Every finding on record at Windflower Health Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored, labeled, and dated.2. The facility failed to ensure a safe and sanitary environment.3. The facility failed to ensure 1 of 1 dishwasher reached appropriate temperatures. These failures could place residents who ate food served by the kitchen at risk of food-borne illness, cross contamination, and loss of nutrition.Findings included: In an observation on 06/16/2026 at 8:11 AM, a silver bowl with white powdery substance labeled 6/3 for Thurs dinner written in red on plastic wrap covering bowl- not labeled, a 64 oz Minors Sweet and Sour sauce, located on top pantry shelf, opened 6/9- label stated was to be refrigerated after opening. A 14 oz bottle of Cayenne pepper showed a best by date of 12/5/2024, located on panty 2nd shelf. In an observation on 06/16/2026 at 9:24 AM, 23 bowls containing various fruit were in first refrigerator in Kitchen 1 uncovered, not labeled, and not dated. In an observation on 06/16/2026 at 9:25 AM, the following was discovered in large refrigerator in Kitchen 1: Flour tortillas were not labeled or dated.Corn tortillas were not dated.Open silver container with a ladle hanging out of the right front side of the container with liquid substance in the bottom was uncovered, unlabeled, and undated.In an observation on 06/16/2026 at 9:27 AM, the following was discovered in an ice cream freezer in Kitchen 1:3-gallon [NAME] Valley Vanilla ice cream- not dated, not sealed.3-gallon Blue Bunny Sherbert- not dated, not sealed.3-gallon [NAME] Valley Vanilla ice cream- not sealed.3-gallon [NAME] Valley pink ice cream- not sealed.2 small individual clear ridged bowls with vanilla ice cream uncovered, not labeled, and not dated.In an observation on 06/16/2026 at 9:30 AM, the following was discovered in refrigerator located across from the ice cream freezer in Kitchen 1:2 salads with breaded meat on top- uncovered, not labeled, and not dated.10 small bowls with orange gelatin substance with fruit- uncovered, unlabeled, and undated.40 plates of various desserts- uncovered, unlabeled, and undated.In an observation on 06/16/2026 at 10:56 AM, CK M was observed not wearing a hairnet in Kitchen 2 while walking between stations. In an observation on 06/16/2026 at 11:00 AM, the following was discovered in the refrigerator and freezer in Kitchen 2:33 oz [NAME] Boston Creme Pie was undated.4 boxes of Blue Bunny Chocolate Marble 48 pack, 4 fluid oz undated.Box of 96 Ardmore Farms 4 fluid oz apple juice was undated.Walmart bag with individual Kellogg's [NAME] Krispy Treats not dated.In an observation on 06/17/2026 at 7:48 AM, the EC was observed not wearing a beard cover or gloves while handling food items. Six individual chocolate ice cream, 5 rainbow sherbet, 5 vanilla ice cream, and 1 strawberry in clear single served bowls were not covered, not labeled, and undated. In an observation on 06/17/2026 at 8:00 AM, the dishwasher in Kitchen 1 reached 103 degrees F. A second round was observed and reached 108 degrees F. In an observation on 06/17/2026 at 8:01 AM revealed 22 varied desserts in refrigerator in Kitchen 1 uncovered, undated, and not labeled. In an interview on 06/17/2026 at 7:41 AM, CK M stated that a hairnet/hat was supposed to be worn in the kitchen. CK M stated it was the employee's responsibility to ensure proper headwear was worn and the facility provides hairnets and gloves. CK M stated she was not wearing a hairnet yesterday because she forgot. CK M stated a negative outcome could be hair can get in the food. In an interview on 06/17/2026 at 7:43 AM, DMA U stated employees were to wear a hairnet/hat and gloves in the kitchen. DMA U stated it was the department's responsibility to ensure everyone was wearing hairnet or hats. DMA U stated CK M was not wearing a hairnet yesterday during observation. DMA U stated a negative outcome would be hair being a biological contamination. In an interview on 06/17/2026 at 8:07 AM, EC stated beard and hair should be covered. EC stated the facility provides the cover wear. EC stated it was the employee's responsibility to ensure proper coverage was worn in the kitchen and he was not wearing a beard cover. EC stated a sign at the front door stated proper coverage was to be worn in the kitchen. EC stated that a negative outcome was loose hair in food and contamination. In an interview on 06/17/2026 at 8:09 AM, KA P stated sometimes the dishwasher gets hot enough and management was aware. KA P stated a negative outcome was bacteria. In an interview on 06/17/2026 at 8:13 AM, DM stated that employees are required to wear hairnets/beard coverings and gloves. DM stated the facility supplies the hair nets, beard coverings, and gloves. DM stated everyone was responsible for ensuring everyone wears proper attire. DM stated food was supposed to be covered and labeling and dating were required when anything was open. DM stated that individual ice cream should be covered and large containers should be sealed with the lid. DM stated a negative outcome could be whatever kind of germs that the food could get from the hair and food can spoil as well as things could fall in it if items are not stored properly. In an interview on 06/17/2026 at 8:25 AM, DM stated the correct temperature for the dishwasher was 155 degrees F. DM stated a negative outcome of not reaching proper temperatures was that it would not kill the bacteria. In an interview on 06/17/2026 at 8:26 AM, EC stated the ice cream was to be covered and the large containers should be sealed when closed. EC stated the food in the refrigerator should be covered, labeled, and dated. EC stated a negative outcome could be food could dry out, loss of nutrition, something falls in the food or airborne contact. In a record review of policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised November 2022, stated under heading Policy Statement- Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne. illness. Under heading, Hand Washing/Hand Hygiene, line 6- Employees must wash their hands: letter c- whenever entering or re-entering the kitchen. Letter G stated during food preparation, as often as necessary to remove soiled and contamination to prevent cross contamination when changing tasks. Under heading Gloves and Direct Food Contact, line 8: Contact between food and bare (ungloved) hands was prohibited. Under heading Hair Nets, line 15 stated hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. In a record review of policy titled Date Marketing and Labeling Food, revised 05/24/2020, stated all food shall be labeled with product name and dated to ensure quality and safety of the food serviced to residents. Under heading Procedures, policy stated Culinary Services Team Members shall use the following product description and date marketing practices: all packaged items will have a received date, open date and discard date. All prepared items will have a product name, prepared date, and discard date. House-prepared time and temperature control for safety food shall be dated with a four-day discard date, starting with day of production as day 1. Non-time and temperature control for safety foods shall be dated with a seven-day discard date, starting with day of production/opening as day 1. All received foods shall be dated with the date of receipt before storage. Opened package foods will be dated with discard date as below (totals include opening day): Dry and frozen goods: 6 months. The Culinary Services leader will: 2. Take corrective action if product description and dating is out of compliance. In a record review of a policy titled Auto-Chlor System, Basic Principles of Low- Temperature Warewashing, not dated, it stated wash and rinse heater elements are also eliminated since low-temperature dish machines use water temperature of 120 degrees F to 150 degrees F. Under heading The Hot Water Supply, it stated the ideal temperature for washing dishes was 140 degrees F. Water below 125 degrees F will not melt the grease for effective washing and will cause suds.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours of being admitted for 1 of 18 Residents (Resident #104) that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care Resident #44 did not have a baseline care plan that reflected bed being in the lowest position and a fall mat for safety within 48 hours of being admitted to the facility. This failure could place all newly admitted patients at risk for lack of care, needs not being met, and resident safety.Findings Included: Record review of Resident #104's face sheet, dated 06/16/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included but were not limited to unspecified dementia, unspecified severity, without behavioral disturbance (cognitive decline and memory loss), hypothyroidism (thyroid gland doesn't produce enough thyroid hormone), and hyperlipidemia (high cholesterol). Resident #104 was on hospice. Records review of Resident #104's physical baseline care plan, dated 06/18/2026, revealed Resident #104 was on hospice. Resident #104 required substantial/maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying, and chair/bed-to-chair transfer. Resident #104 was dependent on toilet and tub/shower transfers. Section H, Safety Risks, revealed that Resident #104 does have a history of falls. Resident #104's baseline care plan did not address a fall mat. Page 12 of 12 revealed RN H completed Resident #104's care plan on 06/18/2026. In an observation on 06/16/2026 at 9:34 AM, Resident #104 was lying in bed. Resident #104's bed was in the lowest position with fall mat in place. In an observation on 06/16/2026 at 3:24 PM, Resident #104 was lying in bed. Resident #104's bed was in the lowest position with fall mat in place. In an observation on 06/17/2026 at 3:01 PM, Resident #104 was lying in bed. Resident #104's bed was in the lowest position with fall mat in place. In an observation and interview on 06/18/2026 at 10:20 AM, Resident #104 was lying in bed. Resident #104's family member was in the room and had made a bed out of the floor mat by Resident #104's bed. Resident #104's bed continued to be in the lowest position. In an interview on 06/17/2026 at 3:09 PM, the ADM stated the facility follows the RAI manual for MDS assessments and care plans. In an interview on 06/18/2026 at 10:24 AM, RN H stated that fall mats should be care planned as everyone doesn't use fall mats. RN H stated that Resident #104 was not care planned for a fall mat. RN H stated a negative outcome for a fall mat not being care planned could hinder Resident #104's recovery and could be a risk if it (fall mat) was not care planned. In an interview on 06/18/2026 at 10:47 AM with MDS R and MDS S revealed floor nurses complete baseline care plans. MDS S stated that they review the ADL's, assessment that was in electronic medical record was completed, reviewed and uploaded. At the time of this interview, Resident #104's baseline care plan had not been uploaded to the electronic medical record. MDS S stated the facility utilizes the RAI manual for guidance for care plans and MDS assessments. In an interview on 06/18/2026 at 11:05 AM, the DON stated care plans were patient centered and can include anything regarding the resident's care. The DON stated that MDS nurses assist with care planning. The DON stated fall mats would be carefully planned as it was a part of another incident. The DON stated if it is part of the care plan it was what the resident needed for safety to take care of them. The DON stated a negative outcome was resident safety and it was not documented on the assessment. Record review of the RAI, dated October 2025, on page 2-43, under heading CAA(S) Completion, revealed, within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care.

Based on observations, interviews and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #10 and #89) of 18 residents reviewed for accommodation of needs.The facility failed to ensure Resident #10 and Resident #89's call lights were in reach on 06/16/2026 and 06/17/2026.This failure could place residents at risk of unmet needs, injury, and/or feelings of helplessness and frustration. Findings included:Resident #10Record review of Resident #10's admission record dated 06/17/2026, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, moderate, with other behavioral disturbance (a progressive cognitive disorder that impairs memory, judgement, decision making and safety awareness), anxiety disorder(anxious feelings that affect a resident's ability to cope with stress) and weakness(decreased physical strength that may impair mobility). Record review of Resident #10's Significant Change MDS Assessment completed on 04/10/2026 revealed a BIMS score of 04 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #10 required supervision or touching assistance with sit to stand and chair to bed transfers. Section J Health Conditions revealed Resident #10 had experienced a fall since admission. Record review of Resident #10's care plan completed on 04/27/2026 revealed the resident was a high risk for falls, with interventions directing staff to ensure the resident's call light remained within reach and to encourage the resident to request assistance. The care plan further identified an ADL self-care deficit related to impaired balance and limited mobility and indicated the resident required staff assistance with transfers between surfaces. Resident #89Record review of Resident #89's admission record dated 06/18/2026 revealed an [AGE] year-old female whose most recent admission occurred on 11/18/2025 with diagnoses that included, but were not limited to senile degeneration of brain (a progressive condition associated with cognitive decline, impaired memory, reduced judgement), major depressive disorder (a condition that affects motivation, communication of needs, participation in daily activities) and history of falling (previous fall events).Record review of Resident #89's quarterly MDS Assessment completed on 05/28/2026 revealed a BIMS score of 03 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #89 required supervision or touching assistance with sitting to standing and chair to bed transfer. Record review of Resident #89's care plan completed on 05/26/2026 revealed the resident was at risk for falls, with interventions directing staff to ensure the resident's call light remained within reach and encouraged the resident to request assistance. The care plan further identified an ADL self-care deficit related to dementia and included interventions to encourage the resident to use the call light to obtain assistance. During an observation on 06/16/2026 at 9:12 AM, Resident #10 was observed lying on her back in bed asleep. The resident's call light was observed on the floor, partially underneath the bed and out of the resident's reach. During an observation on 06/16/2026 at 9:23 AM, Resident #89 was observed lying in bed asleep. The resident's call light was observed hanging on the wall across the room and was not accessible to the resident. During an interview and observation on 06/16/2026 at 11:45 AM, Resident #10 was being assisted to her room by an anonymous staff member. The staff member stated Resident #10 was not feeling well and was returning to her room to rest. During an interview and observation on 06/16/2026 at 11:48 AM, Resident #10 was observed sitting in a recliner in her room. The resident's call light was observed hanging on the wall across the room and was not within the resident's reach. Resident #10 stated she returned to her room to rest.During an observation on 06/17/2026 at 11:50 AM, Resident #89 was lying in bed, asleep. The resident's call light was observed hanging on the wall across the room and was not within the resident's reach. During an interview on 06/17/2026 at 11:52 AM, RN A stated call lights were required to remain within residents' reach at all times. RN A stated all staff members were responsible for ensuring residents had access to their call lights. RN A further stated residents might be unable to obtain needed assistance and could be at risk for falls if call lights were not in reach. During a telephone interview on 06/18/2026 at 8:49 AM, Resident #89's family member stated Resident #89 was capable of using her call light to request assistance. During an interview on 06/18/2026 at 9:02 AM, the ADM stated call lights should be in reach or residents at all times. She stated all staff were responsible for ensuring call lights were in reach of residents. The ADM stated a resident could be negatively impacted if their call light was out of reach including being unable to call for assistance when needed and an increased risk for falls or injury. During an interview on 06/18/2026 at 9:41 AM, CNA J stated call lights should be in reach of residents at all times. She stated all staff were responsible for ensuring call lights were in reach of residents. CNA J stated both Resident #10 and Resident #89 were capable of using their call light. CNA J stated if the call light was not accessible to a resident a possible negative outcome would be that a resident could need help and not be able to call.During an interview on 06/18/2026 at 9:44 AM, CNA K stated call lights were to be in reach a resident when a resident was in their rooms. She stated CNAs were responsible for ensuring call lights were within reach of the resident. CNA K stated both Resident #89 and Resident #10 had previously utilized their call lights to request staff assistance. CNA K stated a possible negative outcome would be residents would not be able to call for help when needed. During an interview on 06/18/2026 at 9:47 AM, LVN L stated call lights were to be maintained in a location accessible to the residents. LVN L stated all staff members were responsible for ensuring call lights remained readily accessible, particularly when residents were placed in bed or left resting in their rooms. LVN L further stated a resident could experience negative outcomes if a call light was not within reach, including falling and needing assistance. During an interview on 06/18/2026 at 2:06 PM, the DON stated call lights should be in reach of residents. She stated all staff were responsible for ensuring proper placement of call lights. The DON stated if a call light was out of reach of a resident the resident may not get the help they needed.During an observation and interview on 06/18/26 at 2:22 PM, Resident #10 was observed sitting in a chair outside her room. Resident #10 stated she was able to use her call light to request assistance. Resident #10 stated she had not frequently used the call light in the past; however, she reported she had not been feeling well, had experienced dizziness and had recently been using the call light more often to obtain staff assistance. During an observation and attempted interview on 06/18/26 at 2:36 PM Resident #89 was sitting in her wheelchair, she did not answer when asked if she had a call light or had ever used a call light.Record review of facility's policy titled Resident Call light System/Call System dated 11/08/2024 revealed the following: .The resident's call system will be at each resident's bedside. The Call light will be positioned conveniently for use and within reach .

Based on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 2 (Resident #5, Resident #14) of 18 residents reviewed for comprehensive care plans.The facility failed to update the comprehensive person-centered care plans to address Resident # 5 and Resident #14's needs within 7 days after MDS assessment was completed.The failure could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings included: In a record review of Resident #5's face sheet, dated 06/16/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #5's diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance (presence of cognitive decline and memory loss), unspecified atrial fibrillation (irregular heart rhythm), and cognitive communication deficit (ability to communicate was impaired). Record review of Resident #5's MDS, dated [DATE], revealed a BIMS score of 11, indicating a moderate cognitive impairment, suggesting some memory or thinking difficulties that may require additional support. Record review of Resident #5's last 2 quarterly MDS assessments revealed completion dates of 03/05/2026 and 06/13/2026. Record review of Resident #5's last 2 completed care plans revealed completion dates of 04/27/2026 and 06/11/2026. Record review of Resident #14'd facesheet, dated 06/17/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #14's diagnoses include cerebral infarction due to embolism of unspecified cerebral artery (stroke), type 2 diabetes (insulin resistance and high blood sugar levels), hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness). Record review of Resident #14's MDS, completed 06/13/2026, revealed a BIMS score of 14 which indicated that resident had intact cognitive function. Record review of Resident #14's last 2 quarterly MDS assessments revealed completion dates of 03/09/2026 and 06/13/2026. Record review of Resident #14's last 2 completed care plans revealed completion dates of 03/06/02026 and 06/11/2026. In an interview on 06/17/2026 at 3:09 PM, the ADM stated the facility followed the RAI policy for care planning.In an interview on 06/18/2026 at 10:52 AM, MDS S stated the MDS coordinators complete comprehensive care plans. MDS S stated care plans were due within 7 days the comprehensive assessment. MDS R stated that Resident #14's last care plan was completed on 06/11/2026. MDS R stated MDS was completed was on 06/11/2026. MDS R stated the MDS was completed when the RN signs the assessment. MDS R stated it was on 06/13/2026 that the assessment was completed. MDS R and MDS S stated the care plan was done before the completion date. MDS R stated there was no negative outcome as there would not be an alteration to the MDS versus the care and if there were any changes within those 7 days, the care plan would be updated accordingly. MDS S stated the team would still catch whatever was done between those dates when asked a negative outcome if the comprehensive care plan was completed prior to the MDS assessment completion. MDS R stated if a care plan was completed after 7 days something may have occurred that was not updated into the care plan. In an interview on 06/18/2026 at 11:05 AM, the DON stated that care plans were patient centered and there was anything specific to the resident. The care plan includes nursing care and what they were providing to the resident. The DON stated that she obtains help from MDS coordinators for assistance with due dates. The DON stated if care plans were not completed within 7 days after the MDS assessment was completed or if they were completed more than 7 days after, things could be missed involving the resident's care. Record review of the RAI Manual, dated October 2025, revealed on page 2-44, under heading Care Plan Completion, that the care plan completion date must be either later than or the same date as the CAA but no later than 7 calendar days after the CAA completion date. The RAI Manual revealed on page 4-11 facilities have 7 days after completing the RAI assessment to develop or revise the resident's care plan. The RAI Manual revealed on page 4-12, line 8 that a complete care plan is required no later than 7 days after the RAI is completed.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 18 residents (Resident #64) whose care plans were reviewed. The facility failed to care plan Resident #64 for utilizing a stand to lift assist for activities of daily living. This failure could place residents at risk of receiving inadequate care and increased safety risks.Findings included:In a record review of Resident #64's face sheet, dated 06/16/2026, revealed an [AGE] year-old male, originally admitted to the facility on [DATE] with a readmit date of 05/30/2026. Resident #64's diagnoses included pneumonia, unspecified organism (infection of the lungs), paroxysmal atrial fibrillation (irregular heart rhythm), and essential hypertension (high blood pressure). Record review of Resident #64's MDS, dated [DATE], revealed a BIMS score of 15 which indicated that resident had intact cognitive function. Section GG revealed resident was substantial/maximal assistance for toileting, showering/bathing, upper body dressing, and putting on/taking off footwear with supervision or touch assistance with eating and oral hygiene. Resident #64 was dependent on sit to lying, lying to sitting, sit to stand, [NAME]/bed-to-chair transfer, and toilet transfers.Record review of Resident #64's care plan, dated 06/16/2026, provided an intervention that Resident #64 requires 2 people for maximum assistance for activities of daily living completion.In an interview on 06/16/2026 at 2:34 PM, Resident #64's family care giver indicated that he was assisted with showers and utilizes a lift for transfers.In an interview on 06/17/2026 at 3:09 PM, the ADM stated the facility followed the RAI policy for care planning.In an interview on 06/18/2026 at 9:03 AM, RN F stated that Resident #64 utilized a sit-to-stand mechanical lift. RN F did not know how long the resident had been using the device and was unsure if its use was documented in the care plan. RN F stated that bedside nurses could initiate the use of a lift, while the MDS coordinator oversaw the care planning process. RN F stated a negative outcome could be resident accident or injury.In an interview on 06/18/2026 at 9:06 AM, LVN E stated that Resident #64 utilized a sit-to-stand mechanical lift but was unsure how long the device had been in use. LVN F noted that the resident did not have the lift documented in his care plan, and it was the responsibility of the MDS nurse to update the care plan. LVN F stated that the lift should be included in the care plan, so staff members know how to properly care for and transfer the resident. LVN F stated a negative outcome was the risk of injury to staff or the residents. In an interview on 06/18/20256 at 9:08 AM, MDS S stated that Resident #64 used a mechanical lift and verified it was not documented in Resident #64 care plan. MDS S stated it was the MDS nurse's responsibility for the comprehensive care plan and any nurse could initiate a care plan intervention. MDS S stated a negative outcome was the risk of injury to CNA's or the residents.In an interview on 06/18/2026 at 9:15 AM, the DON stated that they were unaware of when staff began using a mechanical lift for Resident #64 but stated the lift should have been initiated in the care plan by the nurse who first determined the need for it. The DON stated that care plans were a collaborative effort between floor nurses and the MDS coordinator. The DON stated that the negative consequence of failing to document the lift in the care plan was putting both resident and staff safety at risk.In an interview on 06/18/2026 at 10:22 AM, CNA T stated that Resident #64 uses a sit-to-stand for transfers. CNA T stated that therapy said he was supposed to use it (lift). CNA T stated she was not for sure if it was in Resident #64's electronic medical record.In an interview on 06/18/2026 at 10:24 AM, RN H stated care plans were to include lifts to show the facility was allowed to use them. RN H stated that unit managers, therapy, DON, and ADM were who complete care plans. RN H stated a negative outcome could hinder recovery and it was a risk if the resident was not care planned for it (lift).Record review of the RAI Manual, dated October 2025, stated on page 2-44, under heading Care Plan Completion, The resident's care plan but be reviewed after each assessment, as required by 483.20, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussion with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observations, interviews, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation and reviewed the risks and benefits of bed rails with 2 (Residents #38 and #89) of 18 residents or their resident representatives and obtain informed consent prior to installation of bed rails. Resident #38 had (1) one-quarter bed rail, located on right side of bed with no documentation of consent or current safety assessment prior to installation.Resident #89 had (1) one-quarter bed rail, located on left side of bed with no documentation of consent or current safety assessment prior to installation. These failures could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in residents' ability to engage in activities of daily living.Findings included: Resident #38Record review of Resident #38's admission record dated 06/16/2026 revealed a [AGE] year-old female whose most recent admission occurred on 09/03/2026 with diagnoses that included but not limited to unspecified Dementia (loss of cognitive function that interferes with daily life and activities), unspecified fall, subsequent encounter and major depressive disorder, single episode (persistent feelings of sadness, loss of interest in activities).Record review of Resident #38's quarterly MDS assessment completed on 03/15/2026 revealed a BIMS score of 11 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #38 was independent with sit to lying and sit to stand.Record review of Resident #38's care plan completed on 06/16/2026 revealed the resident had one-quarter bed rail for mobility with an intervention to assess quarterly or with a change of condition.Record review of Resident 38's clinical record revealed physician orders dated 06/09/2026 for the use of one-quarter bed rail for positioning and mobility. Record review of Resident #38's Bed Rail Screening and Evaluation dated 02/19/2026 revealed no bed rail was in place, recommended or requested at the time of the assessment. No other bed rail assessment was in Resident #38's clinical file. Record review of Resident #38's clinical record revealed no documentation of a signed bed rail consent. During an observation and interview on 06/16/2026 at 9:18 AM, Resident #38 was observed in her room in her wheelchair dressed for the day. She was observed holding to her right side one- quarter bedrail that was up and locked in place. Resident #38 stated she had been trained on bedrail use and safety. Resident #89Record review of Resident #89's admission record dated 06/18/2026 revealed an [AGE] year-old female whose most recent admission occurred on 11/18/2025 with diagnoses that included, but were not limited to senile degeneration of brain (a progressive condition associated with cognitive decline, impaired memory, reduced judgement), major depressive disorder (a condition that affects motivation, communication of needs, participation in daily activities) and history of falling (previous fall events).Record review of Resident #89's quarterly MDS assessment completed on 05/28/2026 revealed a BIMS score of 03 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #89 required supervision or touching assistance with sitting to standing and chair to bed transfer. Record review of Resident #89's care plan completed on 05/26/2026 revealed the resident had a one-quarter bed rail for mobility and positioning with interventions to assess quarterly or change of condition. Record review of Resident #89's clinical record revealed physician orders dated 06/01/2026 for the use of one-quarter bed rail for positioning and mobility. Record review of Resident #89's Bed Rail Screening and Evaluation dated 03/03/2026 revealed no bed rail was in place, recommended or requested at the time of the assessment. No other bed rail assessment was in Resident #89's clinical file. Record review of Resident #89's clinical record revealed no documentation of a signed bed rail consent. During an observation on 06/16/2026 at 9:23 AM, Resident #89 was observed lying in bed asleep. The resident had a one-quarter bed rail located at head of bed on left side of bed, it was up and locked in place. During an observation on 06/17/2026 at 11:50 AM, Resident #89 was observed lying in bed asleep. The resident had a one-quarter bed rail located at head of bed on left side of bed, it was up and locked in place. During an interview on 06/18/2026 at 8:30 AM, The ADM stated she and the DON had recently conducted an audit of bed rail assessments and consents; however, Resident #89 and Resident #38's use of bed rails had been missed during the audit process. The ADM stated a negative outcome of failing to complete bed rail assessments and obtain informed consent included compromised resident safety. During a telephone interview on 06/18/2026 at 8:49 AM, Resident #89's family member was interviewed due to Resident #89 being unable to respond to interview questions. The family member stated he was aware Resident #89 utilized a bed rail and expressed no concerns related to the bedrail, its use or Resident #89's safety while using the device. During an interview on 6/18/2026 at 9:40 AM, RN A who worked on the hall where Resident #89 resided, stated that completion of bed rail assessments and consents was the responsibility of the charge nurse. RN A stated the assessments and consents were completed quarterly but was unable to explain why Resident #89's bed rail assessment was not located in the clinical file. RN A stated the DON was responsible for overseeing and ensuring required assessments were completed. RN A further stated a potential negative outcome of failing to complete a bed rail assessment and obtain consent included resident entrapment which could result in injury. During an interview on 06/18/2026 at 9:50 AM, LVN L who worked on the hall Resident #38 resided, stated it was the responsibility of the charge nurse to ensure bed rail assessments and consents were completed. LVN L stated she was unaware Resident #38's bed rail assessment had not been completed. LVN L stated a failure to complete a bed rail assessment could place a resident a risk for adverse outcomes, including entrapment or falls while attempting to maneuver around the bed rail. During an interview on 06/18/2026 at 2:06 PM, the DON stated bed rail assessments and consents were required to be completed prior to implementation and reviewed quarterly. The DON stated the missed assessments for Residents #38 and #89 were her responsibility and stated she and the ADM were auditing the assessments and consents and those must have been missed. The DON further stated a potential negative outcome of failing to assess and obtain consent for bed rail would be resident safety.During an attempted interview and observation on 06/18/2026 at 2:36 PM, Resident #89 was awake and in her wheelchair, she did not answer any questions regarding bed rail use. Record review of facility's policy titled Proper use of Bed Rails (no date) revealed the following: .Resident Assessment-The resident evaluation must include a review of the alternatives that were attempted prior to the installation or use of the bed rail and how these alternatives failed to meet the resident's assessed needs. The resident evaluation must also assess the resident's risk for using bed rails. The resident evaluation should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself.Informed Consent-As informed consent from the resident or resident representative must be obtained after the appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom or functional reason for the use of the bed rails.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of drugs for 1 (Resident #43) of 12 residents reviewed to meet the needs of each resident. The facility failed to administer the prescribed anticoagulant (Coumadin) to Resident #43.The facility failed to administer the prescribed anticoagulant (Pradaxa) correctly to Resident #43. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings included: Record review of Resident #43's face sheet dated 06/16/2026 revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses to include peripheral vascular disease (a slow progressive circulatory disorder characterized by the narrowing, blockage, or spasm of blood vessels outside the heart and brain), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #43's Medicare 5-Day MDS assessment dated [DATE] listed Resident #43 with a BIMS of 15 indicating she was cognitively intact, she required partial/moderate assistance for most of her activities of daily living, and she was taking anticoagulant therapy. Record review of the baseline care plan dated 06/05/2026 with admission date of 6/01/26 for Resident #43 revealed the following: Physician orders - see current MAR orders. Record review of hospital discharge records dated 06/13/2026 revealed the following information:- [Resident #43]Date of stay: 5/15/26 - 6/01/26Instructions: Start taking:Warfarin (Coumadin) 2mg tablet - take as directed. Record review of the Prescription Delivered to Facility form dated ?? revealed 60 Dabigatran Etexilate 75mg Capsules were delivered to the facility on 6/02/26. Record review of Resident #43's Medication Administration Record (MAR) dated June 2026 revealed the following orders:- Warfarin Sodium (Coumadin - an anticoagulant used as a blood thinner) Oral Tablet 4 MG (Warfarin Sodium) Give 4 mg by mouth one time a day for afib for 3 Days -Start Date- 06/05/26 1800. - this medication was administered 6/05/26 and 6/06/26. Resident #43 was admitted to the hospital on [DATE] at 11:41 AM and treated for a deformation of the right external iliac stent (any structural, kinking, longitudinal compression, or crushing of the mesh tube placed in the pelvic artery or vein). - Dabigatran Etexilate Mesylate (Pradaxa - an anticoagulant used as a blood thinner) Oral Capsule 75 MG (Dabigatran Etexilate Mesylate) Give 1 capsule by mouth two times a day related to OTHER DISORDER OF CIRCULATORY SYSTEM (I99.8) -Start Date- 06/02/26 0800. - this medication was administered as follows:6/02/26 - AM: not administered - the nurses note documented the medication was not available. 6/02/26 - PM: administered 6/03/26 - AM: administered6/03/26 - PM: not administered - the nurses note documented the medication was not available.6/04/26 - AM: not administered - the nurses note did not provide any documentation of why the medication was not administered. 6/04/26 - PM: administered6/05/26 - AM: not administered - the nurses note did not provide any documentation of why the medication was not administered.6/05/26 - PM: administered6/06/26 - AM: not administered - the nurses note documented the medication was not available.6/06/26 - PM: administered6/07/26 - AM: Resident refused6/07/26 - PM: Resident #43 was in the hospital. During an interview on 06/17/26 at 7:58 AM LVN E the Unit Manager reported she and LVN C received the discharge orders from the hospital for Resident #43. LVN E reported there was some confusion with the Coumadin instructions, so she contacted NP D for clarification. NP D clarified the order later that evening, but she (LVN E) forgot to put the clarified order into the system (LVN E did not indicate to writer what the clarified order was). When the error of not starting the Coumadin was discovered on 6/05/26 a stat order for new lab was given and collected which revealed the lab was out of range. Coumadin was restarted. LVN E reported that as soon as she realized her mistake she reported it to her supervisor, NP D, management, and apologized to the family. LVN E reported she had been reprimanded, re-educated along with other staff, and a new system had been implemented to involve other staff such as the Medical Director and Administrator in notifications of issues with admitting orders to increase accountability and prevent future occurrences. LVN E reported not following orders and not giving medication such as coumadin can result in a resident developing a blood clot or not staying in a therapeutic range for treatment. During an interview on 06/17/26 at 9:41 AM NP D reported she assessed/evaluated Resident #43 on 6/03/26 and 6/05/26 and Resident #43 was stable on both occasions. NP D reported she was aware of the issues with the Coumadin for Resident #43 but the resident was covered with her other anticoagulant/antiplatelet therapy and was not at risk. NP D reported she had contacted the hospital for clarification and was instructed Resident #43 was to start her Coumadin so she could wean of her Pradaxa. NP D reported she was not made aware of the missed doses of Pradaxa. NP D reported not following medication administration correctly could be an issue, but she was not concerned due to her assessment completed for Resident #43 on 6/05/26. During an interview on 06/17/26 at 10:03 AM RN H reported she provided care for Resident #43 on 6/04/26 during the morning shift. RN H reported she looked for the medication Dabigatran Etexilate (Pradaxa) in the medication area and the surplus area and could not find it. RN H reported not giving a resident a blood thinner could result in a blood clot. RN H reported she did not report that she did not give the medication and she should have notified someone it was not available. During an interview on 06/17/26 at 10:09 AM RN F reported she remembered taking care of Resident #43 but not very well. RN F reviewed Resident #43's progress notes and reported she documented she did not give Dabigatran Etexilate (Pradaxa) and 'if she did not document a resident, it was because the medication was unavailable. LVN F reported she did not report that the medication was unavailable. LVN F reported a possible negative outcome for not giving medication to a resident such as a blood thinner would be a resident could have a stroke. During an interview on 06/17/26 at 11:59 AM the LPH verified the pharmacy did fill Resident #43's Dabigatran Etexilate (Pradaxa) but stated the facility staff may have had an issue with finding it because the medication must be delivered in a bottle instead of a blister pack so they may not have recognized it. The LPH reported if that medication was not administered per orders, then the resident would be at risk for clotting issues. On 06/17/26 several attempts to contact RN B, LVN I, RN G failed to administer Dabigatran Etexilate (Pradaxa) to Resident #43 resulted in no responses. During an interview on 06/17/26 at 2:37 PM the ADM reported she was not sure if the facility had a policy on reporting medications that were not being administered but it was the expectation that staff would notify the physician. During an interview on 06/17/26 at 3:04 PM the DON reported the expectation when staff cannot administer a medication such as this situation, they are to call the manager on call, the pharmacy which was open 24 hours, and the physician. During an interview on 06/18/26 at 10:53 AM the DON reported when staff do not administer a medication that was significant or can seriously affect a resident's safety such as an anticoagulant, or if the medication was not available they should check their emergency stock and if the medication was not there then notify the pharmacy which was available 24 hours a day. If the resident refuses, they should document the refusal. If the staff cannot give the medication, then they should notify the physician for orders and notify management to include the unit manager and the DON so they can address the issue for the residents' safety. The DON reported she had reviewed Resident #43's record and was aware of the incident with Coumadin and the situation had been addressed, the unit manager was reprimanded, and re-educated and they had changed their reporting process to include management staff so this situation would be resolved in the future. The DON had reviewed the issues with the medication Pradaxa and had noted that the prescription had been delivered to the facility, but the staff did not alert the management the medication was not being administered. The DON reported she was retraining staff on reporting medication issues. The DON reported if staff do not administer medication or report issues with medications then the resident's safety would be at risk, and the residents would not be getting the medication they need to treat their condition. Record review of the facility provided policy titled Reconciliation of Medications on Admission revised February 2024, revealed the following: Purpose:The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, route, and dosages upon admission or readmission to the facility.Seps in the Process:4. Determine if there are discrepancies/conflicts.5. If there is a discrepancy or conflict in the medications, dose, route, or frequency. Determine the most appropriate action to resolve the discrepancy. For example:a. Contact the nurse from the referring facilityb. Contact the physician from the referring facilityd. Contact the residents' primary physician in the communityg. Contact the admitting and/or attending physician. 6. Document finding and actions. Documentation:1. Record the medication reconciliation process completed in the medication record, if discrepancy is identified also document:a. Actions that were taken.b. If the discrepancy was resolve. Record review of the facility provided policy titled Documentation of Medication Administration revised February 2024, revealed the following: 4. Documentation of medication administration includes, as a minimum:f. reason(s) why a medication was withheld, not administered, or refused (as applicable): Record review of the second facility provided policy titled Documentation of Medication Administrator revised 5/27/20, revealed the following: Incomplete medication information for each client will be obtained to the extent possible. Any incomplete medication information which cannot be determined will have documented reasons as to why this information cannot be obtained and the steps the agency has taken to obtain the information as well as what steps will be taken to continue to try to obtain a complete medication list. Medications are prepared safely, appropriately labeled, and dispensed safely.The agency develops processes for managing high-risk or high-alert medications. The agency develops processes specific anticoagulant therapy.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for 1 of (Resident #43) 12 residents reviewed for anticoagulant therapy. Resident #43 did not receive her Pradaxa (anticoagulant medication) correctly or her Coumadin (anticoagulant medication) as ordered. The facility's failure could exacerbate the residents' condition resulting in complications to include increased pain, wounds, amputation, extended recovery time, and hospitalization. Findings included: Record review of Resident #43 face sheet printed 6/18/26 revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses to include peripheral vascular disease (a slow progressive circulatory disorder characterized by the narrowing, blockage, or spasm of blood vessels outside the heart and brain), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #43's Medicare 5-Day MDS assessment printed 6/18/26 was completed 6/05/26 listed Resident #43 with a BIMS of 15 indicating she was cognitively intact, she required partial/moderate assistance for most of her activities of daily living, and she was taking anticoagulant therapy. Record review of the baseline care plan printed 6/16/26 with admission date of 6/01/26 for Resident #43 revealed the following: Physician orders – see current MAR orders. Record review of Resident #43's Medication Administration Record (MAR) printed 6/16/26 with orders scheduled for June 2026 revealed the following order: - Warfarin Sodium (Coumadin - an anticoagulant used as a blood thinner) Oral Tablet 4 MG (Warfarin Sodium) Give 4 mg by mouth one time a day for a-fib for 3 Days -Start Date- 06/05/26 1800. – this medication was administered 6/05/26 and 6/06/26. Resident #43 was admitted to the hospital on [DATE] at 11:41 AM and treated for a deformation of the right external iliac stent (any structural, kinking, longitudinal compression, or crushing of the mesh tube placed in the pelvic artery or vein). - Dabigatran Etexilate Mesylate (Pradaxa – an anticoagulant used as a blood thinner) Oral Capsule 75 MG (Dabigatran Etexilate Mesylate) Give 1 capsule by mouth two times a day related to OTHER DISORDER OF CIRCULATORY SYSTEM (I99.8) -Start Date- 06/02/26 0800. – this medication was administered as follows: 6/02/26 - AM: not administered – the nurses note documented the medication was not available. 6/02/26 - PM: administered 6/03/26 – AM: administered 6/03/26 – PM: not administered – the nurses note documented the medication was not available. 6/04/26 – AM: not administered – the nurses note did not provide any documentation of why the medication was not administered. 6/04/26 – PM: administered 6/05/26 – AM: not administered – the nurses note did not provide any documentation of why the medication was not administered. 6/05/26 – PM: administered 6/06/26 – AM: not administered – the nurses note documented the medication was not available. 6/06/26 – PM: administered 6/07/26 – AM: Resident refused 6/07/26 – PM: Resident #43 was in the hospital. Record review of the Prescription Delivered to Facility form provided by the facility on 6/17/26 revealed 60 Dabigatran Etexilate 75mg Capsules were delivered to the facility on 6/02/26. Record review of hospital discharge records received on 6/16/26 revealed the following information: - Resident #34 Date of stay: 5/15/26 – 6/01/26 Instructions: Start taking: Warfarin (Coumadin) 2mg tablet – take as directed. Record review of laboratory results with admission date of 6/01/26, collection date of 6/02/26, and results of 6/02/26 revealed the following: INR – 2.30 Final. -Suggested therapeutic ranges using INR for stable anticoagulated patients: routine oral anticoagulant therapy equals 2.0 – 3.0. -Oral anticoagulant therapy for patients with thromboembolic events on standard doses of coumadin and those with mechanical heart valves equals 2.5 – 3.5. Record review of laboratory results with admission date of 6/01/26, collection date of 6/05/26, and results of 6/05/26 revealed the following: INR – 1.20 Final. -Suggested therapeutic ranges using INR for stable anticoagulated patients: routine oral anticoagulant therapy equals 2.0 – 3.0. -Oral anticoagulant therapy for patients with thromboembolic events on standard doses of coumadin and those with mechanical heart valves equals 2.5 – 3.5. During an interview on 06/17/26 at 7:58 AM LVN E the Unit Manager reported she and LVN C received the discharge orders from the hospital for Resident #43. LVN E reported there was some confusion with the Coumadin instructions, so she contacted NP D for clarification. NP D clarified the order later that evening, but she (LVN E) forgot to put the clarified order into the system (LVN E did not state what the clarified order was). When the error of not giving Resident #43 her Coumadin was discovered on 6/05/26 a stat order for new lab was given and collected which revealed the lab was out of range. Coumadin was restarted. LVN E reported that as soon as she realized her mistake she reported it to her supervisor, NP D, management, and apologized to the family. LVN E reported she had been reprimanded, re-educated along with other staff, and a new system had been implemented to involve other staff such as the Medical Director and Administrator in notifications of issues with admitting orders to increase accountability and prevent future occurrences. LVN E reported not following orders and not giving medication such as coumadin can result in a resident developing a blood clot or not staying in a therapeutic range for treatment. During an interview on 06/17/26 at 9:41 AM NP D reported she assessed/evaluated Resident #43 on 6/03/26 and 6/05/26 and Resident #43 was stable on both occasions. NP D reported she was aware of the issues with the Coumadin for Resident #43 but the resident was covered with her other anticoagulant/antiplatelet therapy and was not at risk. NP D reported she had contacted the hospital for clarification and was instructed Resident #43 was to start her Coumadin so she could wean of her Pradaxa. NP D reported she was not made aware of the missed doses of Pradaxa. NP D reported not following medication administration correctly could be an issue, but she was not concerned due to her assessment completed for Resident #43 on 6/05/26. During an interview on 06/17/26 at 10:03 AM RN H reported she provided care for Resident #43 on 6/04/26 during the morning shift. RN H reported she looked for the medication Dabigatran Etexilate (Pradaxa) in the medication area and the surplus area and could not find it. RN H reported not giving a resident a blood thinner could result in a blood clot. RN H reported she did not report that she did not give the medication and she should have notified someone it was not available. During an interview on 06/17/26 at 10:09 AM RN F reported she remember taking care of Resident #43 but not very well. RN F reviewed Resident #43 progress notes and reported she documented she did not give Dabigatran Etexilate (Pradaxa) and 'if she did not document a resident, it was because the medication was unavailable. RN F reported she did not report that the medication was unavailable. RN F reported a possible negative outcome for not giving medication to a resident such as a blood thinner would be a resident could have a stroke. During an interview on 06/17/26 at 11:59 AM the LPH verified the pharmacy did fill Resident #43's Dabigatran Etexilate (Pradaxa) but stated the facility staff may have had an issue with finding it because the medication must be delivered in a bottle instead of a blister pack so they may not have recognized it. The LPH reported if that medication was not administered per orders, then the resident would be at risk for clotting issues. On 06/17/26 several attempts to contact RN B, LVN I, RN G who failed to administer Dabigatran Etexilate (Pradaxa) to Resident #43 resulted in no responses. During an interview on 06/17/26 at 2:37 PM the ADM reported she was not sure if the facility had a policy on reporting medications that were not being administered but it was the expectation that staff would notify the physician. During an interview on 06/17/26 at 3:04 PM the DON reported the expectation when staff cannot administer a medication such as this situation, they are to call the manager on call, the pharmacy which was open 24 hours, and the physician. During an interview on 06/18/26 at 10:53 AM the DON reported when staff do not administer a medication that was significant or can seriously affect a residents safety such as an anticoagulant, scheduled narcotics, antibiotics, or if the medication was not available they should check]their emergency stock and if the medication was not there then notify the pharmacy which was available 24 hours a day. If the resident refuses, they should document the refusal. If the staff cannot give the medication, then they should notify the physician for orders and notify management to include the unit manager and the DON so they can address the issue for the residents' safety. The DON reported she had reviewed Resident #43 record and was aware of the incident with Coumadin and the situation had been addressed, the unit manager was reprimanded, and re-educated and they had changed their reporting process to include management staff so this situation would be resolved in the future. The DON had reviewed the issues with the medication Pradaxa and had noted that the prescription had been delivered to the facility, but the staff did not alert the management the medication was not being administered. The DON reported she was retraining staff on reporting medication issues. The DON reported if staff do not administer medication or report issues with medications then the resident's safety would be at risk, and the residents would not be getting the medication they need to treat their condition. Record review of the facility provided policy titled Medication Errors revised 5/27/20, revealed the following: Policy Statement -Significant medication errors and significant adverse drug reactions are reported in a timely manner. Policy Interpretation and Procedure: Definitions: Drug errors that cause or could cause harm to clients. -Serious physical problems, in some cases death to the client. High Risk Medications: High risk medications require special care. High risk medication are drugs that have the potential to cause serious injuries or death if not used exactly as intended. -INR/MD/RN dose turnaround for warfarin. (Coumadin)

Based on observation, interview, and record review the facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and in accordance with physician's orders and the resident's goals and preferences for 1 (Resident #1) of 8 residents reviewed for parenteral therapy services.The facility failed to ensure timely PICC (external access line for medication) line dressing changes were completed as ordered and failed to ensure ongoing assessment and monitoring of the PICC line dressing for integrity and signs of infection for Resident #1. This failure could place residents at risk of harm due to infection.Findings Included:Record review of Resident #1's admission record dated 05/19/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cellulitis of left lower limb (bacterial skin infection that affects the deep layers of the skin and underlying tissues), type 2 diabetes mellitus(inability to process sugar), morbid (severe) obesity due to excess calories (excess body fat due to high caloric intake), unspecified atrial fibrillation (irregular heart rhythm), and acute-on-chronic systolic heart failure (stable history of heart failure and reduced pumping capacity with a sudden, severe, worsening of symptoms).Record review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition.Record review of Resident #1's baseline care plan initiated on 05/12/26 revealed no documented interventions, monitoring, or care planning related to the resident's PICC line or intravenous antibiotic therapy. Record review of Resident #1's Order Summary Report dated 05/19/26 revealed the following orders and corresponding order start dates:05/11/26 Monitor PICC line site every shift for signs and symptoms of infection. Active order. 05/18/26 Change PICC line dressing weekly, every shift, every Monday. Active order. Record review of the Medication Administration Record dated 05/19/26 revealed documentation indicating the PICC line dressing change had been completed on 05/18/26. During an observation and interview on 05/19/26 at 1:43 PM, Resident #1's PICC line dressing was observed to be visibly stained, loosening around the edges, and dated 05/08/26. Resident #1 stated the dressing had not been changed since admission to the facility on [DATE]. During an interview on 05/19/26 at 2:48 PM, ADON A stated any nurse who was certified in PICC line care could provide care for Resident #1's PICC line. She stated for PICC lines, they follow orders for when they are to be changed. ADON A stated dressing changes were usually done once a week. She stated if they were not changed weekly or as needed, there could be a risk of infection. During an interview on 05/19/26 at 3:04 PM, ADON B stated Resident #1's PICC line dressing should have been changed yesterday. She stated if a PICC line dressing looked rough, or was coming off, then they had PRN orders to change it more frequently. She stated the RN charge nurse was going to do it today. ADON B stated a possible negative outcome of not doing PICC line dressing changes as ordered was the resident could get an infection.During an interview on 05/19/26 at 3:07 PM, RN C stated she was responsible for changing the dressing for Resident #1. She stated standard treatment for dressings on PICC lines would be once a week but if a dressing was coming off or looking bad, she would check orders, reinforce the dressing or do a PRN change. RN C stated if they were not changed, there could be a risk of infection. During an interview on 05/19/26 at 3:10 PM, the DON stated that PICC lines are to be changed every 7 days and Resident #1's should have been changed yesterday. She realized it was late, and had just told the charge nurse to change Resident #1's dressing today. The DON stated that if dressings aren't changed as ordered, there could be a risk of infection. She also stated if a dressing was coming off or had become soiled, there are PRN orders to change as needed. Record review of facility policy titled Central Venous Catheter Care and Dressing Changes dated March 2022 revealed the following in part: Purpose: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 3. Change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 days for TSM Dressing.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 2 of 2 kitchens when they failed to: A. Ensure stored food was properly labeled, dated and covered. B. Ensure general cleanliness was maintained. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 4/9/25 at 8:20 am, Kitchen # 2 was located inside the LTC facility and had capabilities of storing and preparing food items for the LTC, as well as a steam table for plating and serving foods. In an observation on 4/9/25 at 8;22 am, of the kitchen prep area for Kitchen #2, the following was observed: 1. Food crumbs and spills were observed in the bottom of the 4-door cooler. All 4 door handles were grimy and sticky to the touch. 2. The utensil drawer had food crumbs and debris inside the drawer holding the cooking utensils. There were 5 dirty food caked utensils with food debris inside the drawer with clean utensils. 3. The toaster had food crumbs on the inside of the toaster, the outside of the toaster and around the counter. 4. There were crumbs and food debris on the tops of coffee cups stored in a blue dishwashing crate in the middle of the kitchen. Some of the cups were right side up and laying on their sides. There were plastic lids, plastic jugs, potholders and bowls on top of the coffee cups in the plastic dishwasher crate. 5. The plate holder had food debris and crumbs inside and on top of the plates. 6. The plate covers were stored right side up and had food crumbs inside the lids and on the shelf. 7. The serving cart had crumbs on the inside crevices of the shelves and the outside cart handles were sticky to the touch. 8. The walls of the kitchen had food splatters and grease on the surface. 9. An opened block of cheese wrapped in saran wrap, dated 3/17/25 had 2 black spots on the surface of the cheese stored in the cooler. In an observation on 4/9/25 at 8;45 am of Kitchen #1, which was located in a free-standing building across the street from the LTC facility. Kitchen #1 had the capabilities and the task for cooking, preparing, storing, and serving meals for the LTC facility. In an observation on 4/9/25 at 8:45 am of the pantry in Kitchen #1, the following was found: 1. A package of vanilla wafers, opened, no label or date not in original box. 2. The plastic sugar, flour and rice bins were sticky and grimy to the touch. There were food crumbs on the sides and top of the bins. The sugar had black and brown specks of food and paper in the sugar. 3. A plastic bin held loose dry rice on the bottom of the bin and loose dried pasta on the top of the rice in the bin. 4. A bag of pasta opened, no label or date, not in original box. 5. A plastic tub of brown rice was sitting on top of a 25-pound bag of cornmeal on a shelf. 6. The floor, shelves and trays holding food items had crumbs on all surfaces, were sticky to the touch. There was food and trash in the floor under shelves. In an observation on 4/9/25 at 9:00 am of the walk-in cooler in Kitchen #1, the following was found: 1. 2 trays of individual bowls of fruit uncovered to air, no label or date and 1 tray of individual bowls of salad, uncovered no label or date. The salad was dried up, brown and stuck to the bottom of the bowls. In an observation on 4/9/25 at 9: 08 am of the walk-in freezer in Kitchen #1, the following was found: 1. 2 bags of biscuits, no label or date, not in original box. 2. 2 packages of cookie dough, no label or date, not in original box 3. 2 bags of sweet corn nuggets and 1 bag of okra, no label or date, not in original box. 4. 8 brown bags, no label or date, not in original box. 5. There was trash, paper cups, and food debris in the floor of the freezer. In an observation on 4/9/25 at 9:25 am of the walk-in cooler in Kitchen #1, the following was found: 1. A rack of 6 trays of dessert dough, covered with a plastic sheet with a large hole in the side of the covering that allowed air into the rack, no label or date, 2. The walk-in cooler had trash and food debris on the floor. Observations of Kitchen #2 on 4/10/25 at 9:45 am revealed the same concerns in the kitchen with no corrections. Observations of Kitchen #1 on 4/11/25 at 8:45 am revealed the same concerns in the kitchen with no corrections. In an interview with the Director of Dining Services, (DDS), on 4/10/25 at 3:30 pm, the DSS stated he expected all staff to label and date all foods as they are used. He stated he expected the discard date on the sticker to be filled out as well like the sticker said. He stated he was not aware it had not been filled out for some foods. He stated staff would not know what date to discard the food if the date was not filled out. The DDS stated he was not aware there were food items in the freezer with no sticker. The DDS stated he was not aware of foods not being covered and stated he expected all foods to be covered, labeled and dated. The DDS stated he expected staff to clean every day and as they go. He stated he had not made any cleaning schedules. The DDS stated he told the staff what to clean and when to do it and expected the staff to follow his directions. He stated he had not been aware of the dirt and grime in the kitchen until this conversation. The DDS stated he trained the staff in the kitchen duties and also oversaw the LTC kitchen #2. He stated he had no policies but would try to locate some policies. In an interview and a walk through with the DM on 4/11/25 at 9:00 am the DM acknowledged the issues in the kitchen. She stated the cheese had been dated with the opened date. She stated she was told she did not have to label it any further or have an expiration date. She stated she expected staff to clean as they went and do what needed to be done. She stated she had no check off list for cleaning and she tried to go behind staff to see if cleaning had occurred. She stated she trained staff in kitchen duties. The DM stated she had no policies for the kitchen. She stated the only thing she had were signs posted around the kitchen and the paper titled Daily Cleanups sheet. Record review of the facility's policy titled, 'Date Marking for Food Safety dated 3/25/25, documented: the facility adheres to a date marking system to ensure the safety of ready to eat, time temperature control for safety food. The food shall be clearly marked to indicate the date by which the food shall be consumed or discarded. The individual opening or preparing the food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be discarded. The discard date may not exceed the manufacturers use by date, or 4 days, whichever is earliest. The date of opening counts as one day. The DM shall spot check refrigerators weekly for compliance and document accordingly. Prepared foods that are delivered to the nursing units shall be discarded after 2 hours if not consumed. These items shall not be refrigerated as the time/temperature cannot be verified. Record review of the facility 'Daily Cleanup sheet from the DM in Kitchen #2 revealed the morning shift was responsible for wiping down toaster, wiping down all shelves, wiping down all carts inside and outside, sweeping and mopping and taking out trash.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Residents #8) who was observed for medication administration. -RN I administered medication to Resident #8 via nebulizer and left Resident #8 unattended. These deficient practices can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization . Findings included: Record review of Resident #8's face sheet, dated 04/11/2025, revealed Resident #8 was an [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #8 had diagnoses of, but not limited to, parainfluenza virus pneumonia, unspecified asthma with acute exacerbation (a sudden worsening of asthma symptoms characterized by difficulty breathing, coughing, wheezing, and chest tightness), chronic obstructive pulmonary disease with acute exacerbation (a sudden worsening of COPD symptoms, like increased shortness of breath, cough, and sputum production), type 2 diabetes mellitus without complications (elevated blood sugar levels in the blood), congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), atrial fibrillation (a common heart rhythm disorder characterized by an irregular and often rapid heartbeat, affecting the upper chambers of the heart (atria)), and weakness. Record review of Resident #8's MDS, dated [DATE], revealed that Resident #8's BIMS Score was 15 out of 15, which indicated Resident #8 had not cognitive deficits. Resident #8's functional abilities ranged from partial/moderate assistance needed with lower body dressing and putting on/taking off footwear, and supervision or touching assistance was needed for upper body dressing and shower/bathing. Resident #8 was able to perform toileting hygiene, oral hygiene, and eating with setup or clean-up assistance only. Record review of Resident #8's care plan, dated 04/11/2025, revealed the following: Focus o I have COPD Goal o The resident will be free of s/sx of respiratory infections through review date. Interventions o The resident will display optimal breathing patterns daily through review date. o Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. o Head of bed elevated to 45 deress or out of bed upright in a chair during episodes of difficulty breathing. o Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. o Monitor/document/report PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. o OT consult for energy conservation recommendations. o OXYGEN SETTINGS: O2 via nasal cannula @ 2-3L prn Record Review of Resident #8's active physicians orders, dated 04/11/2025 revealed the following: Acetylcysteine Inhalation solution 10% (Acetylcysteine)5ml inhale orally four times a day related to PARAINFLUENZA VIRUS PNEUMONIA (J12.2); UNSPECIFIED ASTHMA WITH (ACUTE) EXACERBATION (J45.901) During an observation on 04/10/25 at 07:18 AM revealed Resident #8's nebulizer cup with liquid still in cup. RN I stated it appeared Resident #8 didn't take the entire dose the last time the medication was administered. RN I went to dump the remaining medication in the sink of Resident #8's restroom. During an observation on 04/10/25 at 07:21 AM RN I left the nebulizer treatment on the bedside table when she (RN I) left the room to get Resident #8 new nebulizer tubing. During an observation on 04/10/25 at 07:25 AM RN I administered Resident #8 with her nebulizer treatment and left Resident #8 to administer her the nebulizer treatment alone and left the room. During an observation/interview on 04/10/25 at 07:45 AM Resident #8 was administering her breathing treatment alone in her room. Resident #8 stated the treatment usually takes about 10-15min and the nurses never stay with her to administer nebulizer treatment. During an interview on 04/10/25 at 10:03 AM RN I stated Resident #8 preferred to take her breathing treatment by herself. RN I stated the negative outcome for not staying with the resident during a nebulizer treatment would be the resident might not receive her entire dose. and it would not be as therapeutic as it was supposed to be. RN I then stated she was the only nurse for 21 residents and that is another reason why she didn't stay. She (RN I) didn't want to be caught up in a room if someone else needed her. RN I stated the negative outcome for leaving the medication on the bedside table would be the medication could be knocked over. During an interview on 04/10/25 at 10:09 AM Resident #8 stated she had never stated it was her preference to administer the nebulizer alone. Resident #8 stated, The nurses come in hand it to me and leave. During an interview on 04/11/25 at 11:38 AM DON stated the negative outcome for leaving medication on a bedside table was no medication should be left unattended, someone else could come in and drink it. DON stated the negative outcome for a nurse not staying to watch the administration of a breathing treatment would be that the resident might not complete the medication. Record review of the facility provided policy titled, Medication Administration, reviewed 12/01/2021, revealed the following: . Procedure . . Medications are prepared safely, appropriately labeled, and dispensed safely. Record review of facility provided policy titled, Nebulizer Therapy, date implemented: 04/01/2025, revealed the following: . Care of the Resident . .14. Observe resident during the procedure for any change in condition.

Based on observation and record review, the facility failed to store and label drugs and biologics in accordance with professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable to meet the needs of for 1 of 17 (Resident #6,) and 1 of 5 medication carts (LTC Side B medication cart), and 2 of 2 (rehab side and LTC/MC side)medication storage rooms under review. -Medication cart for B side of LTC had a box of anti-diarrheal with an expiration date of 02/2025. -Resident #6's Albuterol inhaler had an expiration date of 01/2025, and a Breo Ellipta inhaler with no open date on medication. -Medication cart for A side of LTC had a box of acid reducer with an expiration date of 12/2024. -Medication cart for A side of LTC had bottle of Geri-Tussin with an expiration date of 03/2025. -Medication cart for Back of Rehab had glucometer control solution with an expiration date of 09/30/2024. -Rehab medication room had 3 bottles of B-Complex with an expiration date of 03/2025, and 1 bottle of Glucosamine Chondroitin complex with an expiration date of 02/2025. -LTC/MC medication room had 3 bottles of B-Complex with an expiration date of 03/2025. The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings include: During an observation on 04/09/25 at 08:27 AM of the medication cart for side B of LTC revealed 4 pink pills in a medication cup in the top medication drawer. LVN C stated they were left there by the night shift and appeared to be Benadryl. 2.5 pills were discovered to be loose in the bottom of the medication drawers. LVN C identified 1.5 pills to be Metoprolol and the brown pill to be Famotidine, and a box of anti-diarrheal with the expiration date of 02/2025. Resident # 67's albuterol had an expiration date of 01/2025 and a Breo Ellipta inhaler with no open date on the inhaler. Resident # 6 had a Breyna inhaler with no open date on the inhaler. Resident #1 had a Wixela inhaler with a discard after 04/07 date written on the inhaler. Discard instructions on box stated to discard after 3 months after opening foil pouch. During an interview on 04/09/25 at 08:41 AM LVN C stated a negative outcome for having loose pills in the medication cart would be the count would be short for the resident at the end of the month. LVN C stated the negative outcome for having expired medications would be the medication would not have the strength that they (medications) need to work. LVN C stated the night shift was responsible for making sure the cart was clean. During an observation on 04/09/25 at 08:46 AM of the Medication cart for side A of LTC revealed a box of acid reducer that had an expiration date of 12/2024 and a bottle of Geri-Tussin with an expiration date of 03/2025. During an observation on 04/09/25 at 08:56 AM of the MC/locked unit medication cart revealed Resident # 218's Breo Ellipta inhaler with no open date on inhaler. Resident # 112 had a Trelegy inhaler with no open date on inhaler. During an observation and interview on 04/09/25 at 09:13 AM of the medication cart for the Back of the rehab side of the facility, revealed Resident # 219 had nasal spray Fluticasone Prop 50mcg spray did not have an open date on the bottle. Control solution for glucometer had an expiration date of 09/30/2024. LVN D stated that the night shift would perform control checks for glucometer machines. During an observation on 04/09/25 at 09:24 AM of the medication cart for the Front of the rehab side of the facility, revealed Resident # 81's Humalog quick pen had an open date of 03/01/2025. During an interview on 04/09/25 at 09:37 AM LVN D stated a negative outcome for having expired controls for the glucometer machines were the blood sugars won't read correctly, they could be wrong. LVN D stated a negative outcome for not having open dates on medications would be the medication might not work because it could be expired. During an observation on 04/09/25 at 09:40 AM of the medication room on the Rehab side of the facility revealed 3 bottles of B-Complex with an expiration date of 03/2025. 1 bottle of Glucosamine Chondroitin complex with an expiration date of 02/2025. During an interview on 04/09/25 at 09:44 AM LVN D stated a negative outcome for having expired medications in the medication storage room would be that someone would come in and grab it, to use it, and the medication would not be effective. During an observation on 04/09/25 at 10:13 AM of the medication room on the LTC/Memory care side of facility reveled 3 bottles of B-Complex with an expiration date of 03/2025. During an interview on 04/09/25 at 10:20 AM LVN C stated a negative outcome for having expired medications in the medication storage room would be that someone can pull them (medication), and put them in the med carts and they won't be effective. During an interview on 04/11/25 at 11:44 AM the DON stated a negative outcome of having expired medications would be the medications would not be effective for the residents. The DON stated the negative outcome for having expired glucometer controls would lead to inaccurate glucose checks for residents. The DON stated the negative outcome for not writing open dates on medications would be that the staff would not know when the medication would expire and lead to an ineffective drug for the resident. The DON stated the negative outcome for having loose pills in the medication carts would be that anyone could take them, it could lead to a resident not having enough medications for the month. The DON stated the night shift was responsible for maintaining the medication carts, but any nurse was responsible for maintaining a clean and orderly cart. The DON stated the negative outcome for having expired medications in the medication rooms would lead to a nurse putting expired medications on a medication cart and them (medications) not being effective for the residents. Record review of the facility provided policy titled, Medication Labeling and Storage, Revised February 2023, revealed the following: Medication Storage . . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4 Compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. .Medication Labeling . .2. The medication label include, at a minimum: . .d. expiration date, when applicable; . Record review of the facility provided policy titled, Medication Administration, Reviewed 12/01/2021, revealed the following: Procedure . .Medications are properly and safely stored throughout the organization.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 (LVN C, CNA F, CNA G, and RNI) staff observed for resident care. -LVN C did not perform hand hygiene, use PPE or sterile technique (to minimize the number of microbes present to as few as possible) to flush Resident #27's suprapubic catheter. -CNA F did not change gloves or perform hand hygiene during incontinent care of Resident #60. -CNA G did not change gloves or perform hand hygiene during incontinent care of Resident #60. -EBP signage or PPE for EBP was in place for Resident #319, who has a PICC line. -RN I did not use PPE while administering IV medications via PICC line for Resident #319. -RN I dumped Resident #8's medication down the bathroom sink. These deficient practices affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings included: During an observation on 04/09/25 at 10:33 AM revealed LVN C was flushing Resident #27's suprapubic catheter. No EBP cart was outside of Resident #27's room and PPE (gown) was not donned. LVN C did not perform hand hygiene before donning gloves to perform the task. No sterile technique was utilized during this procedure. During an observation on 04/09/25 at 10:50 AM revealed LVN C did not perform hand hygiene before the 2nd attempt to flush Resident #27's suprapubic catheter. LVN C did not don PPE (gown) or don sterile gloves or utilize sterile technique for the procedure. During an observation on 04/10/25 at 08:40 AM revealed no EBP precautions signage or PPE was outside the room for Resident #319 who had a PICC line and was receiving IV antibiotics. RN I proceeded to enter into room without PPE (gown) to administer IV antibiotics. During an interview on 04/10/25 at 10:03 AM RN I stated that there was not EBP precautions out in front of Resident #319 room earlier but there was now. RN I stated that the negative outcome for not donning PPE would be that it could lead to an increased risk for infection for the resident. During an observation on 04/10/25 at 02:38 PM revealed perineal care for Resident #60 was performed by CNA G and CNA F. Both CNAs' were asked if they had performed hand hygiene before donning PPE and both of them said that they had not. Both CNAs' walked into the resident's room and started to perform peri-care for Resident #60. Cleaning of Resident #60's peri-area was cleaned in an aseptic technique (minimize the risk of infection by preventing the introduciton of bacteria into an area). Resident #60 was cleaned when CNA F reached for a clean brief with the dirty gloves that CNA F just used to clean the peri-area of Resident #60. CNA G then took the dirty brief and dirty wipes from CNA F and discarded them, then proceeded to pull the clean brief out of the opposite side of the resident with the dirty gloves that they had worn to discard the dirty brief Both CNA's touched the bedspread of Resident #60 and repositioned Resident #60 in the bed. CNA F did not wash or sanitize their hands after removing EBP or gloves after care was complete. During an interview on 04/10/25 at 02:53 PM with CNA F stated that a negative outcome for not changing gloves and washing hands in between the dirty and clean aspect of peri-care could lead to cross contamination. During an interview on 04/10/25 at 02:55 PM CNA G stated that a negative outcome for not changing gloves and performing hand hygiene could lead to an increased risk for infection for the resident During an interview on 04/11/25 at 11:31 AM DON stated that the negative outcome for not performing hand hygiene would be cross contamination, and the negative outcome not having EBP provided for a resident on EBP precautions was that there was a failure in protecting the resident from being introduced to a new organism. Record review of facility provided policy titled Handwashing/Hand Hygiene, revised October 2003, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene . . 2. All personnel are expected to adhere to hand hygiene policies and practice to help prevent the spread of infections to other personnel, residents, and visitors. .Indications for Hand Hygiene 1. Hand hygiene is indicated: a. Immediately before touching a resident; b. Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. After contact with blood body fluids, or contaminated surfaces; d. After touch a resident; . .f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. . Preventing Contamination of sinks and Sink Areas 1. Personnel will refrain from disposing substances that promote the growth of biofilms in handwashing sinks such as: . . b. medications; . Record review of facility provided policy titled Catheter Irrigation, effective date 01/06/2025, revealed the following: Policy Explanation and compliance Guidelines: 1. Urinary catheters shall be irrigated by a licensed nurse using sterile technique . 2. Irrigation through a closed system is the preferred method of irrigation. .b. Perform hand hygiene. Put on gloves and other protective equipment, as needed. .e. Perform hand hygiene, and prepare for sterile procedure. .g. Remove gloves and perform hand hygiene. Record review of facility provided policy titled Perineal Care, revised February 2018, revealed the following: Steps in the Procedure . .2. Wash and dry your hands thoroughly. .9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed cover. Make resident comfortable. .16. Wash and dry your hands thoroughly. Record review of facility provided policy titled Enhanced Barrier Precautions, revised 04/05/2025, revealed the following: Procedures 1. Enhanced barrier precautions (EBP) will be implemented for the following (including new admissions . . Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator regardless of MDRO colonization status. . 3. For new admissions, the admissions team will inform nursing [NAME] before admission to set up EBP. Clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g. gown and gloves) will be in place. .4. All team members will wear appropriate PPE (gown and gloves) for high-contact resident are but not limited to: Peri-care Device care (central line, urinary catheter, ) .

Based on observations, interviews, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with 1 (Resident #319) of 17 residents or their resident representatives and obtain informed consent prior to installation of bed rails. Resident #319 had (2) one-quarter bed rails, one on each side of his bed with no documentation of consent or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #319's Face Sheet dated 04/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), chronic atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and can cause stroke and blood clots), pneumonia due to mycoplasma pneumoniae (a bacterial infection which can cause pneumonia, a lung infection), unspecified toxic encephalopathy (brain dysfunction caused by exposure to toxins that can cause altered mental status, memory loss, but without a specific toxin identified), and muscle wasting and atrophy (breakdown of muscles). Record review of Resident #319's Admission MDS assessment dated [DATE] revealed the admission MDS was not yet completed. Record review of Resident #319's Care plan dated 04/05/2025 revealed the resident was on antibiotic therapy via IV related to pneumonia and was on enhanced barrier precautions due to the indwelling device. The care plan had no mention of bed rail usage. Record review of Resident 319's clinical record revealed no physician orders for bed rails. Record review of Resident #319's clinical record under assessment tab titled Side Rail/Bed Evaluation revealed the following: Use of Rails/Bars- 1. Indicate the type and size of the bed rails/bars to be used: a. No bed rail(s)/Bar(s) used. Record Review of Resident #319's clinical record for bed rail consents revealed no documentation of a signed bed rail consent. During an observation and interview on 04/09/25 at 11:07 AM, Resident #319 was observed lying in bed with the head of the bed raised, (2) one-quarter bed rails were observed at the head of the bed on each side. Resident #319 was alert and interview able and stated he had no concerns about his care. During an interview on 04/11/25 at 8:43 AM, Resident #319 stated he used his bed rails and liked having them for repositioning but could not remember signing a consent form for them. During an interview and observation on 04/11/25 at 2:25 PM, LVN K, the charge nurse on the hallway that Resident #319 resided on, observed the resident's bed, and stated Resident #319 had (2) one-quarter bed rails on his bed. LVN K stated upon admission the residents were asked if they need or want bedrails, and if so, they must be assessed and sign a consent. During an interview on 04/11/25 at 11:20 AM, LVN H stated she was the nurse who completed the side rail/bed evaluation that stated Resident #319 had no bedrails. She stated she did not remember Resident #319 having bed rails on his bed and then stated she must have made a mistake. LVN H stated a possible negative outcome for not having a signed consent or assessment for bed rails could be death. During an interview on 04/11/25 at 11:22 AM, the ADM stated she was not sure what the procedure was for bed rails since she was so new. A negative outcome for not having a signed consent form or assessment for a bed rail could be that it could impede a resident from getting out of bed. Record Review of the facility policy titled Bed Safety and Bed Rails dated August 2022 revealed the following in part . The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including resident assessment, and informed consent. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent .

Based on observations, interviews, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 17 (Resident #60) residents reviewed for PASRR. Resident #60 was not referred for PASRR Level II Assessment when a diagnosis of Mental Illness was identified on 07/03/2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services. Findings included: Record review of Resident #60's clinical record face sheet dated 4/09/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic systolic (congestive) heart failure, type 2 diabetes mellitus without complications (high blood sugar), schizoaffective disorder-bipolar type ( hallucinations and delusion with mood), alcohol dependence, anxiety disorder, and partial traumatic amputation of right foot, level unspecified. Record review of Resident #60's last completed MDS was an annual assessment dated [DATE] revealed Resident #60 had a BIMS score of 12 out of 15 indicating she had moderately impaired cognition. In Section A Identification Information in the annual MDS Assessment revealed the following: A1500 Preadmission Screening and Resident Review Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a relation condition. -Answer was 0: No. In Section I Active Diagnoses in the annual MDS Assessment revealed the following: I5700 Anxiety Disorder was checked I5900 Bipolar Disorder was checked I6000 Schizophrenia (schizoaffective and schizophreniform disorders) was checked. Record review of Resident #60's active physician orders dated 04/10/2025 revealed the following: Order for Olanzapine Oral Tablet 20 mg-Give one tablet by mouth at bedtime related to schizoaffective disorder, bipolar type. Order for Cymbalta oral Capsule delayed release particles 30mg-Give 90 mg by mouth at bedtime for anxiety related to schizoaffective disorder, bipolar type. Record review of Resident #60's care plan last updated on 03/14/2025 revealed she was care planned due to behavior problems, yelling throughout the night with interventions that included to intervene as necessary to protect the rights and safety of others. The care plan also stated Resident #60 was utilizing psychotropic medication r/t to bipolar schizoaffective disorder with interventions to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness. Record review of Resident #60's psychiatry progress note dated 07/03/2024 revealed the following: Nursing staff request to address a psychiatric issue of concern that requires a timely evaluation and medical intervention. Schizoaffective disorder, bipolar type-patient meets DSM-5 (Diagnostic and Statistical Manual of Mental disorders) criteria. Confirms history of episodes of psychosis outside a disturbance of mood. Diagnosis Assessment and Plan: F25.0: Schizoaffective disorder, bipolar type F41.9: Anxiety disorder, unspecified F10.20 Alcohol dependence, uncomplicated Record review of Resident #60's PASRR Level 1 Screening with date of assessment 12/28/2021 revealed the following: C0100 Mental Illness-No C0200 Intellectual Disability-No C0300 Developmental Disability-No Record review of Resident #60's PASRR Level 1 Screening with date of assessment 01/21/2025 revealed the following: C0100 Mental Illness-No C0200 Intellectual Disability-No C0300 Developmental Disability-No During an interview on 04/10/2025 at 8:48 AM, LVN A stated she was one of the two MDS Coordinators for the facility. LVN A stated the MDS Coordinators were responsible for ensuring each PASRR was accurate in a resident's file. LVN A stated if a resident had a new diagnosis, then a new PASRR I would be conducted, and if it was positive then a referral would be made to the local mental health authority for a PASRR II screening. LVN A looked at Resident #60's clinical file and said the new diagnosis on 07/03/2024 of schizoaffective disorder, bipolar type should have triggered a new PASRR I screening. LVN A said the new diagnosis was put in by the previous DON and the screening was missed. LVN A stated that a possible negative outcome for not conducting a new PASRR I screening for a resident after a new diagnosis of mental illness would be the staff would not know what services to provide the resident or if the facility could meet their needs. During an interview on 04/10/2025 at 8:50 AM, LVN B stated a diagnosis of schizoaffective disorder, bipolar type was a diagnosis that would trigger a new PASRR I screening. LVN B stated Resident #60 should have had a new PASRR I screening once she was diagnosed with schizoaffective disorder . During an interview and observation on 04/11/2025 at 9:40 AM, Resident #60 was in bed watching tv, her head slightly raised. Resident #60 stated she was seeing a psychiatrist and received medication for her anxiety. Resident #60 stated she had no concerns about her care and felt her needs were being met by the facility and her psychiatrist. During an interview on 04/11/2025 at 2:00 PM, the DON stated the MDS coordinators and nursing staff were responsible for making sure any new diagnosis of mental disorders or intellectual disabilities were addressed with regard to PASRR screenings, but she was ultimately responsible for overseeing it was getting done. The DON stated a consequence for not screening residents accurately could affect the resident's care pertaining to that specific diagnosis and the resident may not get the services that were needed. Record review of the facility policy, Resident Assessment-Coordination with PASARR Program dated 01/01/2025 revealed the following: Policy explanation and compliance guidelines: This facility coordinates assessment with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individual with a mental disorder intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related condition in accordance with the State's Medicaid rules for screening. a. PASARR Level I-initial pre-screening that is completed prior to admission. A Negative Level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 2. A positive Level 1 screen-necessitates a PASARR [NAME] II evaluation .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #114) of 17 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address Resident #114's pain and the appropriate interventions. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: Record review of Resident #114's admission record dated 04/09/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included disease of spinal cord, malignant neoplasm of prostate (cancer), and pain. Record review of Resident #114's admission MDS completed on 03/19/2025 revealed a BIMS score of 15 out of 15 indicating cognition was intact. Section J of the MDS indicated Resident #114 received scheduled pain medication. Section J-Health Conditions also revealed pain was present in Resident #114 that interfered with his therapy activities as well as his sleep. Resident #114 rated his pain in Section J to be a 6 out of 10 with 10 being the worst. Section V-Care Area Assessment Summary- pain was triggered and to be addressed in the care plan. Record review of Resident #114's active physician orders revealed the following medication orders: An order dated 03/16/2025 for fentanyl transdermal patch 72-hour 75 mcg/hr-Apply 1 patch transdermally in the morning every 3 days for pain and remove per schedule. An order dated 03/22/2025 for Hydrocodone-Acetaminophen Oral Tablet 7.5-325mg -Give 2 tablets by mouth every 6 hours for pain related to disease of spinal cord, unspecified. Record review of Resident #114's medication administration record for March 2025 revealed Resident #114 received fentanyl transdermal patch 72-hour 75 mcg/hr on 3/17/25, 3/20/25, 3/23/25, 3/26/25, and 3/29/25. Resident #114 received Hydrocodone-Acetaminophen Oral Tablet 7.5-325mg every six hours from 3/23/25 to 3/31/25. Record review of Resident #114's medication administration record for 4/1/25 through 4/10/2025 revealed Resident #114 received fentanyl transdermal patch 72-hour 75 mcg/hr on 4/1/25, 4/4/25, 4/7/25, and 4/10/25. Resident #114 received Hydrocodone-Acetaminophen Oral Tablet 7.5-325mg every six hours from 4/1/25-4/9/2025. Record review of Resident #114's care plan dated 03/26/2025 had no mention of Resident #114's pain management with no goals or interventions related to the diagnoses . During an observation and interview on 04/09/2025 at 9:30 AM, Resident #114 was lying in his bed watching tv., He started to cry and said he was in pain. He stated he had prostate cancer that spread to his bones. Resident #114 said the facility was giving him his pain medication as ordered. During an interview on 04/10/2025 at 9:39 AM, LVN A stated if a resident was in pain and receiving pain medication it should be in the care plan. LVN A pulled up Resident #114's care plan and the MDS Assessment and stated Resident #114's pain management should have been documented in his care plan. LVN A stated it was the MDS Coordinator and the DON's responsibility to ensure care plans were completed accurately. LVN A stated a possible negative outcome for not having services in the care plan would be staff would not know about the care and services needed for the resident. During an interview on 04/10/2025 at 3:00 PM, LVN M stated RN's were responsible for ensuring care and services were put in the care plan. LVN M stated a resident's care plan was generated from the MDS Assessment and not having all the services for a resident in the care plan could impede their progress and cause the resident to stay in the facility longer . During an interview on 04/11/2025 at 2:03 PM the DON stated she was responsible for ensuring care plans were completed accurately. She stated each morning she would conduct a morning meeting with her staff and each resident's care would be discussed and if anything changed or came up in the meeting then the MDS Coordinators were responsible for updating the resident's care plan. The DON stated if the care or services needed was not put in the care plan then care could be missed . Record review of facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. .The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . .Assessments of residents are ongoing and care plan are revised as information about the residents and the residents' conditions change .

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #39) of 17 residents reviewed for oxygen thearpy. The facility failed to ensure Resident #39 had physician's order in his chart for oxygen. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: Record review of Resident #39's Face Sheet dated 04/10/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), peripheral vascular disease (blood circulation disorder), heart failure, and unspecified atrial fibrillation (abnormal heartbeat). Record review of Resident #39's Admission MDS completed on 03/25/2025 revealed a BIMS of 15 out of 15 which indicated cognition was intact. Section O of the MDS revealed Resident #39 was not receiving oxygen On Admission or While a Resident. Record review of Resident #39's care plan dated 03/30/2025 revealed a focus area of I have Congestive Heart Failure. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal cannula @2L. Care plan for Resident #39 also revealed a focus area of I have COPD. One of the interventions for this focus area was OXYGEN SETTINGS: O2 via nasal cannula @ 2L. Record review of Resident #39's active physician's orders with last order review date of 3/25/2025 and next order review date of 04/25/2025 revealed no orders for oxygen. During an observation on 04/09/2025 at 9:01 AM Resident #39 was sitting in his wheelchair beside his bed with oxygen nasal cannula in nose. O2 reading was 1 1/2 Lpm. During an observation and interview on 04/11/2025 at 10:00 AM, Resident #39 was lying on his back in his bed with O2 nasal cannula in nose and O2 read 1 1/2 lpm. Resident #39 stated that he used oxygen all the time. During an interview on 04/11/2025 at 10:09 AM LVN K stated he had worked at the facility for 1 1/2 years. He stated that he was working the same hall that Resident #39 resided on. LVN K was asked to pull up the orders for Resident #39's oxygen and how much O2 he was supposed to be receiving. LVN K stated he could not find orders for Resident #39's oxygen. He stated that it was the admitting nurse and all the nurses' responsibility to make sure orders were put in correctly. LVN K stated that Resident #39 had COPD and that a possible negative outcome for not having oxygen orders in a resident file who was receiving oxygen could be difficulty breathing and that the facility was providing medication without a doctor's order. During an interview on 04/11/2025 at 10:14 AM, the DON stated that she could not find Resident #39's orders for oxygen. She stated that all nurses were responsible for putting admission orders in and that it was a problem that his orders were not in his file. The DON stated a possible negative outcome for not having accurate orders for O2 on file could be that they would not know how much O2 to give the resident. During an interview on 04/11/2025 at 1:17 PM, LVN B stated that it was the nurse's responsibility for putting orders in for new admissions. He stated that a possible negative outcome for not having accurate records for oxygen could be a possible medication error. Record review of facility policy titled Oxygen Administration and dated October 2010 revealed the following: . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Record review of facility policy titled Physician Orders and dated 8/16/2024 revealed the following: . A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. 1. The written and/or verbal orders should include at a minimum: b. Medication orders if indicated c. Routine care orders .

Based on interview and record review the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintatined periodically reconciled for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for pharmacy services. 1. The facility failed to prevent LVN B from misplacing narcotics for Resident #2, Resident #5, and Resident #6. 2. The facility failed to ensure Resident #2, #5, and #6's narcotics medications were accounted for: 2 out of the 3 narcotics that were missing. These failures could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes. Findings include: Resident #2: Record review of Resident #2's clinical record, dated 04/02/2025, revealed she was a [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #2 had diagnoses to include spastic diplegic cerebral palsy (a type of cerebral palsy that primarily affects the lower limbs (legs). It is characterized by increased muscle stiffness (spasticity) and difficulty with movement and coordination), acute kidney failure, abnormal posture, hypertension (high blood pressure), neuromuscular dysfunction of bladder (a condition where bladder control is impaired due to brain, spinal cord, or nerve problems, leading to difficulties in emptying or holding urine), and colon cancer. Record Review of Resident #2's MDS, dated [DATE], revealed Resident #2's BIMS score was 15 out of 15 which indicated that Resident #2 did not have any cognitive deficits. Section GG-Functional Abilities revealed Resident #2 required maximal assistance with oral hygiene toileting hygiene, shower/bath, upper body dressing, and lower body dressing. Total dependence was needed for putting on/taking off footwear. Resident #2 only needed set up assistance with eating and touch assistance with personal hygiene. Record review of Resident #2's order summary, dated 04/02/2025, revealed Resident #2 had an order for Acetaminophen-Codeine Tablet 300mg/30mg-Give 1 tablet by mouth every 6 hours as needed for severe pain. This order had a start date of 01/16/2025 and was open ended. Record review of Resident #2's care plan, dated 02/25/2025, revealed in part, the following: Focus o I have alteration in comfort related to pain Goal o I will not have an interruption in normal activities due to pain through the review date. Interventions o Administer medications per orders o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of Resident #2's medication administration record, dated 03/01/2025-03-31/2025 revealed that Resident #2 received her Tylenol 3 at 8:00am and 1:00pm on 03/27/2025 with the initials of LVN B recorded as the administrator of the medication. Record review of Resident #2's narcotic count sheet dated 03/21/2025-03/27/2025, revealed that LVN B dispensed 1 Tylenol 3 tablet on 03/23/2025 with an entry of dropped, another entry on 03/26/2025 of dropped, and 03/27/2025 nurse found, medication wasted. Resident #5: Record review of Resident #5's clinical record, dated 04/02/2025, revealed Resident #5 was a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #5 had diagnoses to include multiple sclerosis (a chronic autoimmune disease where the body's immune system mistakenly attacks the protective sheath (myelin) covering nerve fibers in the brain and spinal cord), right sided hemiplegia (weakness), type 2 diabetes mellitus without complications (elevated blood sugar), muscle wasting and atrophy(muscle loss). Record review of Resident #5's most recent MDS, dated [DATE], revealed Resident #5's BIMS of 15 out of 15 which indicates that Resident #5 had no cognitive deficits. Section GG-Functional Abilities revealed Resident #5 required total assistance with toileting hygiene, shower/bath, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #5 needed set up assistance with eating and oral hygiene; and touch assistance with personal hygiene. Record review of Resident #5's order summary, dated 04/02/2025, revealed Resident #5 had an order for Hydrocodone-Tylenol Tablet 10mg/325mg-Give 1 tablet by mouth every 8 hours as needed for pain. This order has a start date of 04/10/2024 and discontinue date of 03/28/2025. Record review of Resident #5's care plan, dated 03/20/2025, revealed in part, the following: Focus o Potential alteration in comfort related to pain Goal o Will be as comfortable as possible Interventions o Anticipate the resident's need for pain relief and respond immediately to any o Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. o Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. o Pain assessment, administer pain medication as ordered. Record review of Resident #5's medication administration record, dated 03/01/2025-03-31/2025 revealed that Resident #5 received his Hydrocodone-Tylenol 10mg/325mg at 7:00am and 1:00pm on 03/27/2025 with the initials of LVN B recorded as the administrator of the medication. Record review of Resident #5's narcotic count sheet dated 03/23/2025-03/27/2025, revealed that LVN B dispensed 1 hydrocodone/Tylenol 10mg/325mg tablet with no time next to date and signature. Document further revealed the medication was placed in drawer/missing, next to entry. Resident #6: Record review of Resident #6's clinical record, dated 04/02/2025, revealed she was an [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Alzheimer's disease with early onset, dementia, anxiety, hyperlipidemia (high cholesterol), hypertension (high blood pressure), weakness, trigger finger, left finger. Record Review of Resident #6's MDS, dated [DATE], revealed Resident #6's BIMS score was 15 out of 15 which indicated Resident #6 did not have any cognitive deficits. Section GG-Functional Abilities revealed Resident # 6 required set-up assistance with oral hygiene toileting hygiene, shower/bath, putting on/taking off footwear, and personal hygiene. Moderate/partial assistance was needed for dressing both upper and bottom body. Record review of Resident #6's order summary, dated 04/02/2025, revealed Resident #6 had an order for Hydrocodone-Acetaminophen 10-325mg tablet-Give 1 tablet by mouth every 4 hours as needed for pain. Give 1 tab by mouth, while awake do not exceed 3 grams in 24 hours. This order has a start date of 01/07/2023 and was open ended. Record review of Resident #6's care plan, dated 03/14/2025, revealed in part, the following: Focus o I have chronic joint pain Goal o I will verbalize comfort with current pain regime through the review period. Interventions o Administer Norco (hydrocodone-Acetaminophen), Tylenol as ordered. Monitor for side effects/adverse reactions and effectiveness. Report to MD PRN. o Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). o Provide diversional activities as accepted by [Resident #6]. Record review of Resident #6's medication administration record, dated 03/01/2025-03/31/2025 revealed Resident #6 received her Norco at 8:00am and 12:00pm on 03/27/2025 with the initials of LVN B recorded as the administrator of the medication. Record review of Resident #6's narcotic count sheet dated 03/27/2025-03/29/2025, revealed that LVN B dispensed 1 hydrocodone 10mg-325mg tablet with entry for 4:00pm dose missing. During an interview on 04/01/2025 at 8:56am Resident #5 stated he didn't know anything about any medication left for him in a drawer. When asked about the pain medication Resident #5 stated that he didn't like to take it and that the medication had been discontinued. The nurses were really good about giving his my medications when they were due. During an interview on 04/01/2025 at 9:50am CNA A stated she saw LVN B throw narcotics into the trash can on the medication cart. CNA A stated to LVN B there was a drug buster and was how narcotics were destroyed. LVN B replied to CNA A she forgot and would destroy them that way the next time. The 2nd time LVN B discarded a narcotic in the trash can on the medication cart, CNA A made the ADM aware. Both of these wastes of narcotics were for Resident #2. During an interview on 04/01/2025 at 11:09am Resident #2 stated LVN B was supposed to give her meds, but she never gave it to her. Resident #2 stated she had to ask for pain medications because it was PRN. During an interview on 04/01/2025 at 11:41am DON stated the narcotic discrepancies were with Resident #2, Resident #5, and Resident #6. DON stated narcotics for Resident #2 were thrown away in the trash can on the medication cart, and the narcotic discrepancies for Resident #5 and Resident #6 were the narcotics were left in a bedside night stand drawer or on a meal tray. DON stated she performed a narcotic audit of medications at that time. DON stated she asked LVN B where the narcotics were for Resident #5 due to medication being signed out before the end of her shift. LVN B stated she had put them in Resident #5's top drawer of his night stand. DON stated that there was another narcotic sheet that revealed that Resident #5 had 20 Hydrocodone in the medication card, however when the card was visualized it only had a count of 17. LVN B was asked where the pills were, she stated to the DON that she had already gave them to Resident #5. DON stated she interviewed Resident #5 and he had not taken the medication due to him not liking the medication. DON then proceeded to interview Resident #6 regarding medication being on her meal tray (lunch) and Resident #6 stated she had not taken any medication and had not seen any medication on the tray. During a phone interview on 04/01/2025 at 3:23 pm LVN B stated the following: I went to go and pull the meds like I normally do. One resident (Resident #2) was out of facility, and I was in the habit of pulling a Tylenol 3 and placing it in her top drawer of her night stand. This was only the 2nd time that I had done it. The only reason that it happened on Thursday was due to Resident #2 being very tearful and in pain LVN B stated that a negative outcome for preparing a narcotic for a resident and then leaving the medication was we just aren't supposed to do it. That side is very heavy when it comes to med pass, and I know that we are not supposed to do it. LVN B was asked about the medication for Resident #5 and Resident #6; LVN stated the Resident #6 would ask for the medications to be left on bedside table, since she [NAME] her medications one at a time. LVN B stated she did ask if the resident would take the narcotic first and then the resident could take the remainder of her medications on her own. LVN B stated that Resident #5 was starting to move around more and since Resident #5 was eating, LVN B placed the medication in the top drawer of the night stand and when the DON asked her where she put it she went to go and get the medication out of the drawer and the medication was not found. LVN B stated the negative outcome of not staying with residents until medications is taken is that there is no proof that the resident took the medication. LVN B also stated the negative outcome of placing medications in nightstand drawers it is not in our profession, and we are taught not to do that. LVN B stated the reason why she did this was because that the day was just overwhelming, I went with HR to have a drug screen, but I have nothing to hide. During an interview on 04/01/2025 at 4:14pm ADM stated LVN B would be terminated and reported to the Texas Board of Nursing. Copies of those reports were requested by investigator. During an interview on 04/02/2025 at 9:43am DON stated a possible negative outcome of a nurse not staying with a resident to watch the resident take the medication, was that resident's pain would not be addressed and resident not taking the medication and someone else taking it. DON stated the negative outcome of having an incompetent nurse would lead to the safety of residents, and the nurse not following the 5 rights of medication administration and adequate to follow up on resident's to assess if the medication was effective. During an interview on 04/02/2025 at 11:36am Resident #6 stated she never had anyone place medication on her meal tray or in any of her nightstand drawers. Resident #6 stated I just take what they give me. Record review of facility provided policy, titled, Administering Medications, revised April 2019, revealed the following: .5. Medications are administration times are determined by resident need and benefit, not staff convenience. .7. Medications are administered within one (1) hour of their prescribed time, . Record review of facility provided policy titled, Staffing, Sufficient and Competent Nursing revised August 2022, revealed the following: .Competent Staff 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including ( but not limited to) the following areas: a. Resident rights; . .g. Basic nursing skills; . .j medication management; . .k. pain management; .

Based on interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have acess to the keys for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for medication storage. -The facility failed to ensure LVN B stayed with Resident #6 until narcotic medications were taken. -The facility failed to ensure LVN B did not place narcotics in the nightstand table of Resident #5 and Resident #6's meal tray. -The facility failed to ensure LVN B did not destroy narcotic medications for Resident #2, by throwing them away in the medication cart trash can. These failures could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an interview on 04/01/2025 at 9:50am CNA A stated she saw LVN B throw narcotics into the trash can on the medication cart. CNA A stated to LVN B there was drug buster and that was how narcotics were destroyed. CNA A stated that LVN B told her (CNA A) that she (LVN B) forgot and would destroy them that way the next time. CNA A stated that the 2nd time she saw LVN B discarded a narcotic in the trash can on the medication cart, CNA A reported to the ADM. Both of these wastes of narcotics were for Resident #2. During an interview on 04/01/2025 at 11:09am Resident #2 stated LVN B was supposed to give her meds, but she never gave it to her. Resident #2 stated she had to ask for pain medications because it was PRN. Record Review of Resident #2's MDS, dated [DATE], revealed Resident #2's BIMS score was 15 out of 15 which indicated that Resident #2 did not have any cognitive deficits. Record review of Resident #2's order summary, dated 04/02/2025, revealed Resident #2 had an order for (Tylenol 3) Acetaminophen-Codeine Tablet 300mg/30mg-Give 1 tablet by mouth every 6 hours as needed for severe pain. This order had a start date of 01/16/2025 and was open ended. Record review of Resident #2's medication administration record, dated 03/01/2025-03-31/2025 revealed that Resident #2 received her Tylenol 3 at 8:00am and 1:00pm on 03/27/2025 with the initials of LVN B recorded as the administer of the medication. Record review of Resident #2's narcotic count sheet dated 03/21/2025-03/27/2025, revealed that LVN B dispensed 1 Tylenol 3 tablet on 03/23/2025 with an entry of dropped, another entry on 03/26/2025 of dropped, and 03/27/2025 nurse found, medication wasted. During an interview on 04/01/2025 at 11:41am DON stated the narcotic discrepancies were with Resident #2, Resident #5, and Resident #6. DON stated narcotics for Resident #2 were thrown away in the trash can on the medication cart, and the narcotic discrepancies for Resident #5 and Resident #6 were the narcotics were left in a bedside night stand drawer or on a meal tray. DON stated she performed a narcotic audit of medications at that time. DON stated she asked LVN B where the narcotics were for Resident #5 due to medication being signed out before the end of her shift. LVN B stated she had put them in Resident #5's top drawer of his night stand. DON stated that there was another narcotic sheet that revealed that Resident #5 had 20 Hydrocodone in the medication card, however when the card was visualized it only had a count of 17. LVN B was asked where the pills were, she stated to the DON that she had already gave them to Resident #5. DON stated she interviewed Resident #5 and he had not taken the medication due to him not liking the medication. DON then proceeded to interview Resident #6 regarding medication being on her meal tray (lunch) and Resident #6 stated she had not taken any medication and had not seen any medication on the tray. During a phone interview on 04/01/2025 at 3:23 pm LVN B stated the following: I went to go and pull the meds like I normally do. One resident (Resident #2) was out of facility, and I was in the habit of pulling a Tylenol 3 and placing it in her top drawer of her night stand. This was only the 2nd time that I had done it. The only reason that it happened on Thursday was due to Resident #2 being very tearful and in pain LVN B stated that a negative outcome for preparing a narcotic for a resident and then leaving the medication was we just aren't supposed to do it. That side is very heavy when it comes to med pass, and I know that we are not supposed to do it. LVN B was asked about the medication for Resident #5 and Resident #6; LVN stated the Resident #6 would ask for the medications to be left on bedside table, since she [NAME] her medications one at a time. LVN B stated she did ask if the resident would take the narcotic first and then the resident could take the remainder of her medications on her own. LVN B stated that Resident #5 was starting to move around more and since Resident #5 was eating, LVN B placed the medication in the top drawer of the night stand and when the DON asked her where she put it she went to go and get the medication out of the drawer and the medication was not found. LVN B stated the negative outcome of not staying with residents until medications is taken is that there is no proof that the resident took the medication. LVN B also stated the negative outcome of placing medications in nightstand drawers it is not in our profession, and we are taught not to do that. LVN B stated the reason why she did this was because that the day was just overwhelming, I went with HR to have a drug screen, but I have nothing to hide. During an interview on 04/01/2025 at 4:14pm ADM stated LVN B would be terminated and reported to the Texas Board of Nursing. Copies of those reports were requested by investigator. During an interview on 04/02/2025 at 9:43am DON stated a possible negative outcome of a nurse not staying with a resident to watch the resident take the medication, was that resident's pain would not be addressed and resident not taking the medication and someone else taking it. DON stated the negative outcome of having an incompetent nurse would lead to the safety of residents, and the nurse not following the 5 rights of medication administration and adequate to follow up on resident's to assess if the medication was effective. During an interview on 04/02/2025 at 11:36am Resident #6 stated she never had anyone place medication on her meal tray or in any of her nightstand drawers. Resident #6 stated I just take what they give me. Record review of Resident #5's most recent MDS, dated [DATE], revealed Resident #5's BIMS of 15 out of 15 which indicates that Resident #5 had no cognitive deficits. Record review of Resident #5's order summary, dated 04/02/2025, revealed Resident #5 had an order for Hydrocodone-Tylenol Tablet 10mg/325mg-Give 1 tablet by mouth every 8 hours as needed for pain. This order has a start date of 04/10/2024 and discontinue date of 03/28/2025. Record review of Resident #5's medication administration record, dated 03/01/2025-03-31/2025 revealed that Resident #5 received his Hydrocodone-Tylenol 10mg/325mg at 7:00am and 1:00pm on 03/27/2025 with the initials of LVN B recorded as the administer of the medication. Record review of Resident #5's narcotic count sheet dated 03/23/2025-03/27/2025, revealed that LVN B dispensed 1 hydrocodone-Tylenol 10mg/325mg tablet with no time next to date and signature. Document further revealed the medication was placed in drawer/missing, next to entry. Record Review of Resident #6's MDS, dated [DATE], revealed Resident #6's BIMS score was 15 out of 15 which indicated Resident #6 did not have any cognitive deficits. Record review of Resident #6's medication administration record, dated 03/01/2025-03/31/2025 revealed Resident #6 received her hydrocodone-acetaminophen 10mg-325mg tablet at 8:00am and 12:00pm on 03/27/2025 with the initials of LVN B recorded as the administer of the medication. Record review of Resident #6's narcotic count sheet dated 03/27/2025-03/29/2025, revealed that LVN B dispensed 1 hydrocodone-acetaminophen 10mg-325mg tablet with entry for 4:00pm dose missing. Record review of facility provided policy titled, Discarding and destroying Medications, revised November 2022, revealed the following: .1. All unused controlled substances are retained in a securely locked area with restricted access until disposed of. Record review of facility provided policy titled, Administering oral Medications revised October 2010, revealed the following: .21. Remain with the resident until all medications have been taken. Record review of facility provided policy, titled, Administering Medications, revised April 2019, revealed the following: .5. Medications are administration times are determined by resident need and benefit, not staff convenience. .7. Medications are administered within one (1) hour of their prescribed time, .

Based on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments and infividual plans of care considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 5 (LVN B) staff reviewed for nursing services. The facility failed to ensure that LVN B distributed and destroyed narcotic medications in accordance with professional standards and facility policy. This failure could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings include: During an interview on 04/01/2025 at 9:50am CNA A stated she saw LVN B throw narcotics into the trash can on the medication cart. CNA A stated to LVN B there was drug buster and that was how narcotics were destroyed. CNA A stated that LVN B told her (CNA A) that she (LVN B) forgot and would destroy them that way the next time. CNA A stated that the 2nd time she saw LVN B discarded a narcotic in the trash can on the medication cart, CNA A reported to the ADM. Both of these wastes of narcotics were for Resident #2. During an interview on 04/01/2025 at 11:41am DON stated the narcotic discrepancies were with Resident #2, Resident #5, and Resident #6. DON stated narcotics for Resident #2 were thrown away in the trash can on the medication cart, and the narcotic discrepancies for Resident #5 and Resident #6 were the narcotics were left in a bedside night stand drawer or on a meal tray. DON stated she performed a narcotic audit of medications at that time. DON stated she asked LVN B where the narcotics were for Resident #5 due to medication being signed out before the end of her shift. LVN B stated she had put them in Resident #5's top drawer of his night stand. DON stated there was another narcotic sheet that revealed that Resident #5 had 20 Hydrocodone in the medication card, however when the card was visualized it only had a count of 17. LVN B was asked where the pills were, she stated to the DON that she had already gave them to Resident #5. DON stated that she interviewed Resident #5 and that he had not taken them due to him not liking the medication. DON then proceeded to interview Resident #6 regarding medication being on her meal tray (lunch) and Resident #6 stated that she had not taken any medication and had not seen any medication on the tray. During a phone interview on 04/01/2025 at 3:23 pm, LVN B stated the following: I went to go and pull the meds like I normally do. One resident (Resident #2) was out of facility, and I was in the habit of pulling a Tylenol 3 and placing it in her top drawer of her night stand. This was only the 2nd time that I had done it. The only reason that it happened on Thursday was due to Resident #2 being very tearful and in pain LVN B stated a negative outcome for preparing a narcotic for a resident and then leaving the medication was we just aren't supposed to do it. That side is very heavy when it comes to med pass, and I know that we are not supposed to do it. LVN B was asked about the medication for Resident #5 and Resident #6; LVN stated that the Resident #6 would ask for the medications to be left on bedside table, since she takes her medications one at a time. LVN B did state that she did ask if the resident would take the narcotic first and then the resident could take the remainder of her medications on her own. LVN B stated Resident #5 was starting to move around more and since Resident #5 was eating, LVN B placed the medication in the top drawer of the night stand and when the DON asked her where she put it she went to go and get the medication out of the drawer and the medication was not found. LVN B stated the negative outcome of not staying with residents until medications is taken was that there was no proof that the resident took the medication. LVN B also stated that the negative outcome of placing medications in nightstand drawers it is not in our profession, and we are taught not to do that. LVN B stated was asked if this is something that you are not supposed to do then why did you do it? LVN B stated that the day was just overwhelming, I went with HR to have a drug screen, but I have nothing to hide. During an interview on 04/01/2025 at 4:14pm ADM stated LVN B would be terminated and reported to the Texas Board of Nursing. Copies of those reports were requested by investigator. During an interview on 04/02/2025 at 9:43am DON stated a possible negative outcome of a nurse not staying with a resident to watch the resident take the medication, was that resident's pain would not be addressed and resident not taking the medication and someone else taking it. DON stated the negative outcome of having an incompetent nurse would lead to the safety of residents, and the nurse not following the 5 rights of medication administration and adequate to follow up on resident to assess if the medication was effective. During an interview on 04/02/2025 at 11:36am Resident #6 stated she had never had anyone place medication on her meal tray or in any of her nightstand drawers. Resident #6 stated I just take what they give me. Record review of facility provided policy titled, Staffing, Sufficient and Competent Nursing revised August 2022, revealed the following: .Competent Staff 4. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 5. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 6. Staff must demonstrate the skills and techniques necessary to care for resident needs including ( but not limited to) the following areas: b. Resident rights; . .g. Basic nursing skills; . .j medication management; . .k. pain management; .