Every finding on record at Windsor Gardens

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Residents #1 and #2) of eight residents reviewed for resident rights. A) 1.The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 9:35 am. He was sitting in a wheelchair with only a blue hospital gown on, at the north end of the 600 hall. 2. The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 10:39 am. As he was being rolled down the 600 hall and taken to the therapy room, he was seen with a blue hospital gown and a beige blanket tied around his neck. 3. The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 10:42 am. Resident #1 was seen doing therapy with a blue hospital gown and blanket tied around his neck. B) The facility failed to ensure Resident #2 was adequately dressed, on Monday 07/20/26 at 11:10 am. Resident #2 was seen doing therapy in the therapy room with a blue hospital gown on. These failures could affect residents who required assistance with activities of daily living and could place them at risk of embarrassment and shame, which could result in decreased self-worth, mood, and psycho-social well-being. The findings included:A) Record review of Resident #1's Face Sheet dated 07/20/26 revealed, an [AGE] year-old male who admitted [DATE] with diagnoses of hypertensive urgency (severe blood pressure increase), acute kidney failure (sudden loss of kidney function), acute congestive heart failure (heart fails to pump enough blood), hyperlipidemia (high levels of fat in the blood), heart failure (heart not pumping blood and oxygen well), benign prostatic hyperplasia (non-cancerous prostate gland enlargement) , peripheral vascular disease (slow progressive blood circulation disorder), and depression (sadness mood disorder). Record review of Resident #1's Care Plan dated 07/11/26 revealed, the resident has an ADL self-care performance deficit: Dressing - the resident required assistance x1 by CNA, LPN, RN. Resident was dependent on staff with transfer to/from bed to chair wheelchair, standing position: Transfers - required assistance of 1 staff using a gait belt for transfers. The resident had impaired cognitive function/impaired thought processes. Observation on 07/20/26 at 9:35 am, Resident #1 had on a blue hospital gown and no pants on. He was sitting in a wheelchair by a another resident's room door. He was sitting at the north end of the 600 hall and there was no one at the nurses station or by him.Interview and observation on 07/20/26 at 9:45 am revealed, Resident #1 was sitting at the north end of the 600 hall, and no one was at the nurses station. He only had on a blue hospital gown with no pants on and was sitting in a wheelchair then CNA C walked by Resident #1 as she pushed a linen cart and kept walking. After she was asked for an interview she stated Resident #1 just admitted a week ago. She stated he had on a hospital gown because he did not have any clothes to put on and she would go to the laundry room's lost and found, to get him some. Observation on 07/20/26 at 10:39 am, Resident #1 was self-propelling his wheelchair down the 600 hall, he had on a blue hospital gown with a beige blanket tied around his neck, then a male staff started pushing him down the hall and to the therapy room. Observation on 07/20/26 between 10:40 am 10:42 am, Resident #1 was wearing a blue hospital gown with a beige blanket tied around his neck. As Resident #1 passed by his gown was not closed all the way and the upper part of the skin on his back was seen. Resident #1 started using the cycle machine in the therapy room. There were two therapy staff and three other residents who were properly dressed in clothes, who were also in the therapy room working out.Observation and Interview on 07/20/26 at 11:01 am, Resident #1 was sitting at the north end of the 600 hall, he had on a green shirt and grey pants with black socks on. He also had a grey blanket across his lap. He stated he felt better to have on clothes because it was cold at this facility. B) Record review of Resident #2's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE]. He had a BIMS score of 14 (no cognitive impairment) and for his daily preferences it was very important to choose what clothes to wear. He did not use any equipment for mobility. It was very important to do things with groups of people, and he needed partial to supervision assistance with upper and lower ADL assistance. He had diagnoses of heart failure (heart cannot pump blood and oxygen well), hypertension (high blood pressure), orthostatic hypotension (sudden drop in blood pressure), CVA (stroke), syncope and collapse (fainting/loss of consciousness) and depression (sadness mood disorder). Record review of Resident #2's Care Plan dated 06/30/26 revealed he had ADL self-care performance deficit: Dressing - The resident requires assistance x1 by CNA, LPN, RN. Resident was dependent on staff with transfer to/from bed chair wheelchair, standing position. Observation on 07/20/26 at 11:10 am, Resident #2 was in the therapy room exercising with a cycle machine, he had on a blue hospital gown. OT D was in the therapy room at that time. Interview and observations on 07/20/26 at 2:46 pm, Resident #2 was lying in bed, and he was wearing two blue hospital gowns and not clothes in his closet. He stated he would like to get some clothes because he did not have any at this facility. (He did not want to go any further with the conversation). Interview on 07/20/26 at 2:03 pm, CNA C stated Resident #1's FM visited him often, but this FM had not brought him any clothes, despite asking the FM to do so. She stated today 07/20/26, ADON A told her to get Resident #1 some clothes from the laundry department. She stated ADON A told her while they waited for Resident #1's clothes to come, they could get some from the laundry department. She stated today 07/20/26 she was able to get him some clothes from the laundry department. She stated she thought by now the FM would have brought him some clothes. She stated Resident #1 had just had a fall this morning 07/20/26 and she wanted to keep an eye on him, which was why he was sitting in the hallway. She stated she wanted to see what Resident #1 was doing while she went in and out of the other resident's rooms. She stated she did not know how it could affect the residents if they wore hospital gowns outside of their rooms. She stated it was a dignity issue when it came to their appearance because everyone wanted to step out and look nice. Interview on 07/20/26 at 3:52 pm, with OT D was attempted but she did not answer her phone or return call. Interview on 07/20/26 at 4:16 pm, CNA E stated she was Resident #1's CNA. She stated Resident #1 wore a hospital gown since he admitted here. She stated he had a pair of shorts and shirt he wore sometimes but she had not seen anyone drop off any clothes. She stated Resident #1 did not have any clothes and was not sure why he did not have any and guessed it was because the FM did not bring any. She stated she had not gone to laundry department's lost and found to get him any clothes. She stated Resident #2 went to therapy, walked around in his room, and stood in the doorway of his room at times. She stated she was not sure if he wore a hospital gown to therapy in the morning, but she had not seen him in any clothes. She stated she had not seen him in therapy with a hospital gown on. She stated she was not sure if he did therapy, but he was on the therapy hall. She stated she wished she would have known about the laundry department's lost and found bin, she would have gone to get them clothes. She stated she felt residents wearing hospital gowns outside of their room was a dignity issue. She stated she was sure the residents would prefer to put clothes on but had not asked them. Interview on 07/20/26 at 4:28 pm, SW B stated Resident #2 admitted to their skilled nursing facility and was living in the community and he was currently looking for assisted living placement for Resident #2. He stated he was not sure if Resident #2 was hot natured because he normally disrobed himself. He stated normally they had to get him fully dressed to keep his clothes on. He stated he noticed Resident #2 had on a hospital gown outside of his room today 07/20/26. He stated that most times Resident #2 wore clothes but added last week Resident #2 had on hospital gown with pants, sitting in his room. He stated he had not ever seen Resident #2 in the therapy room with a hospital gown on. He stated he knew the therapy department tried to bring residents to therapy with clothes on, but it was their right if they wanted to wear hospital gowns outside of their rooms. He stated he had not asked Residents #1 and #2 what their preferences were yet but would do. He stated this facility had a lost and found area in their laundry department and did not know Residents #1 and #2 were without any clothes at all. He stated Resident #1 had a large family who could have brought him clothes and he did not understand why he did not have any clothes. He stated Resident #2 only had a few items and they had been trying to get his clothes from his previous residence and was waiting for them to be dropped off. He stated the facility had a rather large supply of extra clothes in the laundry department. He stated he was going to call Resident #1's FM about bringing his clothes and Resident #2's contact to do the same. He stated wearing hospital gowns outside of their rooms was a dignity issue because it could make the residents uncomfortable. He stated Resident #1's cognition was not that good, but Resident #2's cognition was good. He stated he did not really want the residents outside of their rooms or in the therapy gym with hospital gowns because it was a dignity issue. He stated getting dressed with clothes was a part of therapy. Interview on 07/20/26 at 5:00 pm, ADON A stated Resident #1 fell this morning 07/20/26 and has had a cognitive decline and was quite impulsive. She stated this morning he was brought out of his room to be able to watch more closely. She stated sometimes she saw Resident #1 and #2 in the therapy room wearing hospital gowns. She stated she saw Resident #2 walking from the therapy room in a hospital gown. She stated Resident #1 and #2 wore hospital gowns because they did not have any clothes. She stated for Resident #2 they were waiting for his people at his previous home to bring his clothes. She stated they were going to call to get clothes for them, even though they had already asked for clothes to be brought in for them. She stated she sent a CNA to the laundry room to get Resident #1 some clothes, and they could not find anything for him to wear last week, but did not have the CNA look today. She stated if she did not call the FM/RPs, their nurses would do. She stated wearing hospital gowns outside of their rooms was a dignity issue and she did not think she would want to walk around like that. She stated she had not spoken to the Activities Director about getting her assistance with this matter. Interview on 07/20/26 at 5:11 pm, the DON stated she saw Resident #1 in a hospital gown, but he did not want them to change his clothes. She stated she never saw a blanket tied around Resident #1's neck with a hospital gown on today 07/20/26. She stated she was not sure if Resident #1 had any clothes at this facility. She stated he had on a gown in his room and today 07/20/26 they got him some clothes from the laundry's lost and found department. She stated she saw Resident #2 with two gowns on walking inside of his room. She stated Resident #2 was a therapy resident and she had not seen him in a hospital gown in the therapy room. She stated she thought Resident #1's FM usually came to the facility to drop off his clothes. She stated they had a lot of lost and found clothes in the laundry department, but it depended on the size of the resident on if they had clothes available. She stated everybody, the CNAs and nurses should ensure the residents came out of their rooms with clothes on. She stated wearing a hospital gowns outside of their rooms could affect them if they were cold. She stated there was not a negative effect on the residents wearing hospital gowns out of their rooms unless their skin was exposed and said anyone could always make assumptions about why a resident wore a hospital gown. She stated she was not aware Resident #1's back was exposed this morning 07/20/26. She stated if the staff asked Resident #1 if he were all right with his back being exposed and he said yes they had to go by what he said. She stated they could be infringing on his rights and did not want to do that, then stated she was not sure of what his preferences were for wearing a hospital gown outside of his room. She stated she was not sure if Resident #1 was care planned for this. Interview on 07/20/26 at 5:32 pm, the Administrator stated today 07/20/26, Resident #1 had a fall by the door. She stated he was sitting by the nurse's station for the nurses to keep a better eye on him and was not aware he had on just a hospital gown. She stated from her understanding the staff had been talking to his FM about bringing his clothes to the facility. She stated if residents admitted without clothes the staff needed to call the FM/RP to get their clothes or obtain clothes from the laundry's lost and found. She stated some residents preferred to wear hospital gowns and said she would not like to wear a hospital gown, but the residents had a right to wear them out of their rooms. She stated she was not sure if they had been asked what the residents' preferences were and she would have to find out. She stated wearing hospital gowns outside of their rooms was a dignity issue, but it was a thin line because they could not force the residents to put clothes on. She stated she was not sure if these residents asked for clothes, but the staff were supposed to ask the residents what they would like to wear for therapy or before leaving their rooms. She stated OT was a part of the resident's rehab therapy and was not sure what happened today 07/20/26. She stated she was not sure if the therapy staff or CNA got Resident #1 up today 07/20/26. She stated that usually the administrative team would get reports in every morning meeting letting them know what was going on with the residents. She stated there were no reports from the nursing staff about Residents #1 and #2 needing clothes. She stated the Medicare therapy Residents #1 and #2, did not have trust fund accounts for them to get clothes with. She stated in most cases the CNAs were responsible for ensuring the residents had on regular clothes outside of their rooms. She stated she was not sure if there was something going on with Resident #1 not having clothes that fit. She stated getting clothes for the residents also depended on if there were any clothes in the lost and found bin the residents could wear. She stated she had never noticed Residents #1 and #2 outside their rooms with hospital gowns on. She stated the nurse should let the administrative team know about the resident's clothing needs. She stated the SW and Activity Director needed to assist with finding clothes for the residents and following up with FM/RP. Record review of Resident #1's Progress notes and care plans did not reveal whether he needed clothes and the attempts made to get them or that he refused to wear clothes. Record review of Resident #2's Progress notes and care plans did not reveal whether he needed clothes and the attempts made to get them or that he refused to wear clothes. Record Review of the facility's Resident Rights dated 2025 revealed, Resident rights. The resident has the right to a dignified existence, self-determination, and communication.4. Respect and dignity. The resident has a right to be treated with respect and dignity.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #7, Resident #98, and Resident #104) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #7, Resident #98, and Resident #104's rooms were in a position that was accessible to the resident on 01/13/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #98Review of Resident #98's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait and mobility.Review of Resident #98's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 11/12/2025, reflected the resident had a moderate (resident may need additional support and monitoring) impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 10. The Quarterly MDS Assessment indicated that the resident required moderate assistance for toileting hygiene, dressing, bed mobility, and transfer.Review of Resident #98's Comprehensive Care Plan, dated 08/18/2025, reflected the resident was at risk for falls one of the interventions was to be sure the resident's call light was within reach.During an observation and interview on 01/13/2026 at 9:45 AM revealed Resident #98 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked about her call light, the resident did not reply and just shrugged her shoulders.Resident #104Review of Resident #104's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination.Review of Resident #104's Quarterly MDS Assessment, dated 11/26/2025, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated that the resident required maximal assistance for hygiene, shower, dressing, and transfer. Review of Resident #104's Comprehensive Care Plan, dated 08/18/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach.Observation and interview on 01/13/2026 at 9:49 AM revealed Resident #104 was in her bed, awake. It was observed that the resident's call light was on the floor, between her bed and her side table. When asked where her call light was, the resident said she did not have it.During an observation and interview on 01/13/2026 at 9:51 AM, ADON A stated call lights should be with the residents at all times so they could easily call the staff for assistance. He said call lights were important because the residents used them if they needed to be changed, needed a pain pill, or if they needed a refill of their pitchers. He went inside Resident #98's room, picked up the call light from the floor, and placed it where the resident could reach it. He then went to Resident #104's room, picked up the call light, and placed it where the resident could reach it. He said call lights were for all residents whether dependent or independent. He said an independent resident might be having a heart attack or shortness of breath and could not call anybody because the call light was not with the resident. He said she was one of the responsible in checking if the call lights were with the residents. He said he would start an in-service about making sure call lights were within reach of the residents.Resident #7Record review of Resident #7's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and pain in right ankle.Record review of Resident #7's Quarterly MDS assessment dated [DATE], reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated that the resident required assistance for toileting, shower, dressing, transfer, and personal hygiene.Record review of Resident #7's Comprehensive Care Plan, dated 12/14/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was withing reach. During an observation and interview on 01/13/2026 at 11:33 AM revealed Resident #7 was in her bed, awake. It was observed that the resident's call light was on the floor under the bed. The resident said she had been looking for her call light because she needed to call the staff.During an interview and observation on 01/13/2026 at 11:35 AM, revealed ADON A went inside Resident #7's room and saw the call light on the floor. He picked it up and placed it where the resident could reach it. He said he already started an in-service about the call lights, and he did not understand why there was still a call light on the floor. He said the staff should make sure that the call lights were with the residents before leaving the room. He said the expectation was for all the staff to make sure the call lights were within reach of the residents before they left the residents' rooms.In an interview on 01/13/2026 at 11:33 AM, LVN B stated she was made aware about the call lights that were on the floor on her hall. She said she did not notice that the call lights were on the floor. She said the call lights should be with the residents at all times in case the residents needed the staff. She said the residents might get upset or even fall trying to do things by themselves.In an interview on 01/13/2026 at 11:43 AM, CNA D stated she did not notice that Resident #7, #98, and #104's call lights were not with them. She said the residents used the call lights to call the staff if they needed something or if they needed assistance. She said without the call lights, the residents might fall if they tried to do things by themselves. She said the call lights were for all the residents, whether they used them or not.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that the staff should make sure that the call lights were with the residents before they leave the room. She said the staff should clip the call lights to make sure they would not fall when the residents moved. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless, and the staff would not be able to help the residents when needed. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights.In an interview on 01/15/2026 at 9:04 AM, the DON stated that call lights were safety measures wherein the residents could call the staff if they needed something or needed assistance. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result in a fall and injuries. She said all the staff were responsible for the call lights, including her. She said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. She said an in-service was already initiated but she would closely monitor the staffs' compliance about placing the call lights within reach of the residents. She added that, aside from the nurses and CNAs, she would include the therapists, housekeeping, maintenance, and management in the in-service.Record review of the facility's policy Call Lights: Accessibility and Timely Response P & P Committee revised 12/01/2025 reflected Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . Policy Explanation and Compliance Guidelines . 5. Staff will ensure the call light is within reach of resident and secured, as needed . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for eleven (Residents #2, #5, #33, #40, #44, #49, #53, #91, #100, #116, and #117) of twenty-eight residents reviewed for resident rights. 1. The facility failed to ensure LVN B secured Resident #5's medical information before leaving her cart on 01/13/2026.2. The facility failed to ensure MA C secured Residents #2, #33, #40, #44, #49, #53, #91, #100, #116, and #117's medical information before leaving her cart on 01/14/2026.These failures could place the residents at risk of not having their personal and medical information confidential and exposed to unauthorized individuals.Findings included: 1. Record review of Resident #5's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with end-stage renal disease (a condition where the kidneys can no longer function adequately).An observation on 01/13/2025 at 11:33 AM revealed LVN B took a box of medication from Resident #5's side table and put it on top of the cart. After putting it on top of the cart, LVN B pushed her cart to attend to another resident. She went inside the room the resident's room leaving the box of medication on top of her cart that contained the resident's name and the medication that she was taking.During an observation and interview on 01/13/2026 at 12:04 PM, LVN B stated she should have placed Resident #5's box of medication inside the drawer of her cart because medical information was attached to it. She said the information should be secured and not exposed for everybody to see.2. Resident #2Record review of Resident #2's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pulmonary embolism (blood clot in one of the blood vessels of the lungs).Resident #33Record review of Resident #33's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure).Resident #40Record review of Resident #40's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #44Record review of Resident #44's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with heart failure.Resident #49Record review of Resident #49's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #53Record review of Resident #53's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #91Record review of Resident #91's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #100Record review of Resident #100's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #116Record review of Resident #116's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension.Resident #117Record review of Resident #117's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension.An observation on 01/14/2026 at 7:52 AM revealed MA C left her cart in the hallway and went to another hall to get a blood pressure cuff. A piece of paper was on top of the cart with Resident #2, #33, #40, #44, #49, #53, #91, #100, #116, and #117's blood pressures and pulses written beside their names. The cart was facing the hallway. Several residents and non-nursing staff were passing-by the cart.During an observation and interview on 01/14/2026 at 7:57 AM, MA C stated she always writes the residents' BP and pulses on a paper and would put it in the system later. She said she should have flipped the paper before she left her cart because the BP and pulses of the residents were medical information and should be secured. In an interview on 01/15/2026 at 8:16 AM, ADON A stated the medical information of any resident should not be left unattended because it was confidential and could be a HIPAA violation. He said, before leaving the cart, the staff should have secured the box of medication and the piece of paper with medical information on them. He said the medical information should not be visible to unauthorized individuals. He said they already started an in-service about confidentiality of medical records.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that staff must make sure that the residents' medical information was secured and only authorized individuals had access to it. She said it would be a HIPAA violation if the information was left unattended and unauthorized individuals were able to read it. She said the expectation was for the staff to make sure to secure everything that was confidential. She said she coordinated with the DON about the issue regarding confidentiality of records.In an interview on 01/15/2026 at 9:04 AM, the DON stated that if what was written on the box and on the piece of paper were medical information of the residents, then it should not be left unattended because the information was confidential. She said what the resident was taking and their blood pressures and pulses were medical information and leaving them unattended was a HIPAA violation. She said the expectation was for the staff to be mindful and protect the residents' information. She said she already started an in-service and would closely monitor the staffs' compliance about confidentiality of records.Record review of the facility's policy, Resident Rights The Compliance Store, undated, reflected 7. Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . a. Personal privacy includes accommodations, medical treatment . b. The resident has a right to secure and confidential personal and medical records.

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 the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Residents #2, #100, and #111) of twelve residents reviewed for care plans. 1. The facility failed to ensure Resident #2's care plan, dated 01/09/2026, included a care plan for pulmonary embolism. 2. The facility failed to ensure Resident #100's care plan, dated 01/09/2026, included a care plan for hypertension. 3. The facility failed to ensure Resident #111's Comprehensive Care Plan reflected the use of a BiPAP machine (noninvasive ventilation that helps you breathe) on 01/13/2026.These failures could place the residents at risk of not receiving the necessary care and services.Findings included: 1. Record review of Resident #2's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pulmonary embolism (blood clot in one of the blood vessels of the lungs). Record review of Resident #2's Comprehensive MDS Assessment, dated 12/30/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had pulmonary embolism. Record review of Resident #2's Physician Order, dated 12/27/2025, reflected Xarelto Oral Tablet 15 MG (Rivaroxaban) Give 1 tablet by mouth one time a day for hx of pulmonary embolism. Record review of Resident #2's Comprehensive Care Plan, dated 01/09/2026, reflected the resident did not have a care plan for pulmonary embolism. Record review of Resident #2's Physician Order, dated 12/29/2025, reflected Anticoagulant SE Monitoring: Observe closely for significant side effects of Anticoagulant medication including . sudden changes in mental status or vital signs. 2. Record review of Resident #100's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #100's Comprehensive MDS Assessment, dated 11/30/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #100's Physician Order, dated 12/04/2025, reflected Hyzaar Oral Tablet 50-12.5 MG (Losartan Potassium & Hydrochlorothiazide) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP less than 100, Hold for Diastolic blood pressure less than 60. Record review of Resident #100's Comprehensive Care Plan, dated 12/03/2025, reflected the resident did not have a care plan for hypertension. During an observation and interview on 01/14/2026 at 12:56 PM, MDS Nurse F stated if the resident had hypertension or pulmonary embolism, then there should be care plan for it. He said care plans should be in place so the staff knew the interventions and goals for the resident and would be in sync in terms of the care to be provided. He said he was not responsible for doing Resident #2 and Resident #100's care plans but he could check their profiles. He logged onto his computer and saw that Resident #2 did not have a care plan for pulmonary embolism and Resident #100 did not have a care plan for hypertension. He said he would put a care plan for both. He opened the profile of both residents and placed a care plan for pulmonary embolism and hypertension. He said if the residents did not have a care plan, there would be confusion on their care or care would be not provided at all. In an interview on 01/15/2026 at 8:16 AM, ADON A stated care plans were important so the staff would be in sync with the care of the residents. He said without the care plan, needed interventions might not be provided. He said the expectation was all the issues of the residents were care planned. He said he would coordinate with the DON and the MDS Nurse to make sure the residents had appropriate care plans. In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the expectation was for all the residents were care planned appropriately. She said she would coordinate with the DON to make sure all the residents were care planned. In an interview on 01/15/2026 at 9:04 AM, the DON stated that every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. She said the care plan should be in place so that the staff providing care would be on the same page. She said the care plan was important because it reflected the resident's problem lists, goals, and interventions. She said the expectation was for all residents to have care plans with regards to their medical issues. She said she would coordinate with the MDS Nurse to audit the care plans of the residents. 3. Record review of Resident #111's face sheet, dated 01/13/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included COPD (chronic lung disease that makes it difficult to breathe) and asthma (airway narrows and can make breathing difficult). Record review of Resident #111's Quarterly MDS (tool used to measure health status) Assessment, dated 11/13/2025, reflected intact cognition with a BIMS (tool used to measure cognitive status) score of 13. Section I (Active Diagnoses) indicated Resident #111 was treated for COPD. An observation on 01/13/2026 at 9:28 AM revealed Resident #111 was not in his room. Staff reported he was at dialysis. A BiPAP machine with face mask was on Resident #111's nightstand. During an interview on 01/14/2026 at 7:23 AM, Resident #111 was in bed awake. He stated he brought the BiPAP machine from home and had used it every night for almost 15 years. He stated he put the mask on each night before going to sleep and removed it the next morning to put his oxygen on. Record review of Resident #111's Comprehensive Care Plan, dated 12/26/2025, did not reflect the use of a BiPAP machine. Record review of Resident #111's Physician's Orders, on 01/13/2026, did not reflect an order for the BiPAP. During an interview on 01/15/26 at 8:23 AM, the DON stated Resident #111's BiPAP should have been included in his care plan. She stated the MDS Coordinator was responsible for ensuring the BiPAP was included the resident's care plan. She stated it was important to ensure the best possible outcome for the resident. She stated the BiPAP had been added to the resident's care plan. During an interview on 01/15/2026 at 12:20 PM, MDS Nurse G stated any nurse could add a care plan. She stated the staff's morning meetings was the time to capture what going on with residents and discuss care plan updates. She stated it was important to ensure the care plan reflected Resident #111's needs so he received the appropriate care during his stay. She stated the care plan was a way to communicate the resident's needs with other staff members. She stated the resident's care plan had been updated to reflect the BiPAP. Record review of the facility's policy, Comprehensive Care Plans Policy revised October 01, 2025 reflected Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team after each assessment for seven (Residents #33, #44, #91, #98, #100, #104 and #116) of twelve residents reviewed for care plans revision. The facility failed to complete a quarterly care plan for Residents #33, #44, #91, #98, #100, #104, and #116.This failure could place the residents at risk of care and needs not being met. Findings included:Resident #33Record review of Resident #33's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review on 01/14/2026 of Resident #33's Comprehensive MDS Assessment reflected the last MDS was done on 12/29/2025.Record review on 01/14/2026 of Resident #33's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 09/17/2025.Resident #44Record review of Resident #44's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE].Record review on 01/14/2026 of Resident #44's Comprehensive MDS Assessment reflected the last MDS was done on 11/18/2025.Record review on 01/14/2026 of Resident #44's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 08/19/2025.Resident #91Record review of Resident #91's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. Record review on 01/14/2026 of Resident #91's Comprehensive MDS Assessment reflected the last MDS was done on 12/29/2025.Record review on 01/14/2026 of Resident #91's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 08/25/2025.Resident #98Record review of Resident #98's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review on 01/14/2026 of Resident #98's Comprehensive MDS Assessment reflected the last MDS was done on 11/12/2025.Record review on 01/14/2026 of Resident #98's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 08/18/2025.Resident #100Record review of Resident #100's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #100's Comprehensive MDS Assessment, dated 11/30/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. Record review of Resident #100's Comprehensive Care Plan, dated 12/03/2025, reflected the care plan only had two foci in the problem list, the code and ADLs. Resident #104Review of Resident #104's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review on 01/14/2026 of Resident #104's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 08/18/2025.Record review on 01/14/2026 of Resident #104's Comprehensive MDS Assessment reflected the last MDS was done on 11/26/2025.Resident #116Record review of Resident #116's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review on 01/14/2026 of Resident #116's Comprehensive MDS Assessment reflected the last MDS was done on 11/17/2025.Record review on 01/14/2026 of Resident #116's Comprehensive Care Plan reflected the last quarterly care plan completed for the resident was 08/21/2025.In an interview on 01/15/2026 at 8:16 AM, ADON A stated care plans were done during admission and were being updated quarterly. He said the care plans were also updated if there was a change in condition, new wound, or the resident had a fall. He said care plans should be updated so the staff would know if there were new interventions that needed to be done and to monitor the resident's response to the new interventions. He said if the care plans were not updated, it could mess up the monitoring side of the interventions.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that care plans were supposed to be updated quarterly to make sure that the care being given was still appropriate. She said the expectation was for all the residents to be care planned and that the care plans were updated quarterly and when needed. She said she would coordinate with the DON and the NDS Nurses to make sure the care plans were current.In an interview on 01/15/2026 at 9:04 AM, the DON stated that every resident needed a thorough care plan to ensure the residents received the care they needed. She said the care plan should be done quarterly to monitor if there were new interventions or to assess if the goals were being met. She said the care plan could also be updated if there was a change in condition. She said if the care plan was not updated, as if they were not doing their due diligence in terms of assessing the residents. She said she would coordinate with MDS Nurses to audit the care plans of the residents.During an observation and interview on 01/15/2026 at 10:10 AM, MDS Nurse G stated she was responsible in making the care plans of the residents in long term care. She said she was responsible in making the care plans for Residents #33, #44, #91, #98, #100, #104, and #116. She opened the residents' profiles and saw the care plans were all overdue. She said she would work on updating their care plans and would also audit the care plans of the other residents in long term care. Record review of the facility's policy, Comprehensive Care Plans P & P Committee revised October 01, 2025, reflected Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . Policy Explanation and Compliance Guidelines . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three (Residents #5, #17, and #111) of eighteen residents reviewed for medication storage. 1. The facility failed to ensure that Resident #5's carbonate powder used by the resident before dialysis was not inside the room on 01/13/2026.2. The facility failed to ensure that LVN B did not leave Resident #5's carbonate on top of her cart unattended on 01/13/2026.3. The facility failed to ensure that there were no medications inside Resident #17's room on 01/13/2026.4. The facility failed ensure Tums (treats indigestion) tablets were not left in a medicine cup on Resident #111's dresser on 01/13/2026.These failures could place residents at risk of misuse of medications that could lead to overdosing and other adverse reactions.Findings included: 1. Record review of Resident #5's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with end stage renal disease. Record review of Resident #5's Comprehensive MDS Assessment, dated 12/17/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was on dialysis.Record review of Resident #5's Comprehensive Care Plan, dated 11/04/2025, reflected that the resident needed dialysis and one of the interventions was to encourage the resident to go to schedule dialysis appointments. During an observation and interview on 01/13/2026 at 11:30 AM revealed Resident #5 was in her bed, awake. It was observed that there was a box of carbonate on the resident's side table. When asked about the medication, the resident said she did not know who put the medication on her side table.During an observation and interview on 01/13/2026 at 11:33 AM, LVN B stated there should be no medications inside the residents' room because the residents could misuse them or take more than what was recommended. She went inside the room and saw the box of carbonate on Resident #5's side table. She said she did not notice the box when she checked on the resident. She took the box and said the staff were not giving it because the dialysis center was the one administering the medication. She put the box on top of the cart. She said she did not have an order for the carbonate because the dialysis center was the one giving it.2. An observation on 01/13/2026 at 12:04 PM revealed after LVN B placed Resident #5's box of medication on top of her cart, she pushed her cart and stopped on one of a resident's room. She went inside the room leaving the box of medication on top of her cart unattended. Several residents were observed passing by the cart.During an observation and interview on 01/13/2026 at 12:10 PM, LVN B stated she should have secured the box of medication inside her cart before leaving her cart unattended because a resident might take it and consume it. She opened her cart and placed the box of medication in the last drawer of the cart.3. Record review of Resident #17's Face Sheet, dated 01/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and osteoarthritis.Record review of Resident #17's Comprehensive MDS Assessment, dated 11/04/2025, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had dementia and osteoarthritis.Record review of Resident #17's Comprehensive Care Plan, dated 11/06/2025, reflected that the resident was on pain management and one of the interventions was to assess resident and family/caregivers' knowledge of side effects and safetyprecautions related to use of pain medication.Record review of Resident #17's Physician Order, dated 06/03/2025, reflected Pain Monitoring - Assess for pain every shift Pain score is greater or equal to 1 or has been assessed with non-verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or nonpharmacological Pain interventions documented on the Treatment Administration Record.During an observation and interview on 01/13/2026 at 9:47 AM revealed Resident #17 was in her bed, awake. It was observed that there were an antiseptic liquid and topical analgesic inside a transparent container on the resident's bedside. The resident said those were her medications. The medications were in plain view and could be seen as soon as someone entered the room. During an observation and interview on 01/13/2026 at 12:14 PM, LVN B said she was not aware there were medications inside Resident #17's room. She went inside the resident's room and saw the medications. She talked to the resident that she would get the medications and would put them inside the cart. She said those medications should not be there because the resident might consume them or put them in her eyes causing irritation.In an interview on 01/15/2026 at 8:16 AM, ADON A stated medications should not be inside the residents' rooms and should be stored inside the carts. He said Resident #5's box of carbonate was not supposed to be in the facility because it was used in the dialysis clinic. He said the issue was not if the dialysis center mistakenly placed the box on Resident #5's room but that nobody noticed it. He said when the box of carbonate was taken from the Resident #5's side table, it should have placed directly inside the cart or inside the medication room. He said the box should not have been left unattended on top of the cart because residents might be able to get some, consume it, and be allergic to it. He said they already called Resident #17's family member regarding the medications inside the resident's room and the family member said they would come to the facility to pick it up. He said the expectations where no medications would be stored inside the residents' rooms and no medication would be left on top of the cart unattended. He said he already started an in-service about medication storage. He said the facility would also educate the family members that it was alright to bring medications, but they needed to let the staff know so the staff could assess if the medications were needed so they could request an order from the physician.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated the expectation was for the staff to be mindful to scan the residents' rooms for any medication and not to leave any medication on top of the carts for resident's safety. She said the residents might consume or use the medications inappropriately that could result in adverse reactions. She said she would coordinate with the DON regarding the issue about medication storage.In an interview on 01/15/2026 at 9:04 AM, the DON stated medications should not be medications inside the residents' rooms because they could overdose or could have adverse reactions from the medications that they were not supposed to have. She said the same reason applied to not leaving any medication on top of the cart unattended. She said the expectation was that no medications would be inside the rooms of the residents and no medications should be left on top of the carts. She said an in-service was already started and she would closely monitor the staff's adherence to the policy.4. During an observation on 01/13/26 at 9:41 AM, revealed Resident #111 was not in his room. On top of the resident's dresser were some of Resident #111's personal items. There was also a small medicine cup with over-the-counter TUMS in it. During an interview on 01/13/2026 at 2:33 PM, LVN H stated the TUMS should not have been in Resident #111's room and she did not notice it when she rounded that morning. She stated he was at a scheduled procedure. She stated she had removed and discarded the medication. She stated it was important for staff to wait for the resident to take medication before leaving the room. She stated the resident had not been able to eat or drink anything the night before because of the procedure and she did not give him any medication. She stated they did not want the resident to self-medicate. She stated another resident might go in the room and take the medication. During an interview on 01/13/26 at 3:14 PM, RN N stated Resident #111 had been out of the facility for several days. She stated the dialysis center sent him to the hospital on [DATE] and he returned to the facility on [DATE]. She stated she completed his assessment when re-admitted and he went to dialysis the same day. She stated he had an outpatient procedure today (01/13/2026) and had not returned to the facility. She stated she did not see the medication in his room. She stated it was important to ensure residents took their medication before leaving the room. During an interview on 01/13/2026 at 3:25 PM, MA O stated Resident #111 had been gone for a few days. She stated she did not give him the Tums. She stated the medication should not have been in his room. She stated she makes sure all medication is taken before she leaves a resident's room. She stated anyone could wander in and take the medication. MA O stated Resident #111 did have an order for TUMS. She opened the resident's chart to view the medication administration record and stated the last dose of TUMS was administered on 01/06/2026. During an interview on 1/14/2026 at 7:23 AM, Resident #111 was in bed awake. He stated he did not notice the TUMS in the medicine cup on top of his dresser. He stated he did not remember staff ever leaving medicine in his room. Resident #111 stated he had been out of the facility for several days. During an interview on 01/14/2026 at 1:14 PM, the DON stated the facility was providing in-service training to all staff including housekeeping, laundry, and the kitchen. She stated staff were told not to touch, but immediately report to the nurse, any medication in a resident's room. She stated medication should not be left in a resident's room, and staff must observe residents taking medication before leaving the room. She stated it was important for nurses to know what medication the resident was taking and when they were taking it. She stated medication should not be left out where another resident could have access to it. During a telephone interview on 1/15/26 at 1:15 AM, LVN I was at work and stated she worked 10:00 PM - 6:00 AM. She stated she came to work 01/12/2026 at 10:00 PM and worked overnight. She stated she did not take the medicine in the room. She stated she did not see the medicine on Resident #111's dresser. She stated it was important to know what medications the resident had taken. She stated she also did not want another resident to go in the room and take it. She stated it could be a medication another resident was allergic to. She stated Resident #111had been at the hospital for several days and returned to the facility 01/12/2026. She stated he was NPO (nothing by mouth) for a procedure the following day. She stated she did not notice the medication in the room. She stated he asked for a pain pill during the night, but she was unable to give it because he was NPO. During an interview on 01/15/2026 at 9:11 AM, ADON A stated medication should not have been in Resident #111's room. He stated part of rounding was for staff to notice those things. He stated there were elderly residents in their care and some had dementia. He stated some might think it's food and it was important to keep the environment free of anything that could potentially cause harm. He stated the staff received in-service training related to leaving medication in a room. He stated staff were told to immediately report to the nurse any medication observed in a resident's room. He stated nurses were to remove it and find out where it came from.Record review of the facility's policy, Medication Storage P & P Committee revised December 01, 2025, reflected Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms . Policy Explanation and Compliance Guidelines . 1. General Guidelines . a. All drugs and biologicals will be stored in locked compartments.Record review of the facility's policy Medication Administration, revised 12/01/2025, reflected Observe resident consumption of medication.

Based observation, interview and record review the facility failed to establish and 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 three (Residents #24, #77, and #128) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA D and the ABOM wore gowns when Resident #24, who had a catheter, was transferred to his wheelchair on 01/14/2026. 2. The facility failed to ensure CNA E performed hand hygiene and changed her gloves during Resident #77's incontinent care on 01/14/2026.3. The facility failed to ensure LVN M wore a gown when administering an antibiotic via PICC line (tubing inserted into a vein for long-term intravenous therapy) while caring for Resident #128, who was on enhanced barrier precautions, on 01/13/2026. 4. The facility failed to ensure MA C did not put her personal beverage on top of the medication cart while passing medications on 01/14/2026. 5. The facility failed to ensure Resident #102's oral liquid levetiracetam (medication used to treat seizures) did not have an open oral syringe secured to the bottle, with a rubber band, on 01/15/2026.6. The facility failed to ensure Resident #113's oral liquid potassium (vitamin supplement) did not have an open oral syringe secured to the bottle, with a rubber band, on 01/15/2026.These failures could place residents at risk of cross-contamination and development of infections. Findings include:1. Record review of Resident #24's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #24's Comprehensive MDS Assessment, dated 01/02/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had indwelling catheter.Record review of Resident #24's Comprehensive Care Plan, dated 10/13/2025, reflected that the resident had a suprapubic catheter and one of the interventions was to change the catheter as needed.Record review of Resident #24's Physician Order, dated 12/17/2025, reflected Enhanced Barrier Precautions every shift Follow Facility Policy - USE for patients with any of the following . Wounds or indwelling medical devices, regardless ofMDRO colonization status Infection or colonization with an MDRO.Observation on 01/14/2026 at 9:19 AM revealed CNA C and the ABOM were about to transfer Resident #24 to his wheelchair via mechanical lift (mechanical device used to lift and move people who have limited mobility). Both staff washed their hands, put on pairs of gloves, hooked the mechanical lift sling, and transferred the resident to his wheelchair. They did not wear gowns when they transferred the resident. It was observed that there was sign outside of the room on the door that the resident was on EBP and a gown was required during transfer.In an interview on 01/14/2026 at 9:31 AM, the ADOM stated she worked in the business office and she was also a CNA. She said she was not aware that they were supposed to wore a gown when transferring Resident #24. She saw the sign and said maybe there was a sign because the resident had a catheter. She said if the resident had a catheter, then she should have worn a gown to prevent cross contamination.In an interview on 01/14/2026 at 9:36 AM, CNA D stated they would only wear a gown during direct care of Resident #24 who had a catheter. She saw the sign posted outside the resident's door that indicated a gown was required during transfer of a resident with a catheter. She said, she guessed she should have worn a gown when they transferred the resident. She said PPE was required to prevent spread of germs.2. Record review of Resident #77's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with failure to thrive (significant decline in overall health). Record review of Resident #77's Comprehensive MDS Assessment, dated 12/23/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #77's Comprehensive Care Plan, dated 11/23/2025, reflected that the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode. An observation on 01/14/2025 at 12:58 PM revealed CNA E was about to do Resident #77's incontinent care. She put on a gown and a pair of gloves. She did not wash her hands before putting on her gown and gloves. She took a brief, opened it, and placed it beside the resident. She then took a sachet of skin barrier from the resident's overbed table and put it top of the opened brief. She cleaned the front of the resident and then assisted the resident to roll to his side. She then cleaned the resident's bottom. After cleaning the resident's bottom, she took the sachet she placed on top of the opened brief and applied it to the resident's bottom. She pulled the soiled brief and threw it in the trash can. She then pulled the new brief that she placed on the resident's side and placed it under the resident. She rolled back the resident and fixed the brief. She did not change her gloves after cleaning the resident's bottom, before applying the skin barrier cream, and before touching the new brief. She took off her gloves and gown, and washed her hands.In an interview on 01/14/2026 at 1:18 PM, CNA E stated she was supposed to change her gloves after cleaning the Resident #77's bottom and before touching the new briefs to prevent using dirty gloves. She said she applied the skin barrier using dirty gloves. She said using soiled gloves could cause transfer of germs to the new brief. She said it did not occur to her that she was not supposed to place the sachet from the resident's overbed table on top of the brief because she was not sure if the table was clean. In an interview on 01/14/2026 at 1:29 PM, ADON A stated the staff should be mindful that they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, after, and during any care. She said the staff should change their gloves after cleaning the resident's bottom. She said another way to prevent the spread of infection was to wear PPE when residents were on EBP. He said residents with catheters were on EBP to protect the resident and also the staff if the resident had any microorganism that could cling to them. He said he would start an in-service about infection control.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that they always remind the staff to be vigilant with hand hygiene. She said after touching something soiled, the staff should change their gloves and sanitize the hands in between changing of gloves. She said she was not a clinician, but she knew that if there was an EBP sign outside the resident's room, then the staff should wear a gown in addition to the gloves. She said the concerns discussed would all contribute to the development and spread of infection. She said she would coordinate with the DON regarding the issue.In an interview on 01/15/2026 at 9:04 AM, the DON stated that hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom and before touching the new brief. She said the same principle applied before applying the skin barrier cream. She said the sachet of skin barrier cream should not be placed on top of the new brief because the staff was not sure if where it came from was clean. She said every resident with EBP had a sign outside or their room to remind the staff that they needed to wear a gown and gloves every time they had contact with the resident. She said the staff should also read the sign to make sure when they needed to wear a gown. She said EBP was implemented to protect the residents from cross contamination and probable infection. She said ADON A already started an in-service about infection control and would closely monitor the staff's adherence to the policy of infection control. 3. Record review of Resident #128's Face Sheet, dated 01/13/2025, reflected a [AGE] year-old female who admitted to the facility on [DATE]. The resident was diagnosed with osteomyelitis of lumbar vertebra (infection of vertebra in the lower back). Record review of Resident #128's Quarterly MDS Assessment, dated 01/16/2026, reflected moderately impaired cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated Resident #128 was treated for osteomyelitis of lumbar vertebra. Record review of Resident #128's Comprehensive Care Plan, initiated 01/11/2026, reflected The resident is on IV Medications. One intervention was to monitor, document, and report any signs of infection at the IV site. Record review of Resident #128's Physician's Orders, dated 01/13/2026, reflected Enhanced Barrier Precautions. Wear Gown and Glove. PICC Line in use. Every shift.Record review of Resident #128's Physician's Orders, dated 01/11/2026, reflected to administer Vancomycin (antibiotic) intravenous (within a vein) Solution 750 MG/150ML. Use 750 mg intravenously every 12 hours.During an observation and interview on 01/13/2026 at 9:46 AM, revealed Resident #128 had an enhanced barrier precautions sign next to her door. A cabinet below the sign was stocked with personal protective equipment for staff to wear while caring for her. Resident #128 was lying in her bed. She stated she came to the facility two days prior and was receiving IV antibiotics for an infection in her spine. During an observation and interview on 01/13/2026 at 10:05 AM, LVN M entered Resident #128's room and prepared to administer the IV medication. LVN M washed her hands in the resident's restroom and put on gloves. LVN M did not put on a gown prior to administering the IV antibiotic. After exiting the room, LVN M was asked if Resident #128 was on enhanced barrier precautions, and she replied, yes. LVN M stated she did not have to wear a gown to administer IV medication. She stated she would have worn a gown and gloves if she changed the dressing that covered the IV site. She stated gloves and gown should also be worn for residents on dialysis, with a Foley catheter, or wound. LVN M stated enhanced barrier precautions added an extra barrier of protection and was important to help prevent cross-contamination and infection. During an interview on 01/15/2026 at 8:23 AM, the DON stated the enhanced barrier precautions sign on the door explained when staff were to wear personal protective equipment. She stated LVN M should have worn a gown when administering medication via the resident's PICC line. She stated all three shifts of nurses had received in-service training. She stated there was a reason the sign was on the resident's door. She stated her expectation was for staff to read the sign and apply it. She stated wearing the appropriate protection prevented infection and outbreaks. She stated it was best practice. During an interview on 01/15/2026 at 9:11 AM, ADON A stated there were two stops signs on the top of the enhanced barrier protection signs. He stated staff were expected to stop and read the list of things to gown up for. He stated it included residents on dialysis, with a catheter, wound, IV, g-tube (medical device inserted through the abdominal wall into the stomach to provide nutrition, fluids, and medication), and anything that required a dressing. He stated their residents were elderly and some were immunocompromised. ADON A stated enhanced barrier precautions helped to prevent infection and transmission to other residents. 4. An observation on 01/14/2026 at 7:14 AM revealed MA C was passing medications in the hall with a cup of coffee on top of the cart she was using. The Administrator saw the cup of coffee, took it, and told MA C that it should not be there.In an interview on 01/14/2026 at 7:57 AM, MA C stated she could not have her personal tumbler on the cart when passing medications because it could cause cross contamination, create clutter on the medication cart, and might accidentally be mixed with the medications she was preparing.In an interview on 01/15/2026 at 8:16 AM, ADON A stated staff should not put their cup of coffee on the medication carts they were using because aside from being a clutter that might contribute to medication error, staff might bring some microorganism from their home to the medication cart. He said the DON already started an in-service about no personal beverages in the carts. He said the personal beverages should be in the break room.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated she took the cup of coffee from MA C's cart for safety reasons. She said a resident might get a hold of a hot coffee and drink it. She said the coffee could spill on the medications that were being prepared. She said she would coordinate with the DON regarding the issue.In an interview on 01/15/2026 at 9:04 AM, the DON stated that the cup of coffee or any personal drinks should be in the breakrooms. She said aside from the risk of cross contamination, some residents might take it and drink it. She said its content might also spill on the medications the staff were preparing. She said the expectation was for the staff not to put their personal beverages on their carts. was that no residents were administering their medications without proper assessment. The DON said she already started an in-service about no personal beverages on the carts.5. Record review of Resident #102's Face Sheet, dated 01/15/2026, reflected a [AGE] year-old female who admitted on [DATE]. She had diagnoses which included cerebral infarction (stroke: blood flow to the brain is blocked) and seizure (abnormal activity in the brain that temporarily affects consciousness, muscle control, and behavior) disorder. Record review of Resident #102's Quarterly MDS Assessment, dated 11/14/2025, indicated a BIMS was not conducted because the resident was rarely/never understood. The staff assessment for mental status indicated severely impaired cognition for daily decision making. Section N (Medications) reflected Resident #1 received anticonvulsant (used to treat and prevent seizures) medication. Record review of Resident #102's Comprehensive Care Plan, dated 01/11/2026, reflected The resident is on anticonvulsant therapy. One intervention was to give medication as ordered, and monitor and report abnormal labs to the medical doctor. Record review of Resident #102's Physician's Order, dated 10/31/2025, reflected LEVETIRACETAM SOL 100MG/ML Give 5 ml orally two times a day for seizure.6. Record review of Resident #113's Face Sheet, dated 01/15/2026, reflected a [AGE] year-old female who admitted on [DATE]. One diagnosis was hypokalemia (low potassium). Record review of Resident #113's Quarterly MDS Assessment, dated 10/28/2025, indicated a BIMS was not conducted because the resident was rarely/never understood. The staff assessment for mental status indicated severely impaired cognition for daily decision making. Record review of Resident #113's Comprehensive Care Plan, dated 01/09/2026, reflected Resident is at risk for vitamin/mineral deficiency. One intervention was to administer medications as ordered.Record review of Resident #113's Physician's Order, dated 10/31/2025, reflected Potassium Chloride Liquid 20 MEQ/15ML (10%) Give 7.5 ml by mouth one time a day for Hypokalemia Dilute with 3 oz of water before administration.During an observation and interview on 01/15/2026 at 10:44 AM, RN K unlocked the medication aide's cart for hall 200. In one drawer were bottles of oral liquid medication. A bottle of Resident #102's oral liquid levetiracetam had an open oral syringe secured to the bottle with a rubber band. A bottle of Resident #113's oral liquid potassium had an open oral syringe secured to the bottle with a rubber band. RN K stated the syringes should not have been secured to the bottles of medication. She stated there was not a cap on the end of the syringe, and it was exposed to the air and germs. During an interview on 01/15/2026 at 11:04 AM, LVN L stated the oral syringe should not have been secured to the bottle of liquid medication. He stated medication bottles should not be stored like that on the cart. He stated staff must get a new syringe to draw up each medication dose and discard the syringe. He stated the oral syringe should not be open to air, touching other items in the cart, and used to draw up medication for administration. During an interview on 01/15/2026 at 11:09 AM, ADON A stated the syringe should not have been secured to the bottle of medication. He stated the syringes were a one-time use and to discard. He stated the facility had plenty available. He stated the syringes should not touch anything or be left open to air and bacteria. During an interview on 01/15/2026 at 11:26 AM, MA C stated she gave medication on the 200 hall. She stated she did not secure the syringes to the bottles of medication with rubber bands. She stated she got a new syringe from the medication room to administer each liquid medication. She stated she put the bottles of liquid medication back in the cart the way she found them. She stated she should have removed the syringes from the bottles and thrown them away. She stated the syringe was used to draw up the precise measurement of liquid and the medication was put in a plastic drinking cup or small plastic medication cup to administer to the residents. MA C stated she did not remember seeing the bottles that way yesterday. She stated it is important to use a new syringe for each dose of medication and not leave it in the cart where it is open to air and touching other items in the cart. During an interview on 01/15/2026 at 2:17 PM, the DON stated the expectation was for staff to discard an oral syringe after each use. She stated the bottles of liquid medication should not have been stored in that manner in the medication cart. She stated the oral syringes were readily available. She stated it was important for staff to avoid cross-contamination when administering medication. She stated they provided in-serviced training to the nursing staff.Record review of the facility's policy Enhanced Barrier Protection P & P Committee revised December 01, 2025 reflected Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following . urinary catheters . 4. High-contact resident care activities include . Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters . transferring.Record review of the facility's policy Hand Hygiene P & P Committee revised November 01, 2025 reflected Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Policy Explanation and Compliance Guidelines . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens . Before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site.A policy for not putting personal beverages on the cart was requested on 01/15/2026 at 10:17 via email to the Administrator but was not provided prior to exit. Record review of the facility's Medication Administration, revised 12/01/2025, reflected Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission and failed to provide the resident and their representative with a summary of the baseline care plan for two (Resident #127 and Resident #128) of four residents reviewed for baseline care plans. The facility failed to complete in its entirety the baseline care plan for Resident #127 and Resident #128 within 48 hours of admission. This failure could place newly admitted residents at risk of not being informed of their initial goals and services, receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Findings included: Record review of Resident #127's Face Sheet dated 01/14/2026 at 1:59 PM revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included cirrhosis of liver (disease of liver,) cholelithiasis with obstruction (hardened deposits in gallbladder,) and lymphedema (swelling of the tissues.) Record review of Resident #127's Comprehensive Care Plan dated 01/11/2026 revealed missing data from either the plans focus, goal, and/or interventions. Resident's care plan revealed:The focus of Resident requests code status of DNR with a goal stated to carry out in accordance with resident's wishes on an ongoing basis. No interventions were reflected.The focus of Resident has impaired cognitive function/impaired thought processes r/t with no goal(s) listed. Interventions included to administer medications as ordered, ask yes or no questions, or communicate with the resident/family/caregivers regarding resident's capabilities and needs.The focus of Pressure Ulcer Prevention with no goal(s) listed. Interventions included barrier cream, and to turn and reposition every two hours and as needed. Record review of Resident #128's Face Sheet, dated 01/14/2026 12:53 PM revealed she was a [AGE] year old female admitted [DATE]. Relevant diagnoses included type 2 diabetes, heart failure, atrial fibrillation (heart dysfunction,) and back area wedge compression fracture. Record review of Resident #128's Comprehensive Care Plan dated 01/11/2026 revealed missing data from either the plans focus, goal, and/or interventions. Resident's care plan revealed:The focus of The resident has limited physical mobility r/t with a goal to remain free of complications related to immobility . and no interventions were listed.The focus of The resident has impaired cognitive function/impaired thought processes r/t with no goal reflected. The interventions were to administer medications as ordered. Monitor/document for side effects and effectiveness.The focus of The resident as at risk for falls r/t with no goal listed. The intervention included to anticipate and meet the resident's needs.The focus of The resident has/is at risk for constipation r/t with a goal resident will not experience constipation and will have normal pattern of bowel elimination. There are no interventions listed.The focus of Pressure Ulcer Prevention was stated, but no goal nor intervention was stated. In interview with MDS Nurse G on 01/15/2026 at 12:11 PM revealed she was responsible for updating Comprehensive Care Plans but was not responsible for Baseline Care Plans. She stated baseline care plans were important as they planned each residents' care at the facility. In interview with the facility DON on 01/15/2026 at 1:58 PM she stated her expectations were for the MDS department to ensure each new admission had a completed Baseline Care Plan. She stated Resident #127 and Resident #128's Baseline Care Plans were started but not finished and she was not certain as to the reason. She stated it was important for a resident baseline care plan to be completed because a resident's basic care needs can go unmet if not completed. Record Review of Facility's Baseline Care Plan Policy, dated 12/01/25, revealed 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders iv. Therapy services v. Social Services . 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one (Resident #77) of four residents reviewed for incontinent care. The facility failed to ensure that CNA E performed the right technique during Resident #77's incontinent care on 01/15/2026.This failure could place the residents at risk for urinary tract infection.Findings included:Record review of Resident #77's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with failure to thrive. Record review of Resident #77's Comprehensive MDS Assessment, dated 12/23/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #77's Comprehensive Care Plan, dated 11/23/2025, reflected that the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode. An observation on 01/14/2026 at 12:58 PM revealed CNA E was about to do Resident #77's incontinent care. She put on a gown and a pair of gloves. She started cleaning the resident's perineal area (area between the legs), starting on the sides and then on the top part of the perineal area. She then cleaned the resident's penis starting from the base of the shaft towards the tip. She did the procedure twice.In an interview on 01/14/2026 at 1:22 PM, CNA E stated she was not aware that she cleaned Resident #77's penis upward. She said the proper procedure was to clean it downward. She said the resident could have urinary tract infection because the germs from the shaft might go inside the resident's urethra (canal that carries urine out of the body).In an interview on 01/14/2026 at 1:29 PM, ADON A stated the proper technique in cleaning the shaft of the penis was downward and not upward. He said microorganisms might enter the opening on its tip. He said cleaning the penis was the same with clean the perineal area (area between the legs), and it was to clean away from and not towards where germs could have an entry. He said he would start an in-service about the issue.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated that the expectation was for the staff to follow the proper technique of incontinent care to prevent any unwanted outcome like urinary tract infections. She said she would coordinate with the DON about the issue.In an interview on 01/15/2026 at 9:04 AM, the DON stated that cleaning the penis upward was not right because unwanted microorganisms (organism that is too small to be seen) from the shaft could eventually enter the opening on its tip and could probably cause UTI. She said the expectation was for the staff to follow the right procedure in cleaning the penis. She said ADON A already started an in-service about the issue, but she would monitor the staffs' compliance on the right procedure.Record review of the facility's policy Incontinence P & P Committee revised December 01, 2025, reflected Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services . Policy Explanation and Compliance Guidelines . 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #96 and Resident #111) of twelve residents reviewed for respiratory care.1. The facility failed to ensure Resident #96 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 01/13/2026.2. The facility failed to ensure Resident #111 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and BiPAP mask was stored properly when not in use on 01/13/2026. The facility failed to ensure Resident #111 had a physician's order for a BiPAP machine on 01/13/2026. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: 1. Record review of Resident #96's Face Sheet, dated 01/14/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #96's Quarterly MDS Assessment, dated 12/30/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #96's Comprehensive Care Plan, dated 12/01/2025, reflected the resident had oxygen therapy and one of the interventions was provide oxygen therapy as ordered. The Comprehensive Care Plan did not indicate that the resident was the one taking off her nasal canula.Record review of Resident #96's Physician's Order, dated 11/17/2025, reflected Oxygen at 2 LPM every shift for COPD.An observation and interview on 01/13/2026 at 9:41 AM revealed Resident #96 was in her bed, awake. It was observed that there was a nasal canula coiled on the push handle of the resident's wheelchair. The nasal cannula was not bagged and there was no bag at the back of the wheelchair. When asked who took off the nasal cannula, the resident did not reply.During an observation and interview on 01/13/2026 at 9:48 AM, ADON A stated the nasal canula should be bagged when not in use to prevent any respiratory infection. He said sometimes, Resident #96 was the one who would take it off so the staff should closely monitor the resident. He took the nasal canula from the wheelchair and threw it in the trash can. He said he would get a new one and would put it in a bag.In an interview on 01/13/2026 at 11:33 AM, LVN B stated she was made aware about the nasal cannula that was not bagged. She said she did not notice that the nasal canula on Resident #96's wheelchair. She said the nasal canula should be bagged to prevent cross contamination and respiratory infection.In an interview on 01/15/2026 at 8:38 AM, the Administrator stated the expectation was for the staff to bag the nasal cannula when not in use to prevent respiratory issues. She said she would coordinate with the DON about the issue.In an interview on 01/15/2026 at 9:04 AM, the DON stated the staff were responsible in making sure the nasal cannula was bagged when not in use to prevent respiratory infection. She said an in-service was already initiated by ADON A but she would closely monitor the staffs' compliance in bagging the nasal canula when not in use. She said if the resident was the one taking it off, the more the staff should monitor the resident.2. Record review of Resident #111's face sheet, dated 01/13/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. He was diagnosed with COPD. Record review of Resident #111's Quarterly MDS (tool used to measure health status) Assessment, dated 11/13/2025, reflected intact cognition with a BIMS (tool used to measure cognitive status) score of 13. Section I (Active Diagnoses) indicated Resident #111 was treated for COPD. Record review of Resident #111's Physician's Orders, on 01/13/2026, did not reflect an order for the BiPAP. An observation on 01/13/2026 at 9:28 AM revealed Resident #111 was not in his room. The oxygen tubing was connected to the concentrator and draped across the top of the concentrator. It was not stored in a bag. The BiPAP machine and breathing mask was on the nightstand. The breathing mask was not bagged. During an interview on 01/13/2026 at 9:35 AM, CNA J stated the oxygen tubing should have been bagged. She stated she would get new oxygen tubing and place it in a bag. She stated it was important to prevent infection. During an interview on 01/13/26 at 9:37 AM, LVN H stated the BiPAP machine was Resident #111's personal property and he put the mask on and took it off himself at night. She stated for infection control purposes, the BiPAP mask should have been stored in a bag. She stated whoever switched the resident to his portable oxygen tank should ensure the oxygen tubing, connected to the concentrator, was placed in a bag. She stated the nurse was ultimately responsible for ensuring the respiratory items were bagged when not in use. She stated it could have a negative effect on the resident, especially since he was on precautions. She stated Resident #111 was on enhanced barrier precautions related to dialysis. She stated it was important for infection control. During an interview on 1/14/26 at 7:54 AM, LVN H stated Resident #111 came to the facility with the BiPAP machine. She stated she did not touch the BiPAP and had not noticed there was no order. LVN H stated there should have been a physician's order for the resident to use the BiPAP at the facility. She stated any medication or treatment required a physician's order. During a telephone interview on 01/15/2026 at 1:15 AM, LVN I stated she worked the 10:00 PM - 6:00 AM shift. LVN I stated Resident #111 put the BiPAP mask on himself. She stated he was wearing it at the beginning of her shift. She stated she had not noticed him wearing it before. LVN I stated she did not notice he had no order for the BiPAP. She stated the BiPAP mask and oxygen tubing should be stored in a bag when not in use. She stated they can become contaminated if left open to air and the risk to the resident was infection. During an interview on 01/15/2026 at 8:23 AM, the DON stated Resident #111 must have had an order for the BiPAP machine. She stated it was also important to ensure the order included the appropriate settings. She stated resident care was governed by physician's orders and necessary to provide the best possible care for the resident. She stated respiratory items must be bagged when not in use and was important for infection control. She stated the physician and respiratory therapist were notified and an order placed in the resident's chart. She stated staff had received in-service training. During an interview on 01/15/2026 at 9:11 AM, ADON A stated respiratory items must be bagged for infection control. He stated the resident puts the nasal cannula in his nose, which is a point of entrance for bacteria. He stated Resident #111 must have had an order to use the BiPAP at the facility. He stated when a resident brought equipment from home, the physician must be called and an order obtained. He stated staff received in-service training. Record review of the facility's policy Oxygen Concentrator P & P Committee revised November 11, 2025, reflected Policy Explanation and Compliance Guidelines . 4. Use of the Concentrator . l. Keep delivery devices covered in plastic bag when not in use.Record review of the facility's policy Consulting Physician/Practitioner Orders, implemented 11/01/2025, reflected The attending physician shall authenticate orders for the care and treatment of assigned residents. Call the attending physician to verify the order. Document the verification order by entering the order and the time, date, and signature on the physician order sheet.

Based on record review and interview, the facility failed to ensure the resident was provided with pharmaceutical services, including procedures that assure the accurate administration of drugs, to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to check Resident #1's BS on six different occasions between the dates of October 1, 2025, through October 23, 2025. This failure has the potential for the resident being placed in a hypoglycemic state or not receiving the therapeutic dosage. The findings include: Record review of Resident #1's admission record, dated 09/17/25, reflected a [AGE] year-old female with diagnoses that included end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, acute combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus with hyperglycemia, with a reported BIMS score of 15. Record Review of Resident #1's care plan, dated 9/17/25, reflected Resident #1 had been admitted with a diagnosis of DM. In the care plan it further reflected the facility was to administer diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness. Record review of Resident #1's Order Summary Report, dated 09/17/25, reflected NovoLOG Injection Solution 100 UNIT/ML (InsulinAspart) Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units, subcutaneously four times a day for dm IF BS >401 Re-check in 15 minutes. If Blood Sugar still 401 or greater, CALL MD Record review of Resident #1's MAR, dated 11/07/25, reflected six separate occasions where Resident #1's BS was not checked four times a day as ordered. On 10/04/25 at 11:30 AM, 10/11/25 at 11:30 AM, 10/15/25 at 8:30 PM, 10/18/25 at 11:30 AM, 10/19/25 at 11:30 AM, and 10/22/25 at 8:30 PM Resident #1's BS was not checked. No indication as to why the BS was not attempted was charted. An interview and record review with LPN on 11/07/25 at 3:33 PM was conducted. LPN stated all BS checks should be recorded when performed. LPN was shown the MAR and asked to assist in deciphering what could be inferred from the blank portions of the MAR where no record of BS checks can be observed. LPN stated if the MAR was blank then that would mean the procedure was not attempted. LPN further said if the procedure was attempted but if for some reason could not be completed, then the reason for not completing the BS check would be recorded on the MAR. LPN stated there was risk of harm to patients who needed to get their BS checked but did not. LPN said patients that need insulin need to have the BS checked first. LPN further stated if insulin was not administered as ordered then there was a risk of harm to the patient could be worsening of health conditions. An interview and record review with the DON on 11/07/25 at 4:20 PM. The DON stated all procedures and medication administration should be charted in the residents' records. The DON stated the facility had recently changed over to a new patient records system in June 2025 and she did not believe any BS checks had been missed. The DON was shown the October 2025 MAR for Resident #1 and asked what was to be inferred by the six blank entries. The DON initially stated she believed those BS checks were charted someplace else in the system, but she was unable to locate where they would have been charted. The DON was asked what it would mean if there was nothing recorded on the MAR, and she said it meant nothing had been done or attempted. The DON stated there could be a significant risk of harm to residents if they did not get the insulin based on their BS. The DON stated the risks could include renal and cardiovascular damage. On 11/07/25 at 5:30 PM the Administrator was interviewed. The Administrator stated all procedures, and medical administration was required to be recorded in the resident's medical record. The Administrator further said there was a risk of harm to residents if their medical orders are not followed due to worsening DM symptoms and complicating already existing health conditions. Attempts to contact the ordering physician were unsuccessful during the investigation. Record review of facility policy titled Obtaining a Fingerstick Glucose Level, dated revised October 2011, reflected: Purpose The Purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level As well as: Documentation The person performing this procedure should record the following information in the resident's medical record:1) The date and time the procedure was performed2) The name and title of the individual(s) who performed the procedure.3) All assessment data obtained during the procedure.4) How the resident tolerated the procedure.5) If the resident refused the procedure, the reason(s) why the intervention taken.6) The blood sugar results. Follow the facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on a sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc.7) The signature and title of the person recording the data.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received parenteral fluids consistent with professional standards of practice in accordance to physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences for (Resident #1) of five residents reviewed for parenteral fluids. The facility failed to ensure Resident #1 who had intravenous access present upon observation on 08/21/2025 at 9:44 AM had physician's orders for assessment, care, monitoring, and treatment. This failure could place residents at risk of injury, infection, and a decreased quality of life.Findings included: Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted from an acute care hospital 07/30/2025. Relevant diagnoses included dementia (brain dysfunction affecting memory and mood,) subdural hemorrhage (brain bleed,) status post craniotomy (brain surgery) resulting in osteomyelitis (infection) to her scalp. Review of Resident #1's Quarterly MDS dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 05. She was dependent upon staff for toileting, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder. She was admitted with surgical wounds that required applications of ointments/medications. Review of Resident #1's Comprehensive Care Plan dated 08/21/2025 revealed she had:-Impaired cognitive function and thought processes related to dementia with intervention that included that she required assistance for mobility, dressing, and repositioning in bed. -Had an infection [to her scalp] with intervention that included to administer antibiotics as ordered, maintain universal precautions, and monitor, document, and report to provider and signs or symptoms of delirium.-Had intravenous access for the purposes of receiving [antibiotics] with intervention that included to administer intravenous fluids as prescribed, change tubing site dressing every 72 hours, check IV site every 2 hours, observe signs of infection, infiltration (catheter coming out of the vein and into the surrounding tissues.)In observation and interview of Resident #1 on 08/21/2025 9:44 AM revealed her in bed resting with a single lumen intravenous access (one line) present on her on her right upper arm. The dressing appeared clean, dry, and intact and was dated 08/19/2025. The resident stated she received the intravenous access in the hospital but was not able to provide any further detail due to her cognitive status. Review of Resident #1's Physician's Orders on 08/21/2025 at 9:00 AM revealed orders for two intravenous antibiotics with a start and end date of 08/13/2025 - 08/22/2025 respectively. -Cefepime HCL Solution 2 GM/100 ML every 8 hours-Vancomycin HCL Solution 750 MG/150 ML every 24 hoursNo evidence of orders related to the assessment, care, monitoring, and treatment of Resident #1's intravenous access.In an interview with LVN A on 08/21/2025 at 12:38 PM, he stated he had been Resident #1's nurse for a couple of days and today. He stated he was aware that Resident #1 had a PICC line. He stated Resident #1 should have physician's orders for assessment, care, monitoring, and treatment and was not aware of the reason she did not. He stated it was the nurse's responsibility to ensure those orders were in the resident's MAR. He stated it was the ADON's responsibility to catch it if it was missed. He stated it's important for residents with PICC lines (intravenous access) to have provider orders for the safety of the resident and so the care could be documented every shift. In an interview with DON on 08/22/2025 12:32 PM, she stated Resident #1 did have intravenous access and she was re-admitted with it. She stated Resident #1 should have physician orders in the MAR for the nurses to document the assessment, care, monitoring, and treatment of her PICC line. She stated her specific expectations for the assessment, care, monitoring, and treatment of Resident #1's PICC line would be per physician orders. She stated it was the nurse's responsibility to ensure Resident #1 had physician orders for her PICC line and it was the ADON's responsibility to ensure it was completed. She stated she was not aware of why it was missed but it was important for infection control purposes. Record review of facility policy, Care of Peripherally Inserted Central Catheter dated 01/2013, revealed Purpose. To provide standards for the safe maintenance of a PICC line in order to reduce the risk of infection or dislodging. catheter is to remain in place for the duration of treatment unless signs of complications occur.when catheter is not in use flush at least 12-24 hours with 10 ml sodium chloride 0.9% . Procedure. Assess catheter site. Observe for the following: Skin breakdown, drainage site, leaking connections, catheter integrity, any change in catheter position, broken or loose suture. Record review of facility policy, Intravenous Administration of Fluids and Electrolytes, dated 04/2016 revealed 1. A physician order is necessary to give intravenous fluids and electrolytes.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of seven residents reviewed for Comprehensive Care Plans.The facility identified Resident #1 with redness/excoriation around her perineum (genital area) and buttocks area on 08/04/2025 but was not detailed on her Comprehensive Care Plan. This failure could place residents at risk of injury, infection, and a decreased quality of life.Findings Included:Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted from an acute care hospital 07/30/2025. Relevant diagnoses included dementia (brain dysfunction affecting memory and mood,) subdural hemorrhage (brain bleed,) status post craniotomy (brain surgery) resulting in osteomyelitis (infection) to her scalp.Review of Resident #1's Quarterly MDS dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 05. She was dependent upon staff for toileting, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder. She was admitted with surgical wounds that required applications of ointments/medications.Record review of Resident #1's progress notes dated 08/04/2025 at 10:48 AM revealed the nurse did incontinent care on the resident and noted areas of redness [to the genital area] and notified provider. The facility received an order to apply Zinc Oxide 10% cream to the peri area three times a day until healed. Record review of Resident #1's comprehensive care plan dated 08/21/2025 revealed Focus. Pressure Ulcer Prevention date 05/20/2025 with interventions that included:-Barrier Cream-Encourage out of bed-Encourage to float heels as tolerated-Pressure ulcer redistributions mattress-Turn and reposition every 2 hours and as needed-Use suspension devices, pillows, and/or wedges to reduce pressure on heels and bony prominences No evidence of documentation of Resident #1's redness and no interventions specifically related to her redness including care and medication management were reflected in the care plan. In an observation of Resident #1 on 08/21/2025 at 9:44 AM, revealed incontinent care was observed. Resident #1 was observed to have extensively inflamed skin around the genital and buttocks area. In an interview with the facility's ADON on 08/23/2025 at 9:49 AM he stated he was aware of Resident #1's skin redness around her genital area. He stated he was not sure how long it has been present, but she had medications for treatment. He stated Resident #1's skin redness around her genital area should have been captured on her comprehensive care plan. He stated it was the facility nurses' responsibility to accurately assess each resident because care plan interventions were initiated from assessments. He stated the facility had a treatment nurse responsible for assessments, but she was currently out of the country on leave. He stated in her absence it was the other nurse's responsibility to ensure proper care and assessments were completed. He stated it was nursing leadership's responsibility to ensure resident care plans were complete as care plans guide resident care. In an interview with facility's DON on 08/22/2025 at 12:32 PM, she stated she was not aware of Resident #1's skin concerns around her genital area as it has not been documented or reported to her. She stated she expected any skin changes to be properly assessed by her staff, which would then triggered care plan interventions for her clinical leadership to review and add to the comprehensive care plan to ensure proper care for the resident. Record review of the facility policy Care Plans - Comprehensive, dated 09/2010 revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team in coordination with the resident. develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas b. Incorporate risk factors associated with identified problems c. Build on the resident's strengths . g. Aid in preventing or reducing declines in the resident functional status an/or functional levels h. enhance optimal functioning of the resident by focusing on a rehabilitative program i. Reflect currently recognized standards of practice for problem areas and conditions. 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's conditions change.

Based on observation, interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of seven residents reviewed for skin integrity. 1. The facility failed to ensure Resident #1 received accurate skin assessments that included change of condition around her genital area on 08/04/2025, 08/13/2025, and 08/20/20252. The facility failed to ensure Resident #1 received medication and treatment per provider orders related to her genital area on 08/16/2025, 08/17/2025, and 08/21/2025. 3. The facility failed to ensure Resident #2 received Skin Assessments per doctor's orders on 07/05/2025, 07/12/2025 07/19/2025Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included dementia (brain dysfunction related to memory and mood,) subdural hemorrhage (bleeding in the brain,) status post craniotomy (brain surgery) resulting in osteomyelitis (infection) to her scalp.Review of Resident #1's Quarterly MDS dated [DATE] revealed she was severely cognitively impaired with a BIMS score of 05. She was dependent upon staff for toileting, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder. It was documented that she was re-admitted to the facility with surgical wounds that required applications of ointments/medications. No documentation of skin concerns of the genital area were documented.Record review of Resident #1's Skin Assessment after her re-admission on [DATE] revealed-Right lateral (side) temporal (scalp) area surgical wound was resolved-Front, upper scalp injury was resolved-Right, upper scalp surgical wound. scabbing present, and skin prep was used as dressingNo evidence of skin integrity issues associated with the genital area were observed.Record review of Resident #1's LVN B's progress note dated 08/04/2025 at 10:48 AM revealed she did incontinent care on the resident and noted areas of redness [to her genital area] and notified the provider. LVN B further documented she received an order to apply Zinc Oxide 10% cream to peri area (genitals) three times a day until healed.Record review of Resident #1's Skin Assessment on 08/11/2025 revealed-Right, upper scalp surgical wound. serous exudate (drainage) that was cleansed with normal saline, debrided (removal of damaged tissues,) and a dressing with Mupirocin 2% dressing applied. No evidence of skin integrity issues associated with the genital area were observed.Record review of Resident #1's Skin Assessment on 08/18/2025 revealed :-Right, upper scalp surgical wound. no exudate. cleansed with normal saline, debrided (tissue removed,) and dressed with a dry dressing.No evidence of skin integrity issues associated with the genital area were observed.Record review on 08/21/2025 at 10:00 AM of Resident #1's Physician Orders and TAR revealed Zinc Oxide External Cream 10% (topical) Apply to excoriated peri area/butt topically three times a day for areas with excoriation until healed with a start date of 08/05/2025 at 1:00 AM. Record review of Resident #1's TAR revealed no documented evidence Resident #1 received the Zinc Oxide External Cream 10% on:-08/16/2025 at 1:00 AM and 9:00 AM-08/17/2025 at 1:00 AM and 9:00 AM-08/21/2025 at 1:00 AM Record review on 08/21/2025 at 10:05 AM of Resident #1's Physician Orders and TAR revealed Nystatin Powder Apply to Peri area topically two times a day for yeast for 14 days with a start date of 08/16/2025 at 9:00 PM. Record review of Resident #1's TAR revealed Resident #1 received Nystatin Powder as ordered. Record review on 08/21/2025 at 10:15 AM of Resident #1's Physician Orders and TAR revealed Diflucan Oral 150 MG Give 1 tablet by mouth one time only for fungal infection with a start date of 08/17/2025 at 8:00 AM. Record review of Resident #1's TAR revealed no documented evidence Resident #1 received the medication as ordered. In an observation of Resident #1 on 08/21/2025 at 9:44 AM, revealed CNA G provided incontinent care. Resident #1 had significant redness and inflamed skin around her genital area. In an interview with CNA G on 08/21/2025 at 9:55 AM, CNA G stated Resident #1's skin had been like that for an extended period and that she had informed the nursing staff. She stated Resident #1 has cream for the redness. She stated it was her responsibility to inform the nursing staff if the resident had any new skin changes or refused activity of daily living (ADL's) or incontinent care. Interview with Resident #1 on 08/21/2025 at 9:44 AM was not successful due to her cognition. Record review of Resident #1's Wound Care Provider Visit Notes, dated 08/22/2025, revealed:-Back/Sacrum (tailbone). irritation to sacrum with rash and satellite lesion and serpiginous border (damage or changes to the tissues)-Buttock. irritated dermatitis (irritated skin,) fungal rash with satellite lesions and serpiginous border-Groin/Perineum] (genital area). irritated dermatitis, fungal rash with satellite lesions and serpiginous border. Resident #1 was diagnosed with Tinea Cruris (fungal infection) around her groin and Irritant dermatitis from incontinence around her diaper distribution. Record review on 08/21/2025 at 11:00 AM of Resident #1's Physician Orders and TAR revealed Diflucan Oral 150 MG Give 1 tablet by mouth one time only for fungal infection was re-ordered on 08/22/2025 at 8:00 PM and record review of Resident #1's TAR revealed Resident #1 received Diflucan Oral 150 MG as ordered. In interview with LVN B on 08/21/2025 at 11:45 AM she recalled Resident #1 having skin redness earlier in the month of August 2025 and it had persisted since then. She stated she received an order from the provider for topical Zinc Oxide for treatment earlier in the month. She stated she did not complete a skin re-assessment to reflect the change but stated she should have completed a re-assessment as that was a change in condition for the resident. She stated it was her responsibility to accurately assess the resident as the resident's nurse for resident safety. In interview with 08/23/2025 at 2:11 PM, LVN D stated he was working as the charge nurse on 08/17/2025 and was assigned Resident #1 for that day. He stated he did not recall giving Resident #1's Diflucan as ordered, and stated he did not see the order. He stated he should have provided the medication as ordered and could not state why he did not. He stated it was his responsibility to provide the resident with medications as ordered. Interview with the facility's Treatment Nurse on 08/21/2025 11:00 AM was not successful as she was currently out of the country and could not be accessed via phone. In an interview with the facility's ADON on 08/23/2025 at 9:49 AM he stated he expected his nurses to complete timely and accurate skin assessments. He stated he expected any changes in resident's skin to be captured on skin assessments to catch skin concerns as early as possible for resident care and safety. He stated he was aware of Resident #1's genital area redness, and they've been treating it for an extended period. He stated he expected that to have been documented ion her weekly skin assessments and did not know why it was not. He stated the facility had a treatment nurse but she was currently out of the country on leave. He stated he expected Resident #1 to have received medications and treatment as ordered because the skin is the first line of prevention of infection. He stated he was not sure why Resident #1 did not receive medications and treatments as ordered but stated it was his and the DON's responsibility to ensure these interventions were completed. In an interview with facility's DON on 08/23/2025 at 2:06 PM, she stated Resident #1 was seen by the facility's wound care provider, Physician E, yesterday and new orders were added to Resident #1's treatment regimen. She stated that if Resident #1 had any skin changes dating back to 08/04/2025, the nurse should have completed a new skin assessment. She stated she expected her nurses to assess and document any skin changes of their residents and she expected the assessments her nurses completed to be accurate. She stated the facility had a treatment nurse, but she was currently on leave. She stated her expectation was for her nurses to provide medications as ordered. She stated the missed Zinc Oxide treatments were not acceptable and should have been completed per providers orders. She stated she was not sure why the treatments were not provided and declined to state the importance of this for the resident. She further stated the missed dose of Diflucan was because the order was not activated. She stated she expected the charge nurse to have captured that. She stated it was the charge nurse's responsibility to ensure any new orders for residents were activated and administered as ordered. She stated it was the ADON's responsibility to ensure that was completed for resident care and safety reasons. In an interview with Resident #1's wound care provider, Physician E, on 08/23/2025 at 2:35 PM, she stated she saw Resident #1 yesterday for her genital area. She stated she was already treating Resident #1 for other skin issues on her head; but would not necessarily assess her genital area unless the resident's skin assessments directed her to do so. She stated her visits were focused and she relied on facility staff to tell her what is going on. She stated her expectations were for facility nurses to complete accurate assessments to then guide her skin assessments. Furthermore, she expected facility staff to provide medications and treatments as ordered for the wellbeing of the resident.Record review of Resident #2's face sheet dated 08/22/2025 reflected a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease with late onset,(brain disorder that causes memory loss, confusion, and other cognitive decline), hemiplegia(condition characterized by paralysis or weakness on side of the body), and atherosclerotic heart disease of native coronary artery without angina pectoris(buildup of fats, cholesterol and other substances in and on the artery walls). Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected he had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The resident was considered at risk for developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries.Record review of Resident #2's Comprehensive Care Plan date 07/03/2025 reflected pressure ulcer prevention-barrier cream-turn and reposition every 2 hours and as needed. Keep body in good alignment-encourage to float heels as tolerated-Pressure ulcer redistributions mattress-Use suspension devices, pillows, and/or wedges to reduce pressure on heels and bony prominences Record review of Resident #2's TAR dated 07/1/2025-07/31/2025, revealed orders for weekly head to toe skin assessments every day shift every Saturday. Further review revealed there were no entries for weekly head to toe skin assessments on 07/05/2025, 07/12/2025, and 07/19/2025.Record review of the facility's Census dated 08/20/2025 revealed Resident #2 was discharged to the hospital] on August 8, 2025. In an interview with the DON on 08/22/2025 at 10:40am she stated it was the charge nurse's responsibility to complete weekly skin assessments. She stated staff was expected to follow the physician's orders and complete weekly skin assessments. She stated weekly skin assessments were documented on the TAR. She stated skin assessments were completed to identify any new skin breakdowns or issues. She stated not completing skin assessments was failure to identify a new issue. She stated Resident #2 did not have any pressure ulcers. She stated she could not say why the weekly skin assessments for Resident #2 were not completed and it was the ADON's and DON's responsibility to ensure weekly skin assessments were completed. She revealed Resident #2 was currently in the hospital due to a change in condition.In an interview with the RP for Resident #2 on 8/22/2025 at 3:51pm revealed Resident #2 was currently in the hospital and Resident #2 admitted to the facility 2 years ago. She stated in the past, Resident #2 had skin issues, but he did not have any current skin issues. In an interview with the ADON on 8/23/2025 at 10:01am he stated nurses were responsible for completing skin assessments. He stated skin assessments were supposed to be completed weekly because it gave staff a chance to look at the resident entire head to toe. He stated there should be no reason skin assessments were not completed. He stated skin assessments are documented in the TAR. He stated failure to complete weekly skin assessments can affect the residents tremendously and could lead to sepsis and death. He stated the last in service on wounds took place approximately two weeks ago. In an interview with the ADM on 8/23/2025 at 11:03am she stated it was the charge nurse's and wound care nurse's responsibility to complete weekly skin assessments. She stated there were several systems in place to ensure skin assessments were being completed. She stated she would assume she would assume someone missed the documentation on weekly skin assessments for Resident #2 because nothing was there. She stated failure to document completed skin assessments and follow protocol could cause staff to miss any new skin issues. She stated in-services on skin assessments are completed every quarter and as needed. In an interview with LVN D on 8/23/2025 at 12:26pm he stated it was the charge nurse's or wound care nurse's responsibility to completed skin assessments as ordered. He stated aides should also share any skin issues with the nurse when aides performed incontinent care or showered to residents. He stated skin assessments were documented in the TAR. He stated he could not recall not completing weekly skin assessments on Resident #2 or any other resident. He stated failure to complete skin assessments could cause a big issue such as skin breakdowns that could become worse. He stated staff was in serviced on skin assessments continuously and as needed. He stated he could not recall the last in service on skin assessments. Record review of the facility's Patient Care Management System 1 dated July 2022 revealed 1. The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment. Head to toe assessments must be completed weekly and prior to discharge/transfer of a Patient. 19. The Director of Nursing or designee will audit and verify system compliance weekly including prevention focused rounding and education as appropriate. Record review of facility policy Skin, dated 07/2022, revealed . 2. Head-to-toe assessments must be completed weekly. 7. Non-Pressure Injury Plan of Care will be completed by the Treatment Nurse or Charge Nurse upon identification. and updated with any changes to interventions and upon resolution.

Based on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for two ( Resident #3, and Resident #4) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure that Resident #3 had a dressing that covered the wound on Resident #3's lateral right ankle on 5/20/2025. 2. The facility failed to ensure that Resident #4 had a dressing that covered the wound on Resident #4's sacrum on 5/20/2025. These failures could place residents with wounds at risk for infection, a decline in health, and reduce wound healing. Findings included: 1. Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified intellectual disabilities, anemia (low levels of healthy red blood cells or hemoglobin), and hypertension (high blood pressure). Section C of the MDS assessment revealed a BIMs score of 15 (suggested cognition was intact). Section M of the MDS assessment revealed Resident #3 had one venous or arterial ulcer that required application of a dressing and ointment/medication. Record review of Resident #3's care plan updated 2/10/2025 revealed an intervention for skin concerns was to perform treatments as ordered by the doctor. Record review of Resident #3's printed physician orders dated 5/21/2025 revealed a physician's order for wound care on Resident #3's lateral right ankle dated 2/19/2025 that stated to cleanse the right lateral ankle with normal saline, pat dry, apply xeroform, and apply a dry protective dressing on Monday, Wednesday, and Friday. Record review of Resident #3's wound assessment dated [DATE] revealed the measurements for Resident #3's right lateral ankle wound was 0.5cm long, 0.4cm wide, and 0.2cm deep. Record review of Resident #3's wound assessment dated [DATE] revealed the measurements for Resident #3's right lateral ankle wound was 0.4cm long, 0.4cm wide, and 0.2cm deep. In an observation and interview on 5/20/2025 at 8:50 a.m., revealed Resident #3 reported he had a wound on his right ankle and a nurse used to put a dressing on it. Resident #3 stated they stopped doing it, but Resident #3 did not remember when. Resident #3 stated he wanted them to put a dressing on his wound because it was uncomfortable when it did not have a dressing. Observed an approximately quarter sized area on the lateral right ankle that was open (missing the top layer of skin). No dressing was present. In an observation and interview on 5/20/2025 at 8:58 a.m., revealed Treatment Nurse C entered Resident #3's room and confirmed Resident #3 did not have a dressing on his right lateral ankle. Treatment Nurse C stated Resident #3 was supposed to have a dressing on his right lateral ankle, but it may have fell off when Resident #3 was showered. Treatment Nurse C stated a nurse should have put another dressing over the wound. Treatment Nurse C stated that dressings were important because they promoted healing, and all staff were responsible for monitoring that dressings stayed on the residents. Treatment Nurse C stated the risks to the residents was that they could develop an infection. 23. Record review of Resident #4's Comprehensive MDS assessment revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of pressure ulcer of the sacral region (lower back just above the buttocks), chronic kidney disease, and dysphagia (difficulty swallowing). Section C of the MDS assessment revealed Resident #4's BIMs score was 11 (indicated moderate cognitive impairment). Section M of the MDS assessment revealed Resident #4 had an area of moisture associated skin damage and received pressure ulcer/injury care. Record review of Resident #4's care plan with a print date of 5/21/2025 revealed Resident #4 was at risk for infection and staff should use sterile technique policy for any treatments or care where there was an actual/potential for loss of skin integrity. Record review of Resident #4's printed physician orders dated 5/21/2025 revealed a physician's order for wound care on Resident #4's sacrum that stated to cleanse the area with normal saline or skin cleanser, pat dry, apply gauze-soaked Dakin's Solution (topical antiseptic), and cover with a dry dressing. Record review of Resident #4's wound assessment dated [DATE] revealed Resident #4's sacral wound was 8.0cm long, 8.0cm wide, and 3.0cm deep. In an observation and interview on 5/20/2025 at 8:30 a.m., revealed CNA D turned Resident #4 revealing a large, uncovered wound to Resident #4's sacral area. CNA D stated there should have been a dressing and if there was not a dressing on a resident's wound then the nurse should be notified. CNA D stated the nurse would then apply a new dressing. CNA D stated she was not aware Resident #4's dressing was missing. In an observation and interview on 5/20/2025 at 9:14 a.m., revealed Treatment Nurse C checked Resident #4 for a dressing and confirmed the dressing was missing from the sacral region. Treatment Nurse C stated she had not made her way to Resident #4 yet this morning and was not notified that the dressing was missing. Treatment Nurse C stated the dressing may have fell off when the hospice aide bathed Resident #4 earlier that morning. Treatment Nurse C stated it was not typical for Resident #4 to not have a dressing and the nurse should have put a dressing on Resident #4 if they were aware it was missing. In an interview on 5/20/2025 at 9:39 a.m., LVN E stated no one notified her that Resident #4 did not have a dressing. LVN E stated if she had known Resident #4 did not have a dressing then she would have followed the physician's orders and applied a new one. LVN E stated she would have then notified Treatment Nurse C that a dressing had been applied. LVN E reported the risk to the residents if wounds did not have a dressing was that the wounds could get infected. In an interview on 5/20/2025 at 3:00 p.m., Doctor F reported she visited the facility every Monday to assess the residents' wounds. Doctor F reported that dressings were applied to wounds to protect the area from urine and stool. Doctor F also stated that the dressings optimized healing, and every time a dressing was removed that it took four hours to return to an optimal healing environment. Doctor F reported she expected the wound care nurse to do the treatments when in the building, and the nurses to change the dressings if they became dislodged or dirty. In an interview on 5/21/2025 at 3:06 p.m., the DON reported dressings were applied to wounds to promote healing, and she expected the nursing staff to follow the doctor's orders for wound care. The DON stated CNAs should notify the nurse if they see a dressing was missing or soiled. The DON stated dressing should have the correct date and initials on them. The DON stated the risks to the residents depended on their comorbidities and declined to be more specific. Record review of the facility policy titled Wound Management Policy, copyright dated 2023, revealed The care service ensures that wounds . are managed and dressed appropriately to minimise the distress that they cause and maximise healing.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan for Resident #1 during their stay from 2/23/2025 to 3/30/2025 (35 days ). This deficient practice could place residents at risk of not being provided with the necessary care or services to address their specific needs. Findings included: Review of face sheet dated 05/21/25 reflected Resident #1 admitted to the facility on [DATE] and dischaged from the facility on 03/30/25. Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), diabetes, seizure disorder, a bacterial infection and anxiety. The MDS also revealed a BIMs score of 13 (suggested cognition was intact). Section M revealed Resident #1 was receiving insulin (injectable medication for diabetes), anticonvulsants (seizure medication), an antibiotic (medication for infection), and an anticoagulant (a blood thinner). Section V of the MDS assessment revealed care areas triggered were ADL function/Rehab potential, urinary incontinence or indwelling catheter, nutritional status, and pressure ulcer. The MDS assessment was signed by LVN A and the DON. Review of Resident #1's care plan with effective date of 03.24.25 reflected Resident #1 did not have a comprehensive person-centered care plan. In an interview on 5/21/2025 at 2:01 p.m., MDS A stated there was not a comprehensive care plan for Resident #1, but MDS A stated he had just entered one into their charting system. MDS A stated MDS A was responsible for entering the comprehensive care plan for each resident. MDS A reported the comprehensive care plan was usually completed within 14 days. MDS A stated Resident #1 did not have a care plan while residing in the facility. MDS A stated all nursing staff was responsible for monitoring residents' care plans. MDS A stated if a resident did not have a care plan, then residents care needs, ADL assistance, medications, diets, dialysis, and many other needs would not be brought to the staff's attention. In an interview on 5/21/2025 at 3:06 p.m., the DON reported care plans were completed by unit managers, treatment nurse, the social worker, the MDS nurse, and the DON. The DON reported care plans were also monitored by the unit managers, treatment nurse, the social worker, and the DON. The DON stated if there was not a care plan for a resident then the risk was that there would be no paperwork. The DON stated her expectation for resident care plans was that they were updated and that all residents had a comprehensive care plan in place . A policy for care plans was not received prior to the time of exit on 5/21/2025.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled properly for one ([NAME] medication room) of three medication rooms and two (300 hall and 500hall) of five medication carts reviewed for medication storage and labeling. 1. The [NAME] medication room contained one open multi-dose vial of tuberculin without an open date. 2. The 300-hall cart contained seven open eye drop medications without an open date. 3. The 500-hall cart contained one open eye drop medication without an open date and one bottle of liquid protein without an open date. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications and having possible adverse effects. Findings included: In an observation and interview on 11/05/24 at 11:05 a.m., seven open eye drop medications without an open date were stored on the 300-hall medication cart. MA F stated she did not know when they were opened, and eye drops should have had open dates because they were only good for 30 days after being opened. MA F did not state what the effects to the residents were. In an interview on 11/05/24 at 11:13 a.m., ADON D stated it was important to have an open date on eye drops, so they would know when they were opened. ADON D also stated that the medication may not have the desired effect if used after it should have been discarded. In an observation and interview on 11/05/24 at 11:46 a.m., one multi-dose vial of tuberculin was found in the [NAME] medication room without an open date. ADON E stated she did not know when the vial was opened and removed the tuberculin from the refrigerator to be disposed. ADON E stated the vial should have had an open date. In an observation and interview on 11/05/24 at 2:46 p.m., the 500-hall cart contained one open eye drop medication without an open date and one bottle of liquid protein without an open date. ADON E stated the eye drops and liquid medications should have had open dates and that everyone that used the carts should have monitored for proper labeling of medications. ADON E stated it was primarily the responsibility of the MA or nurse who was administering medications. ADON E also stated that the pharmacy reviewed the carts monthly and this failure could have caused a medication error depending on the medication. In an interview on 11/06/24 at 3:14 p.m., the DON stated there should be an open date on eye drops, insulin vials, and liquid protein. The DON stated that the MA or nurse that opened the medication should have put an open date. The DON stated the unit managers were responsible for monitoring the medication rooms and carts. The DON also stated the pharmacy checked the medication rooms and carts once a month for appropriate medication storage and labeling. The DON stated improper labeling could lead to the medication not having the desired effect, but it depended on the medication. Record review of facility's policy titled Medication Labeling and Storage with a revision date of February 2023, stated Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. It also stated multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filters and vent was free from dirt and dust. 2.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not past the 'best buy', consume by or expiration dates. 4. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the kitchen on 11/05/24 at 09:12 AM revealed the following: -Handwashing sink #1, there was no paper towels in the paper towel dispenser to the upper left side of the sink. - Handwashing sink #1's trash receptacle had trash other than paper towels inside. There was a milk carton, extra-large to-go- cup, a sandwich and an empty drink mix packaging. - Ice machine metal vent, located on the back, left and right sides of the machine, the vent grates and filters had dirty & dust on it. -The prep. table across from reach-in refrigerator, under the prep. table there was an extra-large square clear plastic container with a lid labeled cornmeal, dated 03/22/24, no discard by date. -The prep. table across from reach-in refrigerator, under the prep. table there was an extra-large square clear plastic container with a lid labeled sugar, dated 10/31/24, no discard by date. -Kitchen floor unclean, bits of debris noted along with stains on floor. -Large prep table next to extra-large stand mixer, beneath has 3 extra-large bins with lids: -One bin labeled Rice dated 07/04/24, there was no discard by date. -One bin labeled Flour dated 07/04/24 , no discard by date. -One bin labeled Thickener, there was no prep/opened date, no discard by date. -To the left of that prep table, on the floor in front of a large prep. table was a silver stainless steel scouring pad. Observations of Reach-in Refrigerator #2 on 11/05/24 at 09:34 AM revealed the following: -On the right sided-door: -1 Large zip top bag with approximately 11 boiled, peeled eggs, dated 11/04/24. Several of the eggs on top are still hot while others at the bottom of the bag are cold to touch, no discard by date. -Reach-in-Refrigerator #2 was in a separate area within the kitchen, the floor in that area had a slippery residue and the floor had small amounts of small bits of paper and small pieces of food debris on it. -On the left-sided door: -1 large zip top bag with yellow sliced cheese, previously opened, dated 10/26/24, no discard by date. -1 large box of cooked pork topping (crumbled /ground pork) dated 11/04, no opened date, packaged date was 10/19/24. -1- 5lbs. bag of cooked pork topping, open to air, no open date, no consume by or discard by date. Observations of Reach-in-Refrigerator #1 on 11/05/24 at 09:45 AM revealed the following: -On the right-sided door, 2nd shelf, a 2 qt. clear pitcher with light yellow colored drink dated 11/05/24, there was no label of item description, no discard by date. -Bottom shelf: -1 large pitcher of with lid dated 11/05/24 contained dark colored liquid, there was no label of item description, no discard by date. Observations of Walk-in Refrigerator on 11/05/24 at 09:57 AM revealed the following: -The floor of the walk-in is a little slick/slippery, there is a foul odor like old unclean mop water. There was also a soiled mop string on the floor. -The fan grates overhead in the walk-in unit were dusty. -Mobile metal rack in the middle of the floor: 5th row down from the top -1 large zip top bag with Turkey deli meat, previously opened, dated 11/04/24, no discard by date. -7th row down from top -a sheet pan with Turkey deli meat sandwiches (3) and chicken salad sandwiches (2), dated 11/04/24, no discard by date. -On the top shelf in the back of the walk-in unit: -1-16 oz. block of butter, dated 11/04/24, open to air. The packaging was left open, no discard by date. Observations of the Dry storage room on 11/05/24 at 10:10 AM revealed the following: -1 loaf of sliced white sandwich bread in a bin with other white sandwich bread, dated 11/04/24, manufacturer expiration date 10/25/24. -1-25 lbs. bag of coarse bread crumbs, previously opened, dated 02/29/24, no discard by date. The bag was also only rolled over to closed but not secured closed with a airtight closure. -1 Extra-large zip top bag with toasted oats dry cereal, previously opened, dated 10/25/24, no discard by date. -1 Extra-large zip top bag with approximately 12 large tortillas, previously opened dated 11/02/24, no discard by date. -1 large cardboard box, dated 10/19/24 containing 6 tortillas. There were 2- 28 oz. packages of large tortillas dated 07/08/24. The bags the large tortillas were in looked worn, some of the logo was smeared and one of the bags had a dime-sized hole in the bag in the back of package. -1 large zip top bag with yellow cake mix, previously opened, date 11/02/24, no discard by date. 1-6lbs. 9oz. can of diced peaches, dated 11/01/24, manufacturer's expiration 02/22/27 had dent at bottom of can. Observations of the main dining room on 11/05/24 at10:36 AM revealed the following: -On the counter: -1 extra-large clear drink dispenser with clear liquid and ice. There was no label of item description, no prep/open date and no discard by date. Observations of Kitchen on 11/06/24 at 02:10 PM revealed the following: -Handwashing sink #1's garbage receptacle had used gloves, product packaging as well as paper towels. Observation of Reach-in-refrigerator on 11/06/24 at 02:11 PM revealed the following: -Right-sided door: -1 large zip top bag of boiled eggs dated 11/04/24, previously had approximately 11 boiled eggs of hot and cold temperatures not had 30 boiled eggs., no discard by date. -1 small square clear container with lid with chicken salad dated 11/04/24, no discard by date. The green lid also had a crack in it, near one of the corners preventing a airtight seal. -1 small square clear container with lid contained mashed potatoes dated 11/04/24, no discard by date. There was a crack in the lid on the left side, preventing an airtight seal. Observation of the Kitchen on 11/07/24 at 12:05 PM revealed the following: -DM had gone out into the dining room earlier during service. She re-entered the kitchen from the dining room. She went over to the steam table, did not wash her hands then got a plate for a resident in the dining room and took it out to the resident. - Dietary Aide went out into the dining room, touched the door on her way out then place her hands on the wall next to the door as she leaned out of the door placing the resident's plate on aa nearby table. She returned to the kitchen but did not change gloves or wash her hands before getting another plate and taking it to another plate to the dining room. In an interview on 11/05/24 at 11:40 AM with the NSD, she stated when asked how long flour, rice and other dry good areas was placed in the large bins on the floor was kept after opening, the NSD stated they were kept 6-12 months, we go by the list (the storage guidelines). She stated there was a posted list for cleaning assignments and everyone has an assignment for cleaning. The NSD confirmed the storage guideline list was for unopened items since opening items shortens the shelf life of a lot of food items. The NSD stated canned goods without manufacturer's expiration dates were kept in their facility for 12 months. She stated cereals prepackaged in bowls that had no manufacturer's date were kept for 6 months. The NSD stated dry cereals that were opened are kept 4-5 days. She said, dust or surfaces that were not clean could cause harm to the residents by contaminating their food and causing illness. She stated the harm to using poor hand hygiene in the kitchen is cross contamination and illness. The NSD implied she did not know about the lids on the food in the refrigerator was cracked but she stated they should not be on there and moved to go look at the reach-in refrigerator. She stated that the cooks help with inventory Review of the facility's Nutrition Services Policy & Procedures Food Production & Food Safety dated March 2009: Revision March 2019, reflected Food Storage Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Procedure: . 4. All food items should be dated with the received date, unless labeled with a readable label from the food vendor. 5. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened. 7. Scoops are to be washed and sanitized on a weekly bases, or as needed. 8. Hand s must be washed after unloading supplies and prior to handling food items. 9. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. A. Old stock is always used fist (First in- First out method.) b. Supervision is necessary to make sure that the person designated to put stock away is rotating int properly. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. 15. Refrigeration .e. All foods should be covered, labeled and dated.16. Frozen Foods .c. Foods should be covered, labeled and dated. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or ware washing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov Review of the USDA website reflected: The United States Department of Agriculture's Food Safety and Inspection Service inspects only meat, poultry and egg products. The United States Food and Drug Administration inspects other foods. Yogurt can be stored in the refrigerator (40 F) one to two weeks or frozen (0 F) for one to two months. Soft cheeses such as cottage cheese, ricotta or Brie can be refrigerated one week but they don't freeze well. Hard cheeses such as cheddar, Swiss and Parmesan can be stored in the refrigerator six months before opening the package and three to four weeks after opening. It can also be frozen six months. Processed cheese slices don't freeze well but can be kept in the refrigerator one to two months. Milk can be refrigerated seven days; buttermilk, about two weeks. Milk or buttermilk may be frozen for about three months. Sour cream is safe in the refrigerator about one to three weeks but doesn't freeze well www.askusda.gov

Based on observation, interview, and record review the facility failed to establish and 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 one of three (CNA C) staff members and nine of nine residents (Resident #16, #41, #50, #74, #104, #265, #266, #267, & #268) reviewed for infection control procedures. CNA C failed to perform hand hygiene after direct contact with residents #16, #41, #50, #74, #104, #265, #266, 267, and #268 while serving meals on the rehabilitation hallways. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #16's admission MDS assessment, dated 10/01/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: anemia (low iron levels), hypertension (high blood pressure), and heart failure (heart does not pump blood like it should). Resident #11 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #41's admission MDS Assessment, dated 10/25/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #41 had diagnoses which included: heart failure (inability for the heart to work properly), renal insufficiency (kidneys are weak), and diabetes (high blood sugar). Resident #41's, was cognitive and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #50's admission MDS Assessment, dated 11/01/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included: renal insufficiency (weak kidneys), heart failure, hypertension (high blood pressure), and deep vein thrombosis (increased sugar levels). Resident #50 was cognitive and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #74's admission MDS Assessment, dated 10/24/24, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #74 had diagnoses which included: Heart Failure (inability of the heart to work properly), sever protein-calorie malnutrition (skinny), and seizures (epilepsy). Resident #74 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #104's admission MDS Assessment, dated 10/25/24, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #104 had diagnoses which included: coronary artery disease (arteries are clogged), cirrhosis (liver disease), and hypertension (high blood pressure). Resident #104 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #265's 5-day MDS Assessment, dated 11/07/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #265 had diagnoses which included: Heart failure (heart weak not working properly), hypertension (high blood pressure), and atrial fib (irregular heart rate). Resident #265 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #266's admission MDS Assessment, dated 11/06/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #266 had diagnoses which included: fracture of the neck of right femur (broken right hip), hypertension (high blood pressure), and hypothyroidism (thyroid slow to function). Resident #266 was moderately cognitively impaired able to make some decisions and required assistance of one staff for activities of daily living. Record review of Resident #267's 5-day MDS Assessment, dated 11/05/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #267 had diagnoses which included: Congestive obstructive pulmonary disease (short of breath), hypertension (high blood pressure), and anemia (low iron level). Resident #267 was cognitive able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #268's 5-day MDS Assessment, dated 11/07/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #268 had diagnoses which included: Congestive obstructive pulmonary disease (short of breath), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #267 was cognitive able to make decisions and required assistance of one staff for activities of daily living. Observation on 11/05/24 beginning at 12:20 p.m., revealed CNA C had walked down the hallway, did not use hand sanitizer, and served a lunch tray to Resident #265, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #265 and prepared the meal tray for the resident to eat her lunch. CNA C did not have on gloves. CNA C was observed to not wash his hands or use hand sanitizer, available in the hallway. Observation on 11/05/24 beginning at 12:22 p.m., CNA C was observed to enter Resident's #266, #267, and #50 rooms setting up the resident's lunch trays, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for each resident. She did not complete hand hygiene before going to the next resident. Observation on 11/05/24 beginning at 12:25 p.m., CNA C was observed to enter Resident's #104, #268, and #41 rooms setting up the resident's lunch trays, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for each resident. She did not complete hand hygiene before going to the next resident. Observation on 11/05/24 beginning at 12:27 p.m., revealed CNA C had walked down the hallway, did not use hand sanitizer, and served a lunch tray to Resident #16, and Resident #74. CNA C touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #16 and prepared the meal tray for the resident to eat her lunch. CNA C assisted Resident #74 to sit up straighter in the bed. CNA C did not have on gloves. CNA C was observed to not wash her hands or use hand sanitizer, available in the hallway. An interview on 11/06/24 at 1:20 p.m., CNA C stated she did not complete hand hygiene after having direct contact with residents. CNA C stated she was supposed to use the hand sanitizer in between serving each tray or wash her hands. CNA C said she had been educated on completing hand hygiene. CNA C stated she did not sanitize her hands, after the first meal tray that was served because she was nervous and trying to get the lunch trays served. CNA C stated she knew she could spread germs if she did not clean her hands. An interview with the DON on 11/07/24 at 11:30 a.m., revealed that all staff must complete hand hygiene after having contact with residents. She stated CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray service. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON was the infection control preventionist and she stated they do yearly competency training on the CNAs each year and new CNAs are trained on handwashing after they are hired and return demonstration. Record review of an in-service dated June 2024 log revealed CNA C received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in June 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. Record review of the Facility's Policy titled Handwashing/Hand Hygiene revised August 2019 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections . 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. before and after direct contact with residents; . p. before and after assisting a resident with meals

Based on interview and record review the facility failed to ensure one (Resident #1) of six residents reviewed, received treatment with respect and dignity that promoted maintenance of his or her quality of life. The facility failed to ensure CNA H preserved Resident #1's dignity by not providing her with good customer service on 09/09/2024, evidenced by CNA H stating oh, I sure would like to hit you on that big old booty. This failure places the residents at risk for harm by not protecting and promoting their rights to be treated with respect and dignity and have good customer serviced rendered. Findings included: Review of Resident #1's face sheet on 11/07/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Encephalopathy, Essential (Primary) Hypertension [High Blood Pressure]; Hyperlipidemia [High Cholesterol]; Type II Diabetes Mellitus; Malignant Neoplasm of Unspecified Female Breast [Breast Cancer]; Unspecified Dementia. Resident discharged later that night on 09/09/24. Resident #1's was not in facility long enough to have a MDS completed. Resident #1's was not in the facility long enough to have a Care Plan completed. Review of the discharge hospital medical records Progress notes (for 09/04/24 through 09/09/24) indicated the patient was able to transfer from sit to stand at the edge of the bed with walk, sit<>stand from commode with walker, and stand> sit in chair with walker at supervision level and continued to need step by step cues and instruction on how to complete all transfers safely and appropriately. Attempted to Interview CNA H, on 11/04/2024 at 04:11 PM and 11/05/2024 at 10:10 AM but she did not return the calls. Attempted to Interview Resident #1 or their husband on 11/06/2024 at 12:14 PM but did not receive a return call. Interview on 11/06/2024 at 01:42 PM with the Executive Director, she stated with the situation regarding Resident #1 (where CNA H exhibited poor customer service), while in the room the family laughed but later that evening, they lodged a complaint with the staff and the staff called the Executive Director. The family felt the comment was in poor taste not good customer service. She said, they (staff) called me around 11, 11-something at night (on 09/09/24) and said that the family member was upset and wanting to take Resident #1 home. I asked that she put me on speaker phone. The family member asked for my number and she called me from her phone and we talked. She explained she was taking Resident #1 to the car. The family member stated she believed that the CNA was gay because one of the CNA's (CNA H) used bad customer service by a comment she made. The family member B stated something about using a belt and the CNA's misread the room. The family member stated she did not feel comfortable with that. The two CNAs were gone off shift that day. The Executive Director stated she tried to get the family member to let Resident #1stay but Resident #1 & family member B were not sure about staying The Executive Director said, the family member stated the Resident #1 didn't want to be there anyway. I told the family member I would address her concerns, I explained we did not do that here. I called both CNAs that night, they both lied at the time. I told them they would have to come to do there I statements. I spoke to them separately, one (CNA G) admitted that the incident occurred while the other one (CNA H) did not. I spoke to CNA G and we did an in-service with her and her story was similar to the account of the family member. I talked to CNA H and let her know that CNA G had given me a statement that pretty much mirrored that of the daughter. I informed her of the family's concerns. She stated she did not hear any of that part of the conversations that I was talking about. I suspended both immediately. I called the family member again; her story was still the same. I called CNA H back again to see if she would be willing to tell me what really happened. She told me she had already told me what happened. So, we let her go since she would not admit to any wrongdoing. She was the one that it was stated was making the inconsiderate comments exhibiting the poor customer service, by the family member. The family member stated to me, that Resident #1 didn't want to come to a facility anyway, she wanted to be home, so we just took her back home. We, later in-serviced the whole staff on abuse, neglect and customer service. I did call family member B back to check on the patient, she was fine. My expectation is that staff would speak in a customer friendly manner to all of the families, speaking to them with dignity and respect and just do their jobs and not to get too personal with the families. The Executive Director stated they did in-services with the staff, safe surveys of the resident and do random questioning of staff on customer service and verbal abuse as a way of monitoring for understanding and compliance with good customer service. They also ask residents on how they are being treated. Interview on 11/06/2024 at 01:03 PM with the DON, she stated, now family member B, they (resident #1's family) were joking with the CNAs from the time they arrived but then later the family decided it was something different. Family member B meant the gait belt not a real belt. That was CNA G's first day over there on the short-term hall. She likes to try and build a rapport, but she should haven't said that. Sometimes people do not take things the way you mean if they do not understand you are not being mean or that you are being playful. The other one (CNA H), had to go because she would not admit to the situation occurring. Last in-service on abuse and neglect was probably last week. No further situation of this nature since this occurred. My expectations is for it not to happen. I set boundaries all the time, you know you are not to have those types of conversations like that even in a playing manner. If the family or resident is playing decline to join in on that in the correct manner, do your job. If you need clarification, ask, for example: like what kind of belt?. The DON stated what we did to monitor was that the residents had safe surveys done. We in-serviced staff on abuse/neglect and customer service. They do spot checks with the staff to follow up on customer service & abuse, neglect, exploitation, and customer service training. Interview on 11/07/2024 at 03:05 PM with CNA G she stated, the resident admitted to the facility that night for rehabilitation. The CNA assigned (CNA G) was trying to help the resident and her family settle in, the family member asked for sheets she wanted to make up the bed. CNA G asked CNA H to assist her with the resident. The resident was sitting on the side of the bed, the family member wanted to straighten out the sheets. The resident needed assistance to stand. Family member B made a comment about getting a belt after her. The Family and CNAs laughed but CNA G told Resident #1's family member B they do not do that there (at the facility). Then when the CNAs got on each side of the resident, CNA H made the comment about the size of the resident's butt, in what she perceived to be a joking manner. CNA H said, oh, I sure would like to hit you on that big ole booty. The CNAs and family members all laughed again. CAN G said, after this we left the room. Later that night I got a call from the Administrator asking did we make any inappropriate comments to resident #1. I told her what happened. She called me in the next day (09/10/2024) to come write a statement and informed me she would be investigating what happened. I was suspended that day for the whole work week (until that Friday). I had to take classes, paperwork I had to do for training. I was educated on customer service, abuse/neglect and one other thing, I can't remember right now. No issues since. I now do about I am supposed to do when it comes to customer service, resident and family members. CNA G stated she now understand why it was a problem-once her co-worker said what she said she should have asked her to exit the room regarding her remarks. CNA G stated due to watching the videos & in-services she understood why the family did not appreciate the remarks about their loved one. She said, now if I hear something inappropriate, I am going immediately to tell the Administrator. Most recent abuse & neglect in-service was approximately 2 weeks ago. I have not witnessed any other customer service issues. When the resident#1's family member B said belt, I did not think he meant a gait belt. At that time, I perceived CNA H was playing trying to make the family feel comfortable. Review of the facility's Residents Rights Policy & Procedures dated 2001: September 2022, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart . (a)The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; .(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law; . (B)Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the event s that cause the suspicion do not result in serious bodily injury.(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: . (2) Have evidence that all alleged violations are thoroughly investigated. (30 Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days or the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of eight residents reviewed for care plans. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan to ensure safe mechanical lift transfers. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan which required two-person shower assists, which caused Resident #1 to fall from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/2024. While the IJ was removed on 06/22/2024 at 5:51 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of unsafe transfers resulting in major injuries and / or death. Findings include: Record review of Resident #1's Face Sheet dated 06/21/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: quadriplegia (loss of muscle control, the brain cannot manage any automatic processes that rely on brain signaling), anoxic brain damage (caused be complete lack of oxygen to the brain), anxiety disorder (type of mental health condition), hypothyroidism (thyroid gland does not create and release enough thyroid hormone), tracheostomy status (a hole in the neck to provide oxygen to the lungs safely), gastrostomy status (an artificial entrance to the stomach), and dysphasia (difficulty swallowing). Record review of Resident #1's quarterly MDS Assessment, dated 06/13/2024, reflected no BIMS score, indicating it was not completed. She was in a persistent vegetative state. Had functional limitations on both sides for upper and lower extremities. Functional abilities included total dependence for hygiene, toileting, showers, dressing, and all transfers. Record review of Resident #1's Care Plan dated 04/15/2015 - Present, reflected, Problem: [Resident #1's] ADL functions: TOTAL DEPENDENCE STATUS: Intervention: Transfer with Hoyer lift and 2-person assist. Provide 2-person assist with showers. Problem: Transfers (to/from: bed chair wheelchair, standing position) - [Resident #1] is totally dependent on the staff. Intervention: transfer using the transfer board/lift device [mechanical lift] x 2-person. Problem: [Resident #1] has had a fall with injury: Laceration to RT Forehead [Resident #1] had a fall from shower bed while receiving a shower on 6/20/24. Intervention: Assess reason for fall. Provide 2-person assist when giving [Resident #1] a shower. Check shower bed to ensure that it is working properly and locked while giving a shower. Provide 2-person assist with the use of a [mechanical lift] to transfer [Resident #1] to shower bed. Problem: At Risk for Falls R/T impaired mobility, impaired cognition, use of wheelchair. Intervention: May use Hoyer lift x 2-person assist with transfers. Record review of the facility incident report, dated 06/20/2024 at 4:30 PM and signed by LVN D, reflected, [CNA A] called this nurse to shower room. Upon entering shower room noticed [Resident #1] laying on floor on back with legs straight. Open area noticed to mid right side of forehead, appears to be draining red blood. Applied pressure, sent [CNA A] to call other staff for assistance. Another nurse called 911 . Resident going out to Methodist [NAME]. After 911 EMT exited, notified Resident's husband. MD notified. ED notified. DON notified. ADON notified. Record review of the Facility's Investigation Report, dated 06/21/2024, reflected, On 06/20/2024 at 4:30 PM, Nurse Aide was giving the resident her shower on the shower bed. Aide advise she turn resident over to wash her back and the resident rolled off the shower bed. Nurse aide then called for the nurse and the nurse came and found the resident on the floor and she noted the laceration on the head and called 911. Resident #1 was assessed with laceration on forehead and sent to hospital. CNA A was suspended pending the investigation. The facility investigation was ongoing. A written statement from LVN D, dated 06/20/2024, reflected, CNA called this nurse to the shower room. Upon entering shower room noticed res lay on back [with] legs straight out. Open area to mid right side of forehead, appears to be draining red blood. Called for staff to assist STAT. Applied pressure to mid right side. Another nurse called 911. Once 911 exited the facility [with] resident, notified husband. Notified MD. Notified ED, ADON, and DON. A written statement from CNA A, dated 06/19/2024, reflected, I [CNA A] had [Resident #1] on the shower bed in the shower room I turned [Resident #1] over to wash her back and she slid face first on the shower room floor. I immediately notified the nurse. Record review of the Hospital Record, dated 06/20/2024 at 12:55 PM, reflected, [Patient] is a [AGE] year-old female PMHx of anoxic brain injury who presents via EMS with head injury post fall that occurred today. Patient has laceration at forehead. Plan: X-ray pelvis, chest x-ray, CT head, CT facial bones, CT cervical spine non-contrast. Will repair laceration with suture. Problems Addressed: Facial laceration, initial encounter: acute illness or injury. Fall, initial encounter: acute illness or injury Head injury, initial encounter: acute illness or injury. Positive for wound (head injury). Areolar (soft) tissue violated, Wound extent: no fascia violation noted, no foreign bodies/material noted, no muscle damage noted, no nerve damage noted, no tendon damage noted, no underlying fracture noted, and no vascular damage noted. Skin repair: Number of sutures: 3. Result Date: Head, Spine, Face 6/20/2024, IMPRESSION: 1. Severely motion degraded exam. 2. No CT evidence of acute intracranial abnormality. 3. Severe global atrophy. The ventricles are dilated greater than the degree of background atrophy. Communicating hydrocephalus is not excluded. 4. No acute fracture or dislocation of the facial bones. 5. Frontal scalp hematoma. 6. No acute fracture or dislocation of the cervical spine. Social Worker consulted: Per RN and Registration, It was told to SW that pt's family unhappy at current nursing home because they have dropped the pt in the shower room of the facility. They report pt was dropped at the facility and the aide doing pt's shower was crying and admitted it to the family. In an interview on 06/21/2024 at 10:01 AM, the Executive Director stated she was informed of the incident on 06/20/2024 about 5:30 PM. She said she was not able to respond to the facility and the DON was on leave. She said neither her nor the DON went to the facility for follow up with the investigation. She said she was told CNA A was showering Resident #1 and Resident #1 fell from the shower bed and had a laceration on her forehead. She said Resident #1 was sent to hospital. She stated that she learned that CNA A transferred Resident #1, using a mechanical lift, on her own. She said all resident transfers that required a mechanical lift needed to be with two staff for safety. She said CNA A also showered Resident #1 on her own when Resident #1 fell from the shower bed. She said Resident #1 was a two-person mechanical lift transfer and two-person assist for showers and all ADLs. She said she asked LVN D to in-services CNA A on transfers and CNA A was suspended and sent home after the incident occurred. She said CNA A will be terminated for not following the facility's policy. In an interview on 06/21/2024 at 10:15 AM, the DON stated she learned that CNA A use the mechanical lift to transfer Resident #1 from her bed to the shower bed, on her own. She said CNA A also showered Resident #1 on her own when Resident #1 fell from the shower bed. The DON stated Resident #1's care plan indicated two-person transfers using a mechanical lift and for showers. She stated CNA A should know this because all CNAs had access to the daily care guide, which indicated care needs for all residents. She stated She learned from LVN D that CNA A said Resident #1 fell over the top of the shower bed rail. The DON said Resident #1 was not able to move at all so she was not sure how she could fall over the rail. The DON said there should have been two people in the shower when showering Resident #1. She said staff were trained on fall precautions and equipment use at hire. Attempted telephone calls to CNA A on 06/21/2024 at 10:45 AM, 3:25 PM (from the DON's phone), and 06/22/2024 at 11:55 AM revealed no response to messages that requested a call back. In a telephone interview on 06/21/2024 at 11:04 AM, LVN D stated CNA A called her to the shower room because Resident #1 had fallen. She said when she went into the shower room, Resident #1 was on the floor, on her back, bleeding from her forehead. She said the shower bed was upright, but she did not notice if the rails were up of down. She said she assessed the resident and they called 911 to send her to the hospital. She said CNA A told her Resident #1 fell over the top of the shower bed rails when she turned her over. LVN D said she did not know what happened but though it was impossible for Resident #1 to fall from the shower bed unless the bed rail fell down or was not up. She said the shower beds had rails that attached with clips and if they were not fastened correctly they could have allowed the rail to come down. She said she did not notice anything wrong with the bed but did remove it from use as directed by the ED. She said Resident #1 was a two-person shower assist because she could not move on her own. She stated all nursing staff should know the care needs of all residents because they have access to the daily care guide. LVN D said CNAs could also ask the nurse if they were not sure of care needs. She said she did not know why CNA A used a mechanical lift and showered Resident #1 on her own rather than getting assistance from another staff. She stated when she called the ED and DON, they instructed her to get statements from CNA A and in-service her on safe transfers, then send her home pending the incident investigation. She said she did discuss with CNA A resident safety, fall prevention, and to ensure we followed protocol mechanical lift and care plan policy. LVN D said she was I the halls with CNAs but did not see CNA A get Resident #1 ready for a shower. She said she monitored CNAs by following up on rounding and letting them know they could come to her with any questions. An observation on 06/21/2024 at 12:03 PM, revealed Resident #1 in bed. She had multiple limb contractures, and her left side was propped up with pillows. The head of her bed was elevated, she had a trach and feeding tube. She had a bandage on her right forehead and slightly blackened right eye. She was not able to answer questions and did not make any kind of eye contact. Family Member R was present and did seem to get some reaction from Resident #1, when the family member spoke to Resident #1, she smiled. In an interview on 06/21/2024 at 12:05 PM, with Family Member R (in person) and Family Member S (on the telephone), they said Resident #1 was quadriplegic as a result of a heart attack / stroke which caused brain damage. They said Resident #1 did not move on her own. Family Member S said CNA A told her she dropped Resident #1 from the shower bed which caused the cut on Resident #1's forehead and three stitches. They stated Resident #1 should have two people to transfer and two people for showers. In an interview on 06/21/2024 at 12:15 PM, Resident #1's roommate stated she saw CNA A lift Resident #1 with the mechanical lift, on her own. She said CNA A placed Resident #1 onto the shower bed, in the room, but did not know what happened when they went into the shower room. She said she required a mechanical lift for transfer as well. She said staff often lifted her and Resident #1 on their own, with the mechanical lift. In an interview on 06/21/2024 at 12:58 PM, ADON B said LVN D called him on 06/20/2024 at about 5:00 PM to inform him that Resident #1 fell from the shower bed. ADON B said CNA A was showering Resident #1 on her own and without assistance when Resident #1 fell off the shower bed. He stated Resident #1 was total care and required a two-person shower assist. He said CNA A did not implement the care plan to meet Resident #1's needs safely. He said he had not been able to contact CNA A since she was suspended after the incident. He stated when he heard of the incident he recognized the immediacy to address fall prevention and resident care needs as noted in the care guide. He said LVN D was instructed to start in-services on 06/20/2024, which addressed fall prevention, two-person mechanical lifts and transfers. He said nursing staff know to call for assistance when they need it. He said if they need to get assistance from another hall they could do that as well. He said he did not feel CNA A was not able to get assistance but rather did not seek assistance. He said CNA A place Resident #1 in a hazardous situation and compromised Resident #1's safety which caused her injury. In an interview on 06/21/2024 at 4:26 PM, the MD stated he was made aware of Resident #1's fall. He stated Resident #1 was required two-person mechanical lift transfers and two-person assist for showers. He said these were care planed and he expected staff to follow the care plans for all residents. He said he was not sure why CNA A did not follow the care plan because the care guide was available to all staff to ensure resident needs were met safely. In an interview on 06/21/2024 at 5:42 PM, LVN Q stated she worked on another hall when the incident occurred. She said LVN D called her to call 911. She said she did look into the shower room and saw Resident #1 on the floor and LVN D assessing her. She stated she the shower bed was upright but did not notice if the siderails were up of down. She stated the only way Resident #1 could have fell from the shower bed was if the side rail was not up or secured properly because Resident #1 was a total asset and needed assistance to move. She stated CNA A should have known Resident #1 was a two person assist for mechanical lift / transfers and showers. In an interview on 06/21/2024 at 6:10 PM, the Staffing Coordinator stated the facility did not have any staffing issues. She stated shifts were all covered, and she had little or no issue with staffing call ins. She stated she provided some training to staff and said CNAs know all care needs for residents were found and accessible in the Daily Care Guide. She stated all mechanical lifts and transfers were to be completed by two staff. She said Resident #1 required two-person assist for showers because she was totally dependent. She said two people could ensure Resident #1's safety more easily. In an interview on 06/21/2024 at 6:17 PM, CNA O stated she worked on the same Hall as CNA A, when the incident occurred. She said she was in another resident's room when she heard CNA A calling for LVN D. She said she did not see anything that occurred and was not aware CNA A was showering Resident #1. She said CNA A did not ask her for assistance to transfer or shower Resident #1. She said the care needs for all residents were in the care guide, accessible to all nursing staff. She said Resident #1 required total care and was a two-person assist for transfers and showers. She said staff needed to communicate with each other when they required assistance to meet care needs for residents. She said all mechanical lift / transfers required two staff. She said there should have been two staff assisting with Resident #1's shower to ensure safety in case the rail did fall down. Record review of initial training for CNA A, dated 05/07/2024, reflected, trainings titled, Fall prevention, General staff guidelines - Gait belt policy, Safe patient / resident handling and movement program, and oral / written fall prevention competency test. All trainings were signed by CNA A on 05/07/2024. Record review https://opwdd.ny.gov/safty+guidlines+for+mechanical+lifts on 06/30/2024 reflected, Safe Mechanical Lift Operation: Before the initial and subsequent use of mechanical lift equipment, a safety check should be completed in accordance with the manufacturer's guidelines and/or agency protocol to ensure the equipment is in good working order. The number of staff required to perform a transfer is at the discretion of the practitioner who prescribed or recommended use of a mechanical lift device. However, it is always best practice to use mechanical lift equipment with a minimum of two staff. Record review of the facility's policy titled, Care Plans, Person Centered, revised March 2022, reflected, 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. Services provided for or arranged by the facility and outlined in the comprehensive care plan are, provided by qualified persons The Executive Director, and DON were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 06/21/2024 at 4:14 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 06/22/2024 at 10:14 AM and included: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: The resident sustained a left forehead laceration from the fall and was fully assessed and sent to the ER for further evaluation and treatment. The resident returned the same day, 06/20/2024, with sutures to the forehead, with no further injuries and returned back to their baseline. Immediate ins-services were started on the day of incidence, 06/20/2024, which included Abuse and Neglect and Mechanical Lift/ Transfer with 2 Person Assistance. All direct care staff remaining will be in-service by the DON and/or clinical designee prior to the start of their next shift until complete compliance is met. On 06/20/2024, the day and time of incidence, The C.N.A was interviewed and given a one-to-one in-service by her charge nurse prior to suspension, pending investigation. On the evening 06/20/2024 the questionable shower bed was taken out of rotation and usage and an audit of all other shower beds were examined for any deficits; none were found. The state was notified on 06/20/2024 (Intake #512683). The responsible party was notified immediately, as well as the attending physician. How the facility will identify other residents having the potential to be affected by the same deficient practice: Residents who require a two-person assistance with mechanical lifts were reviewed by the Director of Nursing (DON) on 06/21/2024 to determine if there were any other residents that experienced accidents as a result of this same practice. No other issues were found. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur: On 06/21/24, The DON and nurse mangers completed one-on-one education, in person, to Certified Nursing Assistants (CNA), licensed and registered nurses regarding requirement of two-person assistance with any mechanical lift. This was done to ensure understanding that all mechanical lifts and transfer require 2-person assistance. Abuse and neglect in-services were also continued; On 06/21/2024 the facility also added in-serving on Following Resident Care Plans. Direct care staff will be ongoing not in-serviced will be in-serviced prior to the start of their next shift until compliance is met, with a goal date of Monday June 24th,2024. Any employee that did not receive the education will be removed from the schedule until education is completed. All new nursing employees will be educated, during orientation and prior to taking an assignment the following in-services: 'Abuse and Neglect Prevention', 'Mechanical Lift Transfers with 2-Person Assistance' and 'Following the Residents Care Plan'. Residents that have a fall will be reviewed by the Nursing Administration and any deficiencies noted will be corrected by Unit Manager or designee and new interventions put in place as required. The staff involved will be provided with education or corrective action as necessary. Falls will be reviewed daily in the morning IDT Meeting and as they occur by nursing administration and the Licensed Administrator. The Maintenance Director has completed a safety audit of as of 06/21/2024, with no further findings and will complete safety checks audit all shower chairs shower beds and mechanical lifts on a weekly basis for maintenance and functionality. How the facility plans to monitor its performance to make sure that solutions are sustained: DON/designee will audit 5 falls a week beginning 06/24/24 to ensure interventions and Care Plans are completed weekly for four weeks then twice a month for two months and monthly for three months. The Nurse Managers will observe 5 direct care staff a week beginning 06/24/24, during care, of residents who require mechanical lifts, to ensure that staff are competent and knowledgeable of the 2- Person mandate and that they are following the individual residents Care Plan. This will be done for four weeks, and then 5 staff every two weeks for two months. The findings will be reviewed at the quarterly Quality Assurance/Performance Improvement (QAPI) meetings for 2 quarters. The Administrator is responsible for implementing the acceptable plan of correction. On 06/22/2024 at 12:00 PM the surveyor began monitoring the facility's Plan of Removal. In an interview on 06/22/2024 at 11:17 AM, with the Executive Director and DON, the DON stated, the Regional Director of Clinical Services in-serviced her and the Executive Director on the failures surrounding the IJ. She said those included abuse and neglect policy, mechanical lift processes, the care guide and how staff need to follow it, resident care plans, and ensuring all equipment was safe for use. She said she then in-serviced ADON B and RN C. She said they had been completing one-on-one in-servicing with staff since 06/21/2024. She stated staff were in-serviced in person and prior to starting their shift. The Executive Director said she estimated at least half their staff had completed in-services and this would be on-going until all staff had been in-serviced. She said her expectation was that the CNAs be trained, and the nurses trained to follow up to ensure everyone was following care plans and meeting resident's needs. She stated it was her expectation that staff followed the care guide and communicate care needs and any changes residents may have to ensure the facility staff meet resident's needs. All staff were expected to tell Administration about any issues - this was part of the abuse and neglect training. She stated staff were trained to report maintenance issues or issues with equipment to maintenance and record those issues in the logbook at the front desk. She said the DON or designee was responsible to monitor all of the plan of corrections put in place. She said the management team was responsible to assess all falls daily to identify issues related to resident care and safety. The DON said she planned to do random skills checkoffs for mechanical lift transfers and random checks to ensure aides were following resident care guides. She said this information would then be reviewed in QUPI and the Executive Director would follow up as needed. Interviews on 06/22/2024 between 12:00 PM and 2:53 PM with ADON B, RN C, Social Worker, Human Resources Director, Maintenance Director, Director of Business Development, CNAs E, F, G, H and I, Housekeepers J and K, and LVNs L, M, and N, represented staff who worked 1st, 2nd, 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice's including mechanical lift protocol, where to document maintenance or equipment issues, who to report equipment issues to, policies regarding identifying and reporting abuse or neglect, following care plans and where to find resident care plan information. All staff stated the DON and nurse managers would monitor these actions. Observation on 06/22/2024 at 1:40 PM revealed CNAs E and F performed a mechanical lift transfer for Resident #2. Resident #2 did not communicate verbally. Facial expressions from Resident #2 appeared positive in response to verbal ques from CNAs E and F during the transfer. An observation and interview on 06/22/2024 at 1:55 PM revealed CNAs G and H performed a mechanical lift transfer for Resident #3. Resident #3 stated he felt safe when the CNAs transferred him with the mechanical lift. Record review of the facility's in-service record addressed to CNAs and Nurses, dated 06/21/2024, titled, Mechanical Lift, Falls, Transfers and Fall Prevention, and conducted by ADON B, included the following topics. The importance of following protocols and safety measures when using mechanical lifts. Ensure all staff are knowledgeable and competent to prevent further injury. Nursing staff must use the daily care guides to learn proper transfers for each resident and all lifts are to be used with 2 people, no exceptions! Total care x two assist for showers and [mechanical lift] transfers x two assist. This includes that all lifts are in mechanical working order. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/2024. While the IJ was removed on 06/22/2024 at 5:51 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred by two people using a mechanical lift as indicated in the comprehensive care plan. The facility failed to ensure two people assisted Resident #1 during showers as indicated in the comprehensive care plan. Resident #1 fell from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. The facility failed to ensure they had a system in place to monitor equipment (shower beds) for safe working order and log audits on a regular basis. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/2024. While the IJ was removed on 06/22/2024 at 5:51 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of major injuries and / or death. Findings include: Record review of Resident #1's Face Sheet dated 06/21/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: quadriplegia (loss of muscle control, the brain cannot manage any automatic processes that rely on brain signaling), anoxic brain damage (caused be complete lack of oxygen to the brain), anxiety disorder (type of mental health condition), hypothyroidism (thyroid gland does not create and release enough thyroid hormone), tracheostomy status (a hole in the neck to provide oxygen to the lungs safely), gastrostomy status (an artificial entrance to the stomach), and dysphasia (difficulty swallowing). Record review of Resident #1's quarterly MDS Assessment, dated 06/13/2024, reflected no BIMS score, indicating it was not completed. She was in a persistent vegetative state. Had functional limitations on both sides for upper and lower extremities. Functional abilities included total dependence for hygiene, toileting, showers, dressing, and all transfers. Record review of Resident #1's Care Plan dated 04/15/2015 - Present, reflected, Problem: [Resident #1's] ADL functions: TOTAL DEPENDENCE STATUS: Intervention: Transfer with Hoyer lift and 2-person assist. Provide 2-person assist with showers. Problem: Transfers (to/from: bed chair wheelchair, standing position) - [Resident #1] is totally dependent on the staff. Intervention: transfer using the transfer board/lift device [mechanical lift] x 2-person. Problem: [Resident #1] has had a fall with injury: Laceration to RT Forehead [Resident #1] had a fall from shower bed while receiving a shower on 6/20/24. Intervention: Assess reason for fall. Provide 2-person assist when giving [Resident #1] a shower. Check shower bed to ensure that it is working properly and locked while giving a shower. Provide 2-person assist with the use of a [mechanical lift] to transfer [Resident #1] to shower bed. Problem: At Risk for Falls R/T impaired mobility, impaired cognition, use of wheelchair. Intervention: May use Hoyer lift x 2-person assist with transfers. Record review of the facility incident report, dated 06/20/2024 at 4:30 PM and signed by LVN D, reflected, [CNA A] called this nurse to shower room. Upon entering shower room noticed [Resident #1] laying on floor on back with legs straight. Open area noticed to mid right side of forehead, appears to be draining red blood. Applied pressure, sent [CNA A] to call other staff for assistance. Another nurse called 911 . Resident going out to [Hospital]. After 911 EMT exited, notified Resident's husband. MD notified. ED notified. DON notified. ADON notified. Record review of the Facility's Investigation Report, dated 06/21/2024, reflected, on 06/20/2024 at 4:30 PM, nurse Aide was giving the resident her shower on the shower bed. Aide advise she turn resident over to wash her back and the resident rolled off the shower bed. Nurse aide then called for the nurse and the nurse came and found the resident on the floor and she noted the laceration on the head and called 911. Resident #1 was assessed with laceration on forehead and sent to hospital. CNA A was suspended pending the investigation. The facility investigation was ongoing. A written statement from LVN D, dated 06/20/2024, reflected, CNA called this nurse to the shower room. Upon entering shower room noticed res lay on back [with] legs straight out. Open area to mid right side of forehead, appears to be draining red blood. Called for staff to assist STAT. Applied pressure to mid right side. Another nurse called 911. Once 911 exited the facility [with] resident, notified husband. Notified MD. Notified ED, ADON, and DON. A written statement from CNA A, dated 06/19/2024, reflected, I [CNA A] had [Resident #1] on the shower bed in the shower room I turned [Resident #1] over to wash her back and she slid face first on the shower room floor. I immediately notified the nurse. Record review of the Hospital Record, dated 06/20/2024 at 12:55 PM, reflected, [Patient] is a [AGE] year-old female PMHx of anoxic brain injury who presents via EMS with head injury post fall that occurred today. Patient has laceration at forehead. Plan: X-ray pelvis, chest x-ray, CT head, CT facial bones, CT cervical spine non-contrast. Will repair laceration with suture. Problems Addressed: Facial laceration, initial encounter: acute illness or injury. Fall, initial encounter: acute illness or injury Head injury, initial encounter: acute illness or injury. Positive for wound (head injury). Areolar (soft) tissue violated, Wound extent: no fascia violation noted, no foreign bodies/material noted, no muscle damage noted, no nerve damage noted, no tendon damage noted, no underlying fracture noted, and no vascular damage noted. Skin repair: Number of sutures: 3. Result Date: Head, Spine, Face 6/20/2024, IMPRESSION: 1. Severely motion degraded exam. 2. No CT evidence of acute intracranial abnormality. 3. Severe global atrophy. The ventricles are dilated greater than the degree of background atrophy. Communicating hydrocephalus is not excluded. 4. No acute fracture or dislocation of the facial bones. 5. Frontal scalp hematoma. 6. No acute fracture or dislocation of the cervical spine. Social Worker consulted: Per RN and Registration, It was told to SW that pt's family unhappy at current nursing home because they have dropped the pt in the shower room of the facility. They report pt was dropped at the facility and the aide doing pt's shower was crying and admitted it to the family. In an interview on 06/21/2024 at 10:01 AM, the Executive Director stated she was informed of the incident on 06/20/2024 about 5:30 PM. She said she was not able to respond to the facility and the DON was on leave. She said neither her nor the DON went to the facility for follow up with the investigation. She said she was told CNA A was showering Resident #1 and Resident #1 fell from the shower bed and had a laceration on her forehead. She said Resident #1 was sent to the hospital. She stated that she learned that CNA A transferred Resident #1, using a mechanical lift, on her own. She said all resident transfers that required a mechanical lift needed to be with two staff for safety. She said CNA A also showered Resident #1 on her own when Resident #1 fell from the shower bed. She said Resident #1 was a two-person mechanical lift transfer and two-person assist for showers and all ADLs. She stated she asked the nursing staff to check all the shower beds to ensure they were in good working condition. She said she asked LVN D to remove the shower bed used in the incident, until it could be checked by Maintenance, and make an entry in the Maintenance Logbook. She said the Maintenance Director checked the shower bed on 06/21/2024 and found no maintenance concerns. She said she did not know when the shower equipment was inspected last and was not sure if there was a record of the equipment inspections. She said she asked LVN D to in-service CNA A on transfers and CNA A was suspended and sent home after the incident occurred. She said CNA A will be terminated for not following the facility's policy. In an interview on 06/21/2024 at 10:15 AM, the DON stated she learned that CNA A use the mechanical lift to transfer Resident #1 from her bed to the shower bed, on her own. She said CNA A also showered Resident #1 on her own when Resident #1 fell from the shower bed. The DON stated Resident #1's care plan indicated two-person transfers using a mechanical lift and for showers. She stated CNA A should know this because all CNAs had access to the daily care guide, which indicated care needs for all residents. She stated She learned from LVN D that CNA A said Resident #1 fell over the top of the shower bed rail. The DON said Resident #1 was not able to move at all so she was not sure how she could fall over the rail. The DON said there should have been two people in the shower when showering Resident #1. She said staff were trained on fall precautions and equipment use at hire. She stated there was no formal training for staff to report maintenance issues, but staff have been verbally instructed to report and log any concerns with maintenance or equipment in the maintenance log at the front desk. Attempted telephone calls to CNA A on 06/21/2024 at 10:45 AM, 3:25 PM (from the DON's phone), and 06/22/2024 at 11:55 AM revealed no response to messages that requested a call back. In a telephone interview on 06/21/2024 at 11:04 AM, LVN D stated CNA A called her to the shower room because Resident #1 had fallen. She said when she went into the shower room, Resident #1 was on the floor, on her back, bleeding from her forehead. She said the shower bed was upright, but she did not notice if the rails were up of down. She said she assessed the resident and they called 911 to send her to the hospital. She said CNA A told her Resident #1 fell over the top of the shower bed rails when she turned her over. LVN D said she did not know what happened but thought it was impossible for Resident #1 to fall from the shower bed unless the bed rail fell down or was not up. She said the shower beds had rails that attached with clips and if they were not fastened correctly they could have allowed the rail to come down. She said she did not notice anything wrong with the bed but did remove it from use as directed by the ED. She said Resident #1 was a two-person shower assist because she could not move on her own. She stated all nursing staff should know the care needs of all residents because they have access to the daily care guide. LVN D said CNAs could also ask the nurse if they were not sure of care needs. She said she did not know why CNA A used a mechanical lift and showered Resident #1 on her own rather than getting assistance from another staff. She stated when she called the ED and DON, they instructed her to get statements from CNA A and in-service her on safe transfers, then send her home pending the incident investigation. She said she did discuss with CNA A resident safety, fall prevention, and to ensure we followed protocol mechanical lift and care plan policy. LVN D said she was rounding in the hall with CNAs but did not see CNA A get Resident #1 ready for a shower. She said she monitored CNAs by following up on rounding and letting them know they could come to her with any questions. An observation on 06/21/2024 at 12:03 PM, revealed Resident #1 in bed. She had multiple limb contractures, and her left side was propped up with pillows. The head of her bed was elevated, she had a trach and feeding tube. She had a bandage on her right forehead and slightly blackened right eye. She was not able to answer questions and did not make any kind of eye contact. Family Member R was present and did seem to get some reaction from Resident #1, when the family member spoke to Resident #1, she smiled. In an interview on 06/21/2024 at 12:05 PM, with Family Member R (in person) and Family Member S (on the telephone), they said Resident #1 was quadriplegic as a result of a heart attack / stroke which caused brain damage. They said Resident #1 did not move on her own. Family Member S said CNA A told her she dropped Resident #1 from the shower bed which caused the cut on Resident #1's forehead and three stitches. They stated Resident #1 should have two people to transfer and two people for showers. In an interview on 06/21/2024 at 12:15 PM, Resident #1's roommate stated she saw CNA A lift Resident #1 with the mechanical lift, on her own. She said CNA A placed Resident #1 onto the shower bed, in the room, but did not know what happened when they went into the shower room. She said she required a mechanical lift for transfer as well. She said staff often lifted her and Resident #1 on their own, with the mechanical lift. In an interview on 06/21/2024 at 12:58 PM, ADON B said LVN D called him on 06/20/2024 at about 5:00 PM to inform him that Resident #1 fell from the shower bed. ADON B said CNA A was showering Resident #1 on her own and without assistance when Resident #1 fell off the shower bed. He stated Resident #1 was total care and required a two-person shower assist. He said CNA A did not implement the care plan to meet Resident #1's needs safely. He said he had not been able to contact CNA A since she was suspended after the incident. He stated when he heard of the incident he recognized the immediacy to address fall prevention and resident care needs as noted in the care guide. He said LVN D was instructed to start in-services on 06/20/2024, which addressed fall prevention, two-person mechanical lifts and transfers. He said he did no come to the facility and did not resume in-services until 06/21/2024. He said the night shift staff were not in-serviced on 06/20/2024. He said nursing staff know to call for assistance when they need it. He said if they need to get assistance from another hall they could do that as well. He said he did not feel CNA A was not able to get assistance but rather did not seek assistance. He said CNA A placed Resident #1 in a hazardous situation and compromised Resident #1's safety which caused her injury. In an interview on 06/21/2024 at 4:26 PM, the MD stated he was made aware of Resident #1's fall. He stated he had been in the facility after Resident #1 was sent to hospital and witnessed staff explaining to Resident #1's family what happened. He stated Resident #1 was required two-person mechanical lift transfers and two-person assist for showers. He said these were care planed and he expected staff to follow the care plans for all residents. He said he was not sure why CNA A did not follow the care plan because the care guide was available to all staff to ensure resident needs were met safely. In an interview on 06/21/2024 at 5:02 PM, the Regional Director of Clinical Services stated when she was informed on the incident on 06/20/2024, she asked the ED to go to the facility and have all the shower equipment assessed for any maintenance issues. She said she asked that the shower bed be taken out of commission until it could be evaluated for defects. She stated she asked the ED to ensure they started in-services immediately to prevent additional incidents. She stated she realized that in-services were not completed timely, and the night shift was not in service. She stated someone from the management team should have come to the facility when the incident occurred to ensure task were completed to ensure the safety of all residents. In an interview on 06/21/2024 at 5:42 PM, LVN Q stated she worked on another hall when the incident occurred. She said LVN D called her to call 911. She said she did look into the shower room and saw Resident #1 on the floor and LVN D assessing her. She stated she the shower bed was upright but did not notice if the siderails were up of down. She stated the only way Resident #1 could have fell from the shower bed was if the side rail was not up or secured properly because Resident #1 was a total asset and needed assistance to move. She stated CNA A should have known Resident #1 was a two person assist for mechanical lift / transfers and showers. She stated if there were equipment issues, staff were required to log them in the Maintenance Logbook at the front desk for maintenance staff follow up. In an interview on 06/21/2024 at 5:54 PM, the Maintenance Director stated he was asked to follow up with an assessment to the shower bed involved in the incident. He said there were no maintenance concerns when he looked at it earlier today. He said the rails were held up with two pins that slid into the side and then clip to secure them. He said if the pins were not secured, they could fall out and the rail would fall down. He stated when he assessed the shower bed, he noticed one of the pins, on the left side of the shower bed, was not in the rail and the cable that attached it to the shower bed was hanging down the side of the bed. He said there was not a pin attached to the cable. He said he was not sure if someone removed the pin after the incident or if it was not there at the time of the incident. He said he replaced the pin this today. He said his Maintenance Log did not note a missing pin but did note, Shower bed rail broken, dated 06/20/2024. He said he did not have any documented evidence of maintenance checks on equipment but estimated he did checks at least monthly. He said staff were instructed to log any equipment issues in the Maintenance Logbook at the front desk and he reviewed the log daily for follow up. He said staff were not formally trained on documenting in the Logbook but rather verbally instructed to do so. He stated all mechanical lifts / transfers needed to be done by two staff to ensure resident safety. In an interview on 06/21/2024 at 6:10 PM, the Staffing Coordinator stated the facility did not have any staffing issues. She stated shifts were all covered, and she had little or no issue with staffing call ins. She stated she provided some training to staff and said CNAs know all care needs for residents were found and accessible in the Daily Care Guide. She stated all mechanical lifts and transfers were to be completed by two staff. She said Resident #1 required two-person assist for showers because she was totally dependent. She said two people could ensure Resident #1's safety more easily. In an interview on 06/21/2024 at 6:17 PM, CNA O stated she worked on the same Hall as CNA A, when the incident occurred. She said she was in another resident's room when she heard CNA A calling for LVN D. She said she did not see anything that occurred and was not aware CNA A was showering Resident #1. She said CNA A did not ask her for assistance to transfer or shower Resident #1. She said the care needs for all residents were in the care guide, accessible to all nursing staff. She said Resident #1 required total care and was a two-person assist for transfers and showers. She said staff needed to communicate with each other when they required assistance to meet care needs for residents. She said all mechanical lift / transfers required two staff. She said she used the shower bed in the past and knew the rail pins need to be clamped once they were put in place to ensure they stayed in place. She said there should have been two staff assisting with Resident #1's shower to ensure safety in case the rail did fall down. She said she had told a nurse about the missing pin, on the left side of the shower bed, for a few days. She said she did not recall which nurse. She said she did not log the missing pin in the Maintenance Logbook because it was at the front desk and far from the Hall where she worked. Record review of the facility's Maintenance Logbook, between 06/02/2024 and 06/20/2024, reflected one entry related to shower beds. The entry was on 06/20/2024 and stated, Shower bed rail broken - 100 Hall shower bed, entered by LVN D. Record review of initial training for CNA A, dated 05/07/2024, reflected, trainings titled, Fall prevention, General staff guidelines - Gait belt policy, Safe patient / resident handling and movement program, and oral / written fall prevention competency test. All trainings were signed by CNA A on 05/07/2024. Record review of the facility's policy titled, Resident Rights, dated November 2016, reflected, .i) Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide: (1) A safe, clean, comfortable, and homelike environment . i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Record review of the facility's policy, titled, Accidents and Hazards - Investigating and Reporting, revised July 2017, reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . 3. Facility is compliant with current rules and regulations governing accidents and/or incidents involving a medical device The facility's policy on accidents and hazards was requested on 06/22/2024 and a procedure guide was provided, titled, Accidents / Hazards, dated May 2016. The guide outlined the steps to be taken in the event of an accident and did not reflect the facility's role in preventing accidents or hazards. No other policy was received at the time of exit. Record review of the facility's, Safety Policy and Procedure Manual - safe patient handling and movement program, dated January 4, 2010, reflected, 3. Once the Care Plan has been developed, the Resident's Daily Care Guide should be updated to include instructions to staff on how to lift, transfer, reposition and move a Resident. 4. Staff will complete training initially, annually, and as needed for proper equipment use and understanding of safe Resident handling and movement using the Mechanical Lift Skills Competency Checklist. 8. Licensed Nurses, with the assistance of the director of Maintenance, shall ensure that mechanical lifting devices and other equipment/aids are maintained regularly and kept in proper working order. 3. Ensure that all staff is trained on Safe Patient Handling and Movement Practices. QUALITY ASSURANCE COMMITTEE and/or SAFETY COMMITTEE shall: 1. Implement this policy to identify, assess, and develop strategies to minimize risk of injury to Residents and direct-care staff associated with Resident lifting, transferring, repositioning, or movement. 2. Review and analyze the data gathered from the Resident Accident/Incident Reports and/or Employee Incident Reports related to the identification, assessment, and development of strategies to analyze and minimize risk of injury to Residents and direct-care staff associated with Resident lifting, transferring, repositioning, or movement. 3. At least annually, conduct an analysis of risk injury to Residents and direct-care staff posed by the Resident handling of needs of the population served by the Center and the physical environment in which handling, and movement occurs. Record review of the facility's policy, titled, Supplies and Equipment, Environmental Services, revised February 2009, reflected, .equipment shall be readily available so that department personnel can perform necessary tasks. Equipment must be ready for use at all times of the day and night to serve the residents' needs Record review https://opwdd.ny.gov/safty+guidlines+for+mechanical+lifts on 06/30/2024 reflected, Safe Mechanical Lift Operation: Before the initial and subsequent use of mechanical lift equipment, a safety check should be completed in accordance with the manufacturer's guidelines and/or agency protocol to ensure the equipment is in good working order. The number of staff required to perform a transfer is at the discretion of the practitioner who prescribed or recommended use of a mechanical lift device. However, it is always best practice to use mechanical lift equipment with a minimum of two staff. The Executive Director, and DON were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 06/21/2024 at 4:14 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 06/22/2024 at 10:14 AM and included: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: The resident sustained a left forehead laceration from the fall and was fully assessed and sent to the ER for further evaluation and treatment. The resident returned the same day, 06/20/2024, with sutures to the forehead, with no further injuries and returned back to their baseline. Immediate ins-services were started on the day of incidence, 06/20/2024, which included Abuse and Neglect and Mechanical Lift/ Transfer with 2 Person Assistance. All direct care staff remaining will be in-service by the DON and/or clinical designee prior to the start of their next shift until complete compliance is met. On 06/20/2024, the day and time of incidence, The C.N.A was interviewed and given a one-to-one in-service by her charge nurse prior to suspension, pending investigation. On the evening 06/20/2024 the questionable shower bed was taken out of rotation and usage and an audit of all other shower beds were examined for any deficits; none were found. The state was notified on 06/20/2024 (Intake #512683). The responsible party was notified immediately, as well as the attending physician. How the facility will identify other residents having the potential to be affected by the same deficient practice: Residents who require a two-person assistance with mechanical lifts were reviewed by the Director of Nursing (DON) on 06/21/2024 to determine if there were any other residents that experienced accidents as a result of this same practice. No other issues were found. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur: On 06/21/24, The DON and nurse mangers completed one-on-one education, in person, to Certified Nursing Assistants (CNA), licensed and registered nurses regarding requirement of two-person assistance with any mechanical lift. This was done to ensure understanding that all mechanical lifts and transfer require 2-person assistance. Abuse and neglect in-services were also continued; On 06/21/2024 the facility also added in-serving on Following Resident Care Plans. Direct care staff will be ongoing not in-serviced will be in-serviced prior to the start of their next shift until compliance is met, with a goal date of Monday June 24th,2024. Any employee that did not receive the education will be removed from the schedule until education is completed. All new nursing employees will be educated, during orientation and prior to taking an assignment the following in-services: 'Abuse and Neglect Prevention', 'Mechanical Lift Transfers with 2-Person Assistance' and 'Following the Residents Care Plan'. Residents that have a fall will be reviewed by the Nursing Administration and any deficiencies noted will be corrected by Unit Manager or designee and new interventions put in place as required. The staff involved will be provided with education or corrective action as necessary. Falls will be reviewed daily in the morning IDT Meeting and as they occur by nursing administration and the Licensed Administrator. The Maintenance Director has completed a safety audit of as of 06/21/2024, with no further findings and will complete safety checks audit all shower chairs shower beds and mechanical lifts on a weekly basis for maintenance and functionality. How the facility plans to monitor its performance to make sure that solutions are sustained: DON/designee will audit 5 falls a week beginning 06/24/24 to ensure interventions and Care Plans are completed weekly for four weeks then twice a month for two months and monthly for three months. The Nurse Managers will observe 5 direct care staff a week beginning 06/24/24, during care, of residents who require mechanical lifts, to ensure that staff are competent and knowledgeable of the 2- Person mandate and that they are following the individual residents Care Plan. This will be done for four weeks, and then 5 staff every two weeks for two months. The findings will be reviewed at the quarterly Quality Assurance/Performance Improvement (QAPI) meetings for 2 quarters. The Administrator is responsible for implementing the acceptable plan of correction. On 06/22/2024 at 12:00 PM the surveyor began monitoring the facility's Plan of Removal. In an interview on 06/22/2024 at 11:17 AM, with the Executive Director and DON, the DON stated, the Regional Director of Clinical Services in-serviced her and the Executive Director on the failures surrounding the IJ. She said those included abuse and neglect policy, mechanical lift processes, the care guide and how staff need to follow it, resident care plans, and ensuring all equipment was safe for use. She said she then in-serviced ADON B and RN C. She said they had been completing one-on-one in-servicing with staff since 06/21/2024. She stated staff were in-serviced in person and prior to starting their shift. The Executive Director said she estimated at least half their staff had completed in-services and this would be on-going until all staff had been in-serviced. She said her expectation was that the CNAs be trained, and the nurses trained to follow up to ensure everyone was following care plans and meeting resident's needs. She stated it was her expectation that staff followed the care guide and communicate care needs and any changes residents may have to ensure the facility staff meet resident's needs. All staff were expected to tell Administration about any issues - this was part of the abuse and neglect training. She stated staff were trained to report maintenance issues or issues with equipment to maintenance and record those issues in the logbook at the front desk. She said the DON or designee was responsible to monitor all of the plan of corrections put in place. She said the management team was responsible to assess all falls daily to identify issues related to resident care and safety. The DON said she planned to do random skills checkoffs for mechanical lift transfers and random checks to ensure aides were following resident care guides. She said this information would then be reviewed in QUPI and the Executive Director would follow up as needed. Interviews on 06/22/2024 between 12:00 PM and 2:53 PM with ADON B, RN C, Social Worker, Human Resources Director, Maintenance Director, Director of Business Development, CNAs E, F, G, H and I, Housekeepers J and K, and LVNs L, M, and N, represented staff who worked 1st, 2nd, 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice's including mechanical lift protocol, where to document maintenance or equipment issues, who to report equipment issues to, policies regarding identifying and reporting abuse or neglect, following care plans and where to find resident care plan information. All staff stated the DON and nurse managers would monitor these actions. Observation on 06/22/2024 at 1:40 PM revealed CNAs E and F performed a mechanical lift transfer for Resident #2. Resident #2 did not communicate verbally. Facial expressions from Resident #2 appeared positive in response to verbal ques from CNAs E and F during the transfer. An observation and interview on 06/22/2024 at 1:55 PM revealed CNAs G and H performed a mechanical lift transfer for Resident #3. Resident #3 stated he felt safe when the CNAs transf [TRUNCATED]