/2025, I cannot read what times (Resident 2's) IV was flushed. The MDSC stated on Resident 3's IV MAR dated 7/2025, the IV medication was not legible. The MDSC stated Resident 3 was ordered ceftriaxone. The MDSC stated the MDSC could not read Resident 3's diagnosis for IV. The MDSC stated Resident 3 the diagnosis was supposed to be Mycoplasma pneumoniae. The MDSC stated on Resident 4's IV MAR dated 7/2025, the MDSC could not read was times Resident 4's IV was flushed. The MDSC stated the IV MAR indicated to flush between three and one (referring to times), but the IV MAR should have indicated to flush Resident 4's IV between 3 pm and 11 pm. The MDSC stated, I don't know if the order is being followed because none of the flush times are not legible. The MDSC stated Resident 4's allergies were, Hard to read. The MDSC stated Resident 4 had allergies to non-steroidal anti-inflammatory drugs (NSAIDS- type of medication used to treat mild to moderate pain). The MDSC stated the dose of ceftriaxone was not legible. The MDSC stated, It (the dose) looks a ‘T' and not a number. The MDSC stated it was possible Resident 4 could get the wrong treatment. The MDSC stated on Resident 4's POFIT dated 7/2025, the dose for ceftriaxone was supposed to be one (1) gram (gm- unit of measurement), but looked like seven (7) gm. The MDSC stated on Resident 5's IV MAR dated 6/2025, the IV MAR did not indicate if Resident 5 had any allergies. The MDSC stated if Resident 5 had no known drug allergies (NKDA) it should be indicated in the IV MAR. The MDSC stated on Resident 6's IV MAR dated 7/2025, the IV medication was not legible. The MDSC stated Resident 6 had taken caspofungin (type of medication use to treat fungal infections). The MDSC stated Resident 6 had three allergies documented on the IV MAR that were not legible, but stated Resident 6 had 10 allergies documented in the electronic health record (EHR). The MDSC stated allergies needed to documented in the IV MAR to ensure Resident 6 did not receive any medication Resident 6 was allergic to, develop an allergic reaction and get sick. The MDSC stated for Resident 7's IV MAR dated 7/2025, Resident 7's allergies were not legible. The MDSC stated Resident 7 had allergies to phenytoin (type of medication used to treat seizures [sudden, controlled electrical disturbance in the brain that can cause temporary changes in behavior, movement, consciousness, or sensation]) and latex (type of rubber product). The MDSC stated the flush times on Resident 7's IV MAR from 7/12/2025 to 7/17/2025 were not legible. During an interview on 7/17/2025 at 2:13 pm, with the Director of Nursing (DON), the [NAME] stated all documentation (on the IV MAR and POFIT) needed to be filled out completely and legibly so all staff knew what the IV medication order was to avoid medication errors. The DON stated illegible documentation could affect a resident's safety and could lead to complications like hospitalization or even death. During a review of the facility's P&P titled, Documentation- Nursing, implemented 2/9/2024, the P&P indicated the purpose was to provide documentation of resident status and care given by nursing staff. The P&P indicated nursing documentation would concise, clear, pertinent, and accurate. The P&P indicated MARs were completed with each medication completed.

Based on interview and record review, the facility failed to ensure licensed vocational nurses (LVNs) and certified nurse assistants (CNAs) had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to understand different infection types in the healthcare setting by failing to: 1. Ensure the Infection Prevention Nurse (IPN), Director of Staffing Development (DSD), LVN 3, LVN 4, CNA 4, CNA 5 and Restorative Nurse Assistant/CNA (RNA) 1 were aware that Group A Streptococcus (GAS- bacteria that enters the body and causes an illness and affects the skin and throat) were bacteria (organism that enters the body and cause illness) that could cause infections through respiratory droplets (respiratory particles created when coughing, sneezing, or talking) or direct contact. 2. Ensure CNA 4 and RNA 1 were aware the facility had an active outbreak (OB- sudden rise in the incidence of a disease) of GAS. These failures had the potential to result in widespread infection in the facility. Findings: During an interview on 3/14/2025 at 11:29 am, with the IPN, the IPN stated the facility had an active GAS OB since 2/20/2025 and would be in active GAS OB until 4/8/2025. The IPN stated the IPN had done in-services on GAS and infection control. During a telephone interview on 3/14/2025 at 11:38 pm, with the Public Health Nurse (PHN), the PHN stated the facility's GAS OB started on 2/20/2025 when the PHN visited the facility to provide recommendations. The PHN stated the facility was currently in a GAS OB until 4/8/2025. The PHN stated GAS was a type of bacterial infection. During an interview on 3/14/2025 at 1:14 pm, with CNA 4, CNA 4 stated CNA 4 was not aware the facility had a GAS OB at the time of the interview. CNA 4 stated there was no COVID-19 (infectious disease caused by SARS-CoV-2 virus) in the facility. CNA 4 stated CNA 4 did not know what GAS was. During an interview on 3/14/2025 at 1:28 pm, with RNA 1, RNA 1 stated the facility had a GAS OB, but did not currently have a GAS OB at the time of the interview. RNA 1 stated RNA 1 did not know what type of infection GAS was. During an interview on 3/14/2025 at 1:40 pm, with CNA 5, CNA 5 stated GAS was a virus. During an interview on 3/14/2025 at 1:52 pm, with LVN 3, LVN 3 stated the facility had an active OB of, Strep A virus, until they were cleared by the PHN. During an interview on 3/14/2025 at 2:06 pm, with LVN 4, LVN 4 stated GAS was a fungal infection. LVN 4 stated LVN 4 was in-serviced on GAS when the OB was announced (on 2/20/2025). During an interview on 3/14/2025 at 2:16 pm, with the DSD, the DSD stated the facility currently had an active GAS OB. The DSD stated GAS was a viral throat infection that should be treated like a respiratory infection. During an interview 3/14/2025 at 4:20 pm, with the IPN, the IPN stated both the IPN and DSD provided in-services to staff regarding GAS when the GAS OB was announced on 2/20/2025. The IPN stated GAS was a viral infection that was treated with antibiotics (medication used to treat bacterial infections). During an interview on 3/14/2025 at 4:27 pm, with Registered Nurse Supervisor (RNS) 1, RNS 1 stated GAS was a bacterial infection that was treated with antibiotics. RNS 1 stated if staff did not know what GAS was, did not know what type of infection GAS was, then staff may end up spreading GAS to other residents, who could get sick and end up hospitalized . RNS 1 stated it was important to be educated on the in-services and know what was going on in the facility so staff could keep the residents safe. During a review of the facility's GAS frequently asked questions (FAQ)/fact sheet, undated, the GAS FAQ/fact sheet indicated GAS were bacteria commonly found in the throat and on the skin. During a review of the Centers of Disease Control and Prevention (CDC) website titled, About Group A Strep Infection, updated on 3/1/2024, the website indicated Group A strep bacteria can cause many different types of infections that range from minor to serious. Group A strep bacteria were contagious. Generally, people spread the bacteria to others through respiratory droplets or direct contact. [https://www.cdc.gov/group-a-strep/about/index.html] During a review of the facility's policy and procedure (P&P) titled, Competency Evaluation, dated 8/2017, the P&P indicated it was the facility's policy to perform competency evaluation for all employees. The P&P indicated the competency checklist would include . staff's skills on assessment, evaluation, planning, and implementation of the resident's plan care of care and resident needs, including infection control.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility ' s policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs [containing 60%-95% alcohol] and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to a variety of hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves), and Resident Isolation- Categories of Transmission-Based Precautions (TBP- set of infection control measures that use PPE to reduce the spread of different organisms) for four of four sampled residents by failing to: 1. Ensure the facility posted their Group A Strep (GAS- bacteria that enters the body and causes an illness and affects the skin and throat) Outbreak (OB- sudden rise in the incidence of a disease) Notification Letter (letter that indicates to staff, residents, and visitors the facility has an active OB) at the front door of the facility, and the GAS frequently asked questions (FAQ)/fact sheet, as recommended by the Public Health Nurse (PHN- focuses on promoting and protecting the health of populations by utilizing nursing, social, and public health knowledge, working in communities to prevent disease and improve health outcomes). 2. Ensure Certified Nurse Assistant (CNA) 1 donned (put on) a mask properly and perform hand hygiene while caring for Resident 3. 3. Ensure CNA 2 performed hand hygiene before and after entering Resident1's room who was on EBP. 4. Ensure the facility including LVN 4 educated Resident 4's visitors (Family 1 and Family 2), who was on contact precautions (used to prevent the spread of infections transmitted by direct or indirect contact with a patient or their environment by wearing a gown and gloves) to wear the appropriate PPE while in the room. 5. Ensure LVN 2 donned a mask properly while in the facility. 6. Ensure CNA 3 donned proper PPE before entering Resident 2's room who was on EBP. As a result of these failures, Residents 1, 2, 3 , and 4 were at risk for exposure to infectious agents. These failures had the potential to spread and transmit infectious agents from staff to residents that had the potential to result in widespread infection in the facility. Findings: During a review of Resident 1 ' s Admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/12/2025, with diagnoses that included end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) and sepsis (the body ' s extreme response to infection and a life-threatening medical emergency). During a review of Resident 1 ' s untitled, undated care plan (CP), the CP indicated Resident 1 had the presence of wounds and indwelling medical devices and needed to be on EBP. The CP interventions included to follow EBP precautions including to use hand hygiene and follow proper infection control practices as indicated. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 had septicemia (blood poisoning by bacteria). During a review of Resident 2 ' s AR, the AR indicated the facility initially admitted Resident 2 on 6/3/2021 and was readmitted on [DATE], with diagnoses that included ESRD and dependence on renal dialysis (treatment to clean one ' s blood by removing waste and extra fluid when the kidneys are unable to). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 had a pressure ulcer (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). During a review of Resident 3 ' s AR, the AR indicated the facility admitted Resident 3 on 1/17/2025 with diagnoses that included type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel) and chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should). During a review of Resident 3 MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. During a review of Resident 4 ' s AR, the AR indicated the facility initially admitted Resident 4 2/11/2025 and was readmitted on [DATE], with diagnoses that included ESRD and DM2. During a review of Resident 4 ' s untitled, undated CP, the CP indicated Resident 4 was on contact isolation for methicillin-sensitive Staphylococcus aureus (MSSA- type of bacteria that is sensitive to the antibiotic methicillin). The CP interventions indicated to educate family/visitors regarding isolation precautions. During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 had MDRO. a. During an observation on 3/14/2025 at 8:30 am, outside the facility ' s entrance, the facility ' s entrance doors and windows were observed. There was no GAS OB Notification Letter on the facility ' s entrance doors and windows indicating the facility had a GAS OB. During a telephone interview on 3/14/2025 at 11:38 am, with the PHN, the PHN stated the PHN sent the facility the GAS OB Notification Letter on 1/24/2025. The PHN stated the GAS Notification Letter was to be posted at the entrance of the facility so all residents, visitors, and staff could see the facility had an active OB. The PHN stated the PHN recommended the facility provide information to all staff and to post the GAS FAQ/fact sheet where staff and residents could see it. The PHN stated the point of making the GAS FAQ/fact sheet visible was so that anyone at the facility could read information about GAS and be informed. During a concurrent interview and record review on 3/14/2025 at 11:51 am, with the Infection Prevention Nurse (IPN), the PHN recommendations were reviewed. The IPN stated the IPN did not remember needing to post the GAS OB Notification Letter at the entrance of the facility. The IPN stated the GAS FAQ/fact sheet was posted in the breakroom for staff to read. The IPN stated it was important for the GAS OB Notification Letter to be posted at the entrance so anyone walking into the facility will know what was going on in the facility will know how to protect themselves. The IPN stated if residents could not see the GAS FAQ/fact sheet then they would not be informed and may not know how to protect themselves. b. During an observation on 3/14/2025 at 11:17 am, of CNA 1 with Resident 3 in the lobby area, CNA 1 was observed. CNA 1 was observed to walk up towards Resident 3 ' s wheelchair. CNA1 ' s mask was not covering CNA 1 ' s nose and mouth. CNA 1 touched the handles on Resident 3 ' s wheelchair to turn it, then assisted Resident 3 to put on Resident 3 ' s jacket. Resident 3 did not perform hand hygiene before providing care to Resident 3 or after and did not appropriately wear the mask. During an interview on 3/14/2025 at 11:18 am, with CNA 1, CNA 1 stated CNA 1 was supposed to wear a mask while in the facility because the facility had COVID-19 (infectious disease caused by SARS-CoV-2 virus) and that it was protocol. CNA 1 did not state why hand hygiene was important. c. During a concurrent observation and interview on 3/14/2025 at 12:25 pm, CNA 2 was observed at Resident 1 ' s room entrance. An EBP sign was posted next to the door indicating anyone entering the room and upon exiting the room must perform hand hygiene. CNA 2 entered Resident 1 ' s without performing hand hygiene. CNA 2 checked on Resident 1, then exited the room without performing hand hygiene. CNA 2 stated the sign next to Resident 1 ' s room door indicated to perform hand hygiene before entering and upon exiting the room. CNA 1 stated it was important to perform hand hygiene with EBP rooms/residents to stop the spread of infection. d. During a concurrent observation and interview on 3/14/2025 at 12:28 pm, at Resident 4 ' s room, Resident 4 ' s Family 1 and Family 2 were observed. The signed next to Resident 4 ' s door indicated Resident 4 was on contact precautions. Family 1 stated Family 1 and Family 2 were given masks, but stated staff at the facility did not tell Family 1 and Family 2 they were supposed to wear masks, and were supposed to don gown and gloves while visiting Resident 4. During a concurrent observation and interview on 3/14/2025 at 12:30 pm, with LVN 1, outside of Resident 4 ' s room, Family 1 and Family 2 were observed. LVN 1 stated Family 1 and Family 2 were touching the side of Resident 4 ' s bed. LVN 1 stated Family 1 and Family 2 were not wearing a mask, gown, or gloves. LVN 1 stated Resident 4 was on contact precautions for MSSA. LVN 1 stated anyone in the room should be wearing a gown and gloves to prevent the spread of infection. LVN 1 stated visitors could get sick or spread germs to others at home. LVN 1 stated Family 1 and Family 2 should be wearing masks to prevent the spread of infection. LVN 1 stated it was all staffs ' responsibility to remind visitors about precautions. e. During a concurrent observation and interview on 3/14/2025 at 12:36 pm, at the nurses ' station, LVN 2 was observed. LVN 2 was at the computer, with a mask that was pulled down below the nose and mouth. LVN 2 stated LVN 2 was supposed to wear properly wear a mask to help prevent the spread of infection because the facility required it. f. During a concurrent observation and interview on 3/14/2025 at 12:45 pm, at Resident 2 ' s room, CNA 3 was observed. A sign next to the door indicating EBP was posted. CNA 3 was at Resident 2 ' s bedside, touching Resident 2 ' s bedding. CNA 3 was not wearing a gown or gloves, and CNA 3 ' s mask was pulled down below the nose and mouth. CNA 3 stated CNA 3 was supposed to wear a gown and gloves because Resident 2 was on HD and needed to stop the spread of infection to keep Resident 2 safe. CNA 3 stated masks were the facility ' s protocol and were supposed to be, worn all the way. During an interview on 3/14/2025 at 4:12, with IPN, the IPN stated hand hygiene was important so staff would not spread germs from resident to resident and other staff. the IPN stated hand hygiene was the number one way to prevent the transmission of germs. The IPN stated staff were supposed to wear masks while in the facility because it was influenza (flu- respiratory infection caused by the influenza virus) season. The IPN stated wearing masks prevented the spread of infection and was for resident safety. The IPN stated staff should be wearing a gown and gloves if touching residents or in EBP rooms because they could come in contact with body fluids and could be spreading infection to others. The IPN stated visitors were supposed to were a gown and gloves in contact precaution rooms so they would not spread germs or catch an infection. The IPN stated it was everyone ' s responsibility to ensure all visitors and vendors were wearing the appropriate PPE while in the facility and to educate them for not following isolation precautions. The IPN stated it was everyone ' s responsibility to keep the resident ' s safe. During a review of the facility ' s P&P titled, Standard and Enhanced Barrier Precautions, dated 4/1/2025, the P&P indicated the facility would ensure the use of appropriate PPE to improve infection control as required in the care of residents. The P&P indicated EBP should be used during dressing, bathing/showering, transferring, personal hygiene, changing linens, changing briefs or assisting with toileting and device care or use. During a review of the facility ' s P&P titled, Hand Hygiene, dated 2/9/2024, the P&P indicated the facility would ensure that all individuals used appropriate hand hygiene while at the facility. The P&P indicated the facility considered hand hygiene the primary means to prevent the spread of infection. The indicated to perform hand hygiene immediately upon entering and immediately upon exiting a resident occupied area. During a review of the facility ' s P&P titled, Resident Isolation- Categories of TBP, dated 2/9/2024, the P&P the facility would ensure that TBP precautions were used when caring for residents communicable (contagious) diseases or transmittable (spreadable) infections. The P&P indicated TBP were used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others. The P&P indicated contact precautions were implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment.