Every finding on record at Windsor Nursing and Rehabilitation Center of Edinb

Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate in accordance with accepted professional standards and practices for 1 of 3 residents (Resident #1) reviewed for accuracy. The facility failed to add a physician's order for a sling to Resident #1's left shoulder after she returned from the hospital on [DATE]. This failure could place residents at risk for errors in care. Finding included: Record review Resident #1's face sheet, dated 07/03/26, revealed an [AGE] year-old female, admitted on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels), Dementia (a decline in mental ability severe enough to interfere with daily life), history of falling, and impaired balance (a reduced ability to maintain stability and spatial orientation). Record review of Resident #1's care plan, dated 03/30/2026, reflected a focus area that Resident #1 had an actual fall on 6/17/2026 related to poor balance and confusion with a goal of the resident would resume usual activities without further incident through the review date. Interventions included review of past falls and attempt to determine cause of falls, xrays, neuro checks, wedges, and to send out to the emergency room. Record review of Resident #1's quarterly MDS assessment, dated 06/25/26, reflected a BIMS of 3, indicated cognition was severely impaired. Section B (hearing, speech and vision) stated Residents #1's ability to express ideas, needs and wants was sometimes understood. Section J (Health Conditions) revealed Resident #1 had a history of 2 falls with no injury (April and May 2026) and 1 fall with major injury (June 2026 at 5:30am) The MDS section J did not reflect the fall that CNA C, D, E stated occurred on 06/17/26 at around 12:30am with no injury. During an observation and interview on 07/01/2026 at 12:30 p.m., Resident #1 was on her bed. Resident #1 said that she did not fall and that she did not have pain. Resident #1 had fall interventions in place as reflected on her care plan, to include bed wedges, bed to lowest position, floor mats on both sides, room was free of clutter, the room was well lit, resident did not have any visible injuries noted, and call light within reach. Record of Resident #1's nursing notes dated 06/17/26 at 6:26 a.m. created by LVN B reflected At approximately 0530, CNAs notified SN that resident was found on the floor at bedside, upon entering room resident noted to be in supine position on the floor next to roommates' bed. Residents bed was at the lowest position. Head to toe assessment complete, noted with skin tears to left elbow and minor swelling to left shoulder. Resident safely transferred to bed x 2 staff assist, while attempting to provide wound care resident pulled away and c/o pain to left arm. Wound cleansed gently, gauze applied and secured with tape. Neuro checks initiated, bed lowered at lowest position, call light left within reach. PRN pain medication administered. ADON, NP and RP notified. Oncoming nurse made aware. Record of Resident #1's imaging report dated 06/17/26 reflected impression: acute fracture to the left humeral head/neck. Record review of Resident #1's discharge hospital records dated 06/17/26 stated Resident discharged with sling to left arm Record review of Resident#1's care plan did not include any verbiage related to Resident #1's arm sling or non-compliance with arm sling. Record review of Resident #1's nurse progress notes, 06/17/26 at 10:35 p.m., created by LVN G, reflected, Resident returned from ER via EMS with no additional orders. Resident has bruising to left shoulder, skin tear to left elbow, right forearm was bandaged from IV insertion, no other skin issues noted, sling to left arm was not applied upon arrival, EMS stated that Resident #1 took off the sling during transport, nurse reapplied. Arrival vital signs T97.7, O2 at 98% on RA, HR 95, BP 167/83, resident had complained of pain on face scale of 3 when nurse reapplied sling but denied pain medication. During an interview on 7/3/26 at 12:35 p.m., MDS RN stated all nurses were responsible for inputting new orders in the resident's electronic medical chart. MDS RN stated he was not aware of the order for the sling to left arm. MDS RN stated that he was responsible for updating Resident #1's care plan. MDS RN stated that he did not see the order on Resident #1's electronic medical chart and was not aware Resident #1 returned from hospital with a sling. MDS RN stated the negative outcome was that the facility did not carry over the correct orders from Resident #1 discharge the hospital on [DATE]. The MDS RN stated he goes by the orders that the nurse put in and did not review the discharge paperwork. The MDS RN stated because the nurse did not input the order for Resident #1's sling he missed it. During an attempted telephone interview on 07/02/2026 at 10:54 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/02/2026 at 02:05 p.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/03/2026 at 10:15 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an interview on 07/03/26 at 04:27 p.m., the DON said Resident #1 had some history of falls and tried to get out of bed without assistance. (Resident #1's care plan included risk of falls due to self transfer) The DON said that nurses were responsible for updating the care plan. The DON said Resident #1 had dementia and that was a disease process not a behavioral issue. The DON said there was not a negative outcome from her not using the sling. The DON said that Resident #1 did not want to use the sling. The DON stated that the sling was supposed to be care planned and stated orders should have been put in place for use of the sling. Record review of the facility's policy titled, Documentation in Medical Record, with implemented date 10/24/2022, reflected, each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 (B hall cart) of 4 medication carts reviewed for storage. The facility failed to ensure that the nurses medication cart for B hall was secured by a lock when it was left unattended by RN A. This failure could place residents at risk of injury if medication left unsecured were consumed. Findings included: During an observation on 7/1/26 at 2:48 p.m., revealed the B Wing Hall nurse's medication cart was left unlocked and unattended against the nurse's station. During the observation RN A was in the nurses' station and left the medication cart unlocked and with the keys attached to the lock. During an interview on 7/1/26 at 2:48 p.m., RN A revealed he was responsible for the nurse's medication cart that was left unlocked. He stated he was expected to lock the nurse's medication cart when he walked away from it. He stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. He stated he had left the cart unlocked because he just went to show a coworker something. During an interview on 7/3/26 at 4:27 p.m., with the DON revealed numerous staff, including her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walk away from the medication cart was to lock it. DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. She stated she had provided in-services to the staff. Record review of facility's policy Medication Administration with a revised date 10/01/2019 revealed The facility maintains equipment and supplies necessary for the preparation and administration of medications of residents. The mobile medication cart will be used to facilitate administration of medications to residents. the purpose of the mobile medication system is to insure appropriate control and surveillance of resident assigned medications. 2. The medication cart is locked at all times when not in use.

Based on interview and record review and observation, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for change in condition. The facility failed to notify Residentnotify Resident #1's MD when she fell on 6/17/26 at around 12:00am. Resident #1 did not sustain any injury due to fall. This failure could place residents at risk of not receiving the appropriate care and services to maintain their health and safety. Finding included: Record review Resident #1's face sheet, dated 07/03/26, revealed an [AGE] year-old female, admitted [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels), Dementia (a decline in mental ability severe enough to interfere with daily life), history of falling, and impaired balance (a reduced ability to maintain stability and spatial orientation) . Record review of Resident #1's quarterly MDS assessment, dated 06/25/26, reflected a BIMS of 3, indicated cognition was severely impaired. Section B (hearing, speech and vision) stated Residents #1's ability to express ideas, needs and wants was sometimes understood. Section J (Health Conditions) revealed Resident #1 had a history of 2 falls with no injury (April and May 2026) and 1 fall with major injury (June 2026 at 5:30am) The MDS section J did not reflect the fall that CNA C, D, E stated occurred on 06/17/26 at around 12:30am with no injury. Record review of Resident #1's care plan, dated 03/30/2026, reflected a focus area that Resident #1 had a risk for falls related to impaired balance, confusion, and self-transfers. Goal: the resident will be free of falls through the review date. Interventions: review on past falls and attempt to determine cause of falls. Record review of Resident #1's nursing notes from 06/16/26 to 06/17/26 did not reflect documentation of a fall at around 12:00am as stated by CNA C, D and E. Record review of incident/accident log list from the facility did not reflect Resident #1 having a fall on 06/17/26 around 12:00am. Record review of Resident #1's assessment list did not reflect documentation of any post fall assessment on 06/17/26 at around midnight., Record review of Resident #1's electronic medical record did not reflect any documentation or notifications made regarding a fall on 06/17/26 at around midnight. During an observation and interview on 07/01/2026 at 12:30 p.m., Resident #1 was on her bed. Resident #1 said that she did not fall and that she did not have pain. Resident #1 had fall interventions in place as reflected on her care plan, to include bed wedges, bed to lowest position, floor mats on both sides, room was free of clutter, the room was well lit, resident did not have any visible injuries noted, and call light within reach. During an interview on 07/02/2026 at 1:30 p.m., the NP stated she was notified of Resident #1's fall that happened on 06/17/2026 at 5:30 a.m which resulted in fracture to shoulder. NP stated that she was not aware that Resident #1 had a previous fall earlier that night on 06/17/26. During an interview on 07/03/26 at 09:30 a.m., CNA C stated that she worked the night when Resident #1 had an unwitnessed fall on 06/17/2026 approximately at midnight. CNA C stated that CNA D found her on the floor mat next to the bed. CNA C stated that CNA D called for help and that she went to notify the nurse. CNA C stated that after the nurse assessed Resident #1 she was told to put Resident #1 back to bed. CNA C stated Resident #1 did not have any injury after her fall at 12:00am and did not express any pain. CNA C stated that Resident #1 had 2 falls the same night, with the first one occurring at around 12:00am and stated that both falls were reported to LVN B. CNA C stated that Resident #1 had her fall interventions in place at time of this fall. CNA C stated Resident #1 had a wet brief when she was found and stated she was last rounded at around 10:00pm and was dry at that time. During a phone interview on 7/3/26 at 9:47 a.m., CNA D stated that she worked with Resident #1 when she had an unwitnessed fall l after midnight on 06/17/2026. CNA D stated she found Resident #1 on the floor mat next to her bed. CNA D stated Resident #1 fell two times during the night, with her first fall occurring around or after 12:00am. CNA D stated that she called the nurse for help and LVN B assessed Resident #1 and, after the assessment, Resident #1 was put back to bed as per care plan stated. CNA D stated the nurses assessment did not identify any injury or pain to Resident #1. CNA D stated that Resident #1 had her fall interventions in place at time of this fall. During an interview on 07/03/2026 at 02:13 p.m., CNA E stated that she worked the night when Resident #1 fell twice during the night. CNA E stated that on the first fall at around 12:00am Resident #1 had an unwitnessed fall and was found next to her bed by CNA D. CNA E stated that she heard that Resident #1 fell around 12:00 a.m. on 6/17/2026 the first time and she went into the room to help with transferring Resident #1 back to bed. The second fall happened around 05:00 a.m. CNA E stated that LVN B was notified on both falls, and Resident #1 was assessed both times by LVN B. CNA E stated after Resident #1's first fall around 12:00am LVN B's assessment of Resident#1 after her fall found no injury or pain present. CNA E stated that Resident #1 had her fall interventions in place at time of this fall. During an attempted telephone interview on 07/02/2026 at 10:54 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/02/2026 at 02:05 p.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/03/2026 at 10:15 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an interview on 07/03/2026 at 04:27 p.m., the DON said it was the responsibility of the charge nurse to notify the physician about the fall. The DON said she expected the nurse to notify the physician when the incident happened or as soon as the resident was stable. The DON said she was not aware LVN B had not notified Resident #1's physician of her first fall occurred on 06/17/26 at around 12:00am The DON stated she was not aware Resident #1 fell twice on 06/17/2026. The DON said that she was aware of the fall on 6/17/2026 at 5:30 a.m and stated the provider was notified and an order for imaging was given and carried out. The DON stated she was not aware of the fall that occurred previously at around 12:00am. She said she expected the charge nurse to fill out the incident reports accurately. The DON stated that all falls had to be reported to the physician. The DON stated LVN B was out and not able to be reached. Record review of facility's policy titled, Notification of Changes, with an implemented date 10/24/2022 reflected: the purpose of this policy is to ensure the facility promptly informs the resident consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #1's order and non compliance with use with a sling to left arm due to an acute fracture to left humerus head/neck after a fall on 06/17/26 at 05:30 a.m. This failure could place residents at risk for their needs not being met. Finding included: Record review Resident #1's face sheet, dated 07/03/26, revealed an [AGE] year-old female, admitted on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels), Dementia (a decline in mental ability severe enough to interfere with daily life), history of falling, and impaired balance (a reduced ability to maintain stability and spatial orientation). Record review of Resident #1's care plan, dated 03/30/2026, reflected a focus area that Resident #1 had an actual fall on 6/17/2026 related to poor balance and confusion with a goal of the resident would resume usual activities without further incident through the review date. Interventions included review of past falls and attempt to determine cause of falls, xrays, neuro checks, wedges, and to send out to the emergency room. Record review of Resident #1's quarterly MDS assessment, dated 06/25/26, reflected a BIMS of 3, indicated cognition was severely impaired. Section B (hearing, speech and vision) stated Residents #1's ability to express ideas, needs and wants was sometimes understood. Section J (Health Conditions) revealed Resident #1 had a history of 2 falls with no injury (April and May 2026) and 1 fall with major injury (June 2026 at 5:30am) The MDS section J did not reflect the fall that CNA C, D, E stated occurred on 06/17/26 at around 12:30am with no injury. During an observation and interview on 07/01/2026 at 12:30 p.m., Resident #1 was on her bed. Resident #1 said that she did not fall and that she did not have pain. Resident #1 had fall interventions in place as reflected on her care plan, to include bed wedges, bed to lowest position, floor mats on both sides, room was free of clutter, the room was well lit, resident did not have any visible injuries noted, and call light within reach. Record of Resident #1's nursing notes dated 06/17/26 at 6:26 a.m. created by LVN B reflected At approximately 0530, CNAs notified SN that resident was found on the floor at bedside, upon entering room resident noted to be in supine position on the floor next to roommates' bed. Residents bed was at the lowest position. Head to toe assessment complete, noted with skin tears to left elbow and minor swelling to left shoulder. Resident safely transferred to bed x 2 staff assist, while attempting to provide wound care resident pulled away and c/o pain to left arm. Wound cleansed gently, gauze applied and secured with tape. Neuro checks initiated, bed lowered at lowest position, call light left within reach. PRN pain medication administered. ADON, NP and RP notified. Oncoming nurse made aware. Record of Resident #1's imaging report dated 06/17/26 reflected impression: acute fracture to the left humeral head/neck. Record review of Resident #1's discharge hospital records dated 06/17/26 stated Resident discharged with sling to left arm Record review of Resident#1's care plan did not include any verbiage related to Resident #1's arm sling or non-compliance with arm sling. Record review of Resident #1's nurse progress notes, 06/17/26 at 10:35 p.m., created by LVN G, reflected, Resident returned from ER via EMS with no additional orders. Resident has bruising to left shoulder, skin tear to left elbow, right forearm was bandaged from IV insertion, no other skin issues noted, sling to left arm was not applied upon arrival, EMS stated that Resident #1 took off the sling during transport, nurse reapplied. Arrival vital signs T97.7, O2 at 98% on RA, HR 95, BP 167/83, resident had complained of pain on face scale of 3 when nurse reapplied sling but denied pain medication. During an interview on 07/02/2026 at 11:11 a.m., LVN F stated he was notified during report at the beginning of his day shift on 06/17/26 from 6:00 a.m. to 2:00 p.m. that Resident #1 fell. LVN F stated he went to assess Resident #1 with the DON. LVN F stated the DON contacted the NP and got orders for x-rays. LVN F stated that after his shift, Resident #1 was sent out to the hospital for further evaluation. LVN F stated that the nurse (LVN B) that received Resident #1 when she returned from the hospital and was responsible for entering the new orders and updating the care plan. LVN F stated Resident #1's sling had to be care planned and added as an order. During an interview on 07/02/2026 at 1:30 p.m., the NP stated she was notified of Resident #1's fall that happened on 06/17/2026 at 5:30 a.m. The NP stated she called the DON and gave orders for x-rays of her left shoulder. The NP stated she was notified of the Xray results and said she gave an order for Resident #1 to be sent to the hospital for further evaluation. During an interview on 7/3/26 at 12:35 p.m., MDS RN stated all nurses were responsible for inputting new orders in the resident's electronic medical chart. MDS RN stated he was not aware of the order for the sling to left arm. MDS RN stated that he was responsible for updating Resident #1's care plan. MDS RN stated that he did not see the order on Resident #1's electronic medical chart and was not aware Resident #1 returned from hospital with a sling. MDS RN stated the negative outcome was that the facility did not carry over the correct orders from Resident #1 discharge the hospital on [DATE]. The MDS RN stated he goes by the orders that the nurse put in and did not review the discharge paperwork. The MDS RN stated because the nurse did not input the order for Resident #1's sling he missed it. During an attempted telephone interview on 07/02/2026 at 10:54 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/02/2026 at 02:05 p.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an attempted telephone interview on 07/03/2026 at 10:15 a.m., LVN B was called unsuccessfully. Voice message was left requesting a call back from LVN B. During an interview on 07/03/26 at 04:27 p.m., the DON said Resident #1 had some history of falls and tried to get out of bed without assistance. (Resident #1's care plan included risk of falls due to self transfer) The DON said that nurses were responsible for updating the care plan. The DON said Resident #1 had dementia and that was a disease process not a behavioral issue. The DON said there was not a negative outcome from her not using the sling. The DON said that Resident #1 did not want to use the sling. The DON stated that the sling was supposed to be care planned and stated orders should have been put in place for use of the sling. Record review of the facility's policy titled, Care Plan Revisions Upon Status Change, implemented date 10/24/2022, revealed: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The care plan will be updated with the new or modified interventions.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed on 08/26/2025 to ensure foods were properly labeled and dated.2. The facility failed on 08/26/2025 to ensure the cook's hands were washed and gloves were worn during food preparation. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the kitchen counter on 08/26/25 at 8:27 AM revealed the following: 2 jars of spices were not labeled or dated 1 jar of spice with the date was smeared off A metal container with individually wrapped rolls was not labeled or dated A tray of covered juice cups was not labeled or dated Observation of the walk-in refrigerator on 08/26/25 at 8:30 AM revealed the following: 1 bag of cabbages was not labeled or dated In an observation and interview on 08/26/25 at 8:34 AM, the cook was observed filling plastic cups with fruit cocktail and covering them with cellophane wrap. The cook was noted not to be wearing gloves while preparing the food. The cook stated he had gone to his vehicle to get his name tag but forgot to wash his hands and put on gloves prior to preparing food. The cook stated it was important to wash his hands and wear gloves while preparing meals because it could have contaminated the food and made residents sick. The cook stated that he simply forgot but that he has always washes his hands or worn gloves before meal preparation. Observation of the walk-in freezer on 08/26/25 at 8:40 AM revealed the following: 2 bags of hotdog buns - not labeled or dated In an interview on 08/26/25 at 8:47 AM, the DM stated that all staff were responsible for ensuring items were stored, labeled and dated. The DM stated every item opened should have an open date in the refrigerator, freezer, and dry storage. The DM stated if food items were not properly labeled and dated, staff may be unaware of when the items were opened, increasing the risk of food spoilage and potential illness for residents. The DM stated dates should have been legible to read to make it easy for staff to discard when needed. The DM stated if food items were not properly labeled or stored, it would have increased the risk of food getting spoiled or it would cause potential illness for the residents. The DM stated the consequences for staff having not washed their hands or wearing gloves would be cross contamination, food borne illnesses and could make residents sick. Record review of the Food Storage Policy dated 06/01/19 revealed the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Dry storage room d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of the Employee Sanitation Policy dated 10/01/18 revealed the following: Policy: The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to maximize the risk of infection and food borne illnesses. Hand Washing Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks After engaging in other activities that contaminate the hands. Use of Gloves Use single use gloves for one task Change gloves: Between each food preparation task. ii. After touching items, utensils or equipment not related to task. iv. When leaving food preparation area for any reason.

Based on record review and interview, the facility failed to maintain medical records on each resident that are accurately documented for 3 of 5 residents (Resident #51 and Resident # 34 and Resident # 10) reviewed for medical records. 1. Facility failed on 8/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident # 34. 2. Facility failed on 08/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident #10. On 09/08/25, record review of August's order summary revealed resident obtained an order for IV hydration, thus revealing resident already had an IV lock in place. No orders were found to indicate the date, time and location the IV lock was initially placed. No orders were found to indicate maintenance on IV lock such as flushes or IV lock replacements. On 09/08/25, observation noted that resident #10 still had an IV lock in place with still no orders for IV access and IV maintenance for IV site. 3. Facility failed on 08/26/2025 to ensure physician orders were written for Contact Precautions for Resident #51for scabies. These failures could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.Findings included: 3) Record review of Resident #51's face sheet dated 08/26/2025 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included Prophylactic for Scabies (treating close contacts of an infested person with the same medications used for treatment, such as permethrin cream or oral ivermectin, along with environmental cleaning and sometimes isolation to prevent the spread of the mites), type 2 diabetes (uncontrolled blood sugar), need for assistance with personal care. Record review of Resident #51 quarterly MDS assessment dated [DATE] reflected Resident #51 had a BIMS of 2, indicating resident was severe cognitive impaired. Review of Resident #51 MAR on 08/26/2025 reflected the following order: Permethrin External Cream 5 % (Permethrin) Apply to Entire Body topically one time a day for Prophylactic Scabies for 1 Administrations Apply from neck down to feet, leave for 12 hours then shower. Review of Resident# 51 order summary on 08/26/2025 did not reflect Contact Precautions for Scabies. During an observation on 08/26/2025 at 10:26 AM of room [ROOM NUMBER]A Contact Precaution sign was at door, personal protective equipment was outside the room in a cart. During an interview on 8/26/25 at 12:30 pm, LVN N said that the resident was on contact precautions for prophylactic for scabies. LVN N said that it was important to have the order in the point click center for staff to be aware of the Resident #51's diagnosis. LVN N said that it was important to use personal protective equipment to prevent the spread of infection. During an interview on 08/28/2025 at 03:50 pm, DON stated that she was not able to find the order for the contact precautions. DON said Resident #51 was not harmed because she did not have the order in the point click center. DON said there was not a negative outcome. On 08/28/2025 facility was asked for their policy for Physician Orders, no policy was provided prior to exit. 1) Record review of Resident # 34 admission record dated 12/06/2024 revealed an [AGE] year-old male that was readmitted to the facility on [DATE]. His diagnosis includes Malignant Neoplasm of Bladder (bladder cancer), Secondary Malignant Neoplasm of Liver and Intrahepatic Duct (liver cancer), Displacement of Nephrostomy Catheter (tube that acts as a temporary detour for urine, allowing urine to drain directly from the kidney into a bag outside the body). Record review of Resident # 34's MDS assessment dated [DATE] revealed a BIMS Score of 12 which is moderate cognitive impairment. Record review of Resident # 34's order summary on 8/20/2025 revealed an order for Aztreonam in Dextrose Solution 1 GM/50 ML Use 1 GM intravenously every 8 hours for bacterial infection. The order summary did not reflect an order for IV access. The order summary did not reflect an order for IV maintenance (IV flush and dressing change). Interview on 8/28/2025 at 9:14 a.m. LVN F that she has been flushing the IV with 10 cc of normal saline before and after medication. She said she had redressed the IV site on 8/24/2025. LVN F said she knows from previous orders to flush with 10 cc of normal saline. LVN F looked at the order summary and did not find an order for an IV access, no order for IV flush, and no order for dressing change. She said that if the IV site was not cleaned and dressing changed that the resident could be at risk for infection to IV site. LVN F said that if the IV access was not flushed it could put the resident at risk for infiltration and patency. She explained the process of receiving physician orders for IV antibiotic and placement. She said she would input the order, check for allergies, inform the resident and family of new orders and clarify IV management with physician such as flush, dressing change and IV catheter size. Interview on 8/28/2025 at 4:48 p.m. RN/ADON B said that standing orders for peripheral IVs and PICC (peripherally inserted central catheter) lines (thin flexible tube inserted in the upper arm that is threaded into a large central vein) populate automatically in the system when an IV antibiotic is ordered. He said the system is finicky at times and the order for the flush and maintenance needs to be manually input. RN/DON B said that training on physician orders and computer systems was done upon hire and as needed. He said new orders and medical records are managed by him and he follows up with the nurses. Interview on 8/28/2025 at 5:13 p.m. DON said physician orders are given for antibiotic regimen and that nurses need an order for IV flush and dressing. She said most physicians order IV site dressing to be changed every 72 hours or as needed but there was no written record (policy) available. Interview on 8/28/2025 at 5:27 p.m. Administrator said that clinical meetings are held every morning, and she takes part in the meeting. She described a start-up which takes place in the AM and there was a review of all changes, then a stand down that takes place in the afternoon. During this time there is a follow-up regarding all pending items from the morning clinical meeting and address clinical issues. Record review of nursing progress notes dated 8/13/2025-8/26/205. First entry addressing IV site is on 8/21/2025 at 8:33 a.m. Aztreonam in Dextrose Solution 1 GM/50 ML Use 1 GM intravenously every 8 hours for bacterial infection for 9 days Intact, patent, dry. Second entry addressing IV site is a Nursing Progress noted dated 8/23/24 at 11:44 p.m. Aztreonam 1 gm/50ml IV every 8 hours for bacterial infection. PIV to left forearm, flushing well, good patency. No redness, or infiltration noted to site. Dressing clean, dry and intact. 2.) Observation on 08/26/25 at 8:53 a.m. revealed Resident #10 was in her room lying in bed. She had a peripheral intravenous lock (a device that is flushed and locked with saline solution when not in use) covered with a transparent dressing on her left hand. There were no signs or symptoms of infection or infiltration (when fluid leaks out of the vein into surrounding soft tissue) noted at the IV site. Record review of Resident #10's admission record dated 06/04/25 revealed an [AGE] year-old female with diagnosis of Colle's' fracture of right radius (type of wrist fracture that occurs when the distal radius ((the lower end of the radius bone in the forearm)) breaks and bends backward), other fractures of lower end of right radius, unspecified protein-calorie malnutrition, major depressive disorder, and dysphagia (difficulty swallowing food or liquids). Record review of Resident #10's quarterly MDS assessment revealed resident #10's BIMS score was a 2 which indicates severe cognitively impaired. Section O - Special Treatments, Procedures, and Programs revealed Resident #10 was receiving IV medications. Record review of Resident #10's Order Summary Report dated August 2025 revealed Resident #10 had an order for Dextrose Intravenous Solution 5 % (Dextrose) Use 80 ml/hr. intravenously every shift for IV hydration for 2 Days with 2 Liters in total, start date 08/20/25 and end date 08/22/25. Record review of Resident #10's Order Summary Report dated August 2025 lacked evidence of orders for IV insertion, IV dressing changes, and IV flushes. In an interview on 08/26/25 at 9:35 a.m. LVN N stated he was the nurse for Resident #10. LVN N stated that when a nurse received doctor's orders for a resident, it was the responsibility of the nurse to also obtain IV site care or maintenance orders. Such orders included how often to replace or flush the IV catheter. LVN N stated that a negative outcome for not receiving and following through with such orders could cause the IV catheter to become clogged and cause infiltration. He also stated if the IV line was to become clogged, it could cause infection to the IV site. LVN N stated he could not recall when the last IV training was. In an interview on 08/27/25 at 9:25 a.m., the DON stated she did not know why there were no orders in place for IV site care. The DON stated that the nurse that had received the order for IV hydration should have also followed through with orders for IV site care and maintenance. The DON searched through orders on the facility's computer system to verify who had received the IV hydration order. Once the DON verified which nurse received the order, she continued to look for the IV site care orders. The DON admitted there were no other orders pertaining to the IV care and stated, I'm not going to lie and say there is an order. If the order is not in the system, then the order is not there. The DON stated that the negative outcome of not having orders for IV flushes or for changing out the IV catheter could have resulted in infection to the IV site or the IV site having had a blockage. She stated that IV administration class was done annually and as needed. Record review of the facility's Physician Visits and Physician Delegation Policy date implemented 10/24/22 revealed: Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Policy Explanation and Compliance Guidelines: The Licensed Nurse should: g. When possible, review the medical record for completeness, prior to the physician leaving the facility j. Execute a verbal order with the attending physician for approval of any orders for care The Physician should: g. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

Based on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 2 of 2 residents reviewed for intravenous fluids. (Resident #10 and #34) 1) The facility failed on 8/26/2025 to ensure the dressing on Resident # 34's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed. 2) The facility failed on 08/26/2025 to ensure the dressing on Resident #10's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications [IV]) was dated and initialed. Dressing on Resident's hand revealed a clear dressing over IV line site with no date of insertion and no initials indicating which nurse had inserted IV line.This failure could place residents at risk of not receiving the appropriate IV care and services. 1) Record review of Resident # 34's face sheet dated 12/06/2024 revealed an [AGE] year-old male with a diagnosis of Malignant Neoplasm of Bladder (bladder cancer), Secondary Malignant Neoplasm of Liver and Intrahepatic Duct (liver cancer), Displacement of Nephrostomy Catheter (tube that acts as a temporary detour for urine, allowing urine to drain directly from the kidney into a bag outside the body) Record review of Resident # 34's person-centered care plan, initiated date on 8/20/2025 revealed he was on IV (intravenous) antibiotic therapy related to Sepsis (condition in which the body responds improperly to an infection). Record review of Resident # 34's MDS assessment dated [DATE] revealed a BIMS score of 12 which is moderate cognitive impairment. Observation on 8/26/2025 at 2:09 p.m. Resident # 34's IV access to left forearm covered with a clear dressing was not labeled and tape coming off the sides. Dried blood noted under the clear dressing. Observation on 8/27/2025 at 5:45 p.m. Resident # 34's IV site unlabeled, tape adhesive coming off and dried blood seen under clear dressing. Interview on 8/27/2025 at 5:50 p.m. Licensed Vocation Nurse (LVN) E said Resident # 34 returned from the hospital two to three days ago with the IV access and that the dressing will be changed tonight. Interview on 8/28/2025 at 9:14 a.m. LVN F said that a physician's order was received on 8/20/25 for IV antibiotic to be administered every eight hours for nine days and that she redressed the dressing on 8/24/25. She said that if IV site is not cleaned there can be a risk of infection to the area. LVN F said she had a training on PPE and infection control this past week. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Isolation Protocol (Transmission-Based Precautions): A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. 2) Record review of Resident #10's admission record dated 06/04/25 revealed an [AGE] year-old female with diagnosis of Colle's' fracture of right radius (type of wrist fracture that occurs when the distal radius ((the lower end of the radius bone in the forearm)) breaks and bends backward), other fractures of lower end of right radius, unspecified protein-calorie malnutrition, major depressive disorder, and dysphagia (difficulty swallowing food or liquids). Record review of Resident #10's quarterly MDS assessment revealed resident #10's BIMS score was a 2 which indicates severe cognitively impaired. Section O - Special Treatments, Procedures, and Programs revealed Resident #10 was receiving IV medications. Record review of Resident #10's Order Summary Report dated August 2025 revealed Resident #10 had an order for Dextrose Intravenous Solution 5 % (Dextrose) Use 80 ml/hr intravenously every shift for IV hydration for 2 Days with 2 Liters in total, start date 08/20/25. Observation on 08/26/25 at 8:53 a.m. revealed Resident #10 was in her room lying in bed. She had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on her left hand. There were no signs or symptoms of infection or infiltration noted at the IV site. In an interview on 08/26/25 at 9:35 a.m. LVN N stated he was the nurse for Resident #10. He stated that the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN N stated that it was important to label the IV site to know when the IV was placed or the last time it was changed. He stated that if the IV was not changed within the ordered time, then it could cause an infection. He stated that the last time he had checked the resident's IV site was this morning, at the beginning of his shift. LVN N stated that the IV site should be checked at every shift. The site was to be checked for any signs of infection, the date and signature on the dressing, and check that the saline lock cap was in place. He stated he could not recall when the last training was he had received on IV administration. LVN N confirmed the resident had a peripheral IV lock on her left hand covered with a transparent dressing that was not labeled or dated. In an interview on 08/27/25 at 9:25 a.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated that the nurse that had inserted the IV should have dated and initialed the dressing that was over the IV site. The DON searched through orders on their computer system to verify who had placed the IV, however, she was not able to find the progress note indicating placement. The DON stated that labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated that the negative outcome of not labeling the dressing was that it could go over the recommended standard time of every 72 hours and could cause infection. She stated that IV administration class was done annually and as needed. Record review of the facility's Infection Prevention and Control Program Policy date implemented 05/13/23 revealed: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. Transmission-Based PrecautionsTransmission-based precautions are used when patients already have confirmed or suspected infections

Based on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 3 of 5 residents (Resident #51 and Resident # 34 and Resident # 10) reviewed for resident record 1. Facility failed on 8/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident # 34.2. Facility failed on 08/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident #10. On 09/08/25, record review of August's order summary revealed resident obtained an order for IV hydration, thus revealing resident already had an IV lock in place. No orders were found to indicate the date, time and location the IV lock was initially placed. No orders were found to indicate maintenance on IV lock such as flushes or IV lock replacements. On 09/08/25, observation noted that resident #10 still had an IV lock in place with still no orders for IV access and IV maintenance for IV site. 3. Facility failed on 08/26/2025 to ensure physician orders were written for Contact Precautions for Resident #51for scabies. These failures could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.Findings included: 3) Record review of Resident #51's face sheet dated 08/26/2025 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included Prophylactic for Scabies (treating close contacts of an infested person with the same medications used for treatment, such as permethrin cream or oral ivermectin, along with environmental cleaning and sometimes isolation to prevent the spread of the mites), type 2 diabetes (uncontrolled blood sugar), need for assistance with personal care. Record review of Resident #51 quarterly MDS assessment dated [DATE] reflected Resident #51 had a BIMS of 2, indicating resident was severe cognitive impaired. Review of Resident #51 MAR on 08/26/2025 reflected the following order: Permethrin External Cream 5 % (Permethrin) Apply to Entire Body topically one time a day for Prophylactic Scabies for 1 Administrations Apply from neck down to feet, leave for 12 hours then shower. Review of Resident# 51 order summary on 08/26/2025 did not reflect Contact Precautions for Scabies. During an observation on 08/26/2025 at 10:26 AM of room [ROOM NUMBER]A Contact Precaution sign was at door, personal protective equipment was outside the room in a cart. During an interview on 8/26/25 at 12:30 pm, LVN N said that the resident was on contact precautions for prophylactic for scabies. LVN N said that it was important to have the order in the point click center for staff to be aware of the Resident #51's diagnosis. LVN N said that it was important to use personal protective equipment to prevent the spread of infection. During an interview on 08/28/2025 at 03:50 pm, DON stated that she was not able to find the order for the contact precautions. DON said Resident #51 was not harmed because she did not have the order in the point click center. DON said there was not a negative outcome. On 08/28/2025 facility was asked for their policy for Physician Orders, no policy was provided prior to exit. Findings included: 1) Record review of Resident # 34 admission record dated 12/06/2024 revealed an [AGE] year-old male that was readmitted to the facility on [DATE]. His diagnosis includes Malignant Neoplasm of Bladder (bladder cancer), Secondary Malignant Neoplasm of Liver and Intrahepatic Duct (liver cancer), Displacement of Nephrostomy Catheter (tube that acts as a temporary detour for urine, allowing urine to drain directly from the kidney into a bag outside the body). Record review of Resident # 34's MDS assessment dated [DATE] revealed a BIMS Score of 12 which is moderate cognitive impairment. Record review of Resident # 34's order summary on 8/20/2025 revealed an order for Aztreonam in Dextrose Solution 1 GM/50 ML Use 1 GM intravenously every 8 hours for bacterial infection. The order summary did not reflect an order for IV access. The order summary did not reflect an order for IV maintenance (IV flush and dressing change). Interview on 8/28/2025 at 9:14 a.m. LVN F that she has been flushing the IV with 10 cc of normal saline before and after medication. She said she had redressed the IV site on 8/24/2025. LVN F said she knows from previous orders to flush with 10 cc of normal saline. LVN F looked at the order summary and did not find an order for an IV access, no order for IV flush, and no order for dressing change. She said that if the IV site was not cleaned and dressing changed that the resident could be at risk for infection to IV site. LVN F said that if the IV access was not flushed it could put the resident at risk for infiltration and patency. She explained the process of receiving physician orders for IV antibiotic and placement. She said she would input the order, check for allergies, inform the resident and family of new orders and clarify IV management with physician such as flush, dressing change and IV catheter size. Interview on 8/28/2025 at 4:48 p.m. RN/ADON B said that standing orders for peripheral IVs and PICC (peripherally inserted central catheter) lines (thin flexible tube inserted in the upper arm that is threaded into a large central vein) populate automatically in the system when an IV antibiotic is ordered. He said the system is finicky at times and the order for the flush and maintenance needs to be manually input. RN/DON B said that training on physician orders and computer systems was done upon hire and as needed. He said new orders and medical records are managed by him and he follows up with the nurses. Interview on 8/28/2025 at 5:13 p.m. DON said physician orders are given for antibiotic regimen and that nurses need an order for IV flush and dressing. She said most physicians order IV site dressing to be changed every 72 hours or as needed but there was no written record (policy) available. Interview on 8/28/2025 at 5:27 p.m. Administrator said that clinical meetings are held every morning, and she takes part in the meeting. She described a start-up which takes place in the AM and there was [BH1] a review of all changes, then a stand down that takes place in the afternoon. During this time there is a follow-up regarding all pending items from the morning clinical meeting and address clinical issues. Record review of nursing progress notes dated 8/13/2025-8/26/205. First entry addressing IV site is on 8/21/2025 at 8:33 a.m. Aztreonam in Dextrose Solution 1 GM/50 ML Use 1 GM intravenously every 8 hours for bacterial infection for 9 days Intact, patent, dry. Second entry addressing IV site is a Nursing Progress noted dated 8/23/24 at 11:44 p.m. Aztreonam 1 gm/50ml IV every 8 hours for bacterial infection. PIV[BH2] to left forearm, flushing well, good patency. No redness, or infiltration noted to site. Dressing clean, dry and intact. [BH1]Tags should be written in past tense, Please correct throughout the document. [BH2]Define all abbreviations throughout the document.

Based on observation, interview and record review, the facility failed to maintain an infection 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 3 (Resident #3, Resident #11, Resident #12) of 5 residents reviewed for infection control practices, in that: 1) The facility failed on 8/26/205 to ensure maintenance A, ADON/RN B, Houskeeper C did not don (put on) PPE before entering Resident #11, Resident #3, Resident #12 room. Residents were under contact precautions as per physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases. The findings included: 1) Record review of Resident #11's face sheet dated 07/24/24 revealed an [AGE] year-old male admitted to the facility on [DATE], with the diagnosis of Dementia (brain disorder that causes a gradual decline in cognitive abilities), Gastro-Esophageal Reflux Disease (Condition where stomach acid flows back into the esophagus, causing symptoms of heartburn), Hypertension (high blood pressure), Muscle Wasting and Atrophy. Review of Resident #11 Physician Orders dated 8/24/2025 revealed Contact Precautions due to Scabies (microscopic mites that burrow into the top layer of skin causing a rash and itchiness. It is highly contagious and spreads through direct skin-to-skin contact or contaminated surfaces) Prophylaxis. All staff/visitors to follow Contact Precautions with PPE including gloves, and disposable gowns, all supplies available on entry Review of Resident #11's MDS dated [DATE] revealed BIMS (Brief Interview for Mental Status) score of 06 which means severe cognitive impairment. Observation on 08/26/25 9:17 a.m. revealed Resident #11 was on contact isolation precautions. Outside Resident #11's room was a signage indicating contact precautions, personal protective equipment (PPE) outside the door that had masks, gloves, and gowns available. Maintenance A entered Resident #11 (contact precautions) room, got on one knee and started working on changing the door handle. After walking out of the room, he sanitized his hands. Interview on 08/26/2025 at 9:22 a.m., Maintenance A said that because he didn't get near the resident, and it was his understanding that he did not need to put on PPE. He said that if precautions were not followed, infections could be spread room to room and to staff as well. His last training on EBP (enhanced barrier precautions) and isolations precautions was two weeks ago. He described the difference between Airborne and Droplet Precautions. Interview on 08/26/2025 at 1:35 p.m., Certified Nurse Aide D (CNA) has been employed at the facility for fifteen years. She said staff meetings are held every one to two weeks which include in-services and training. The last infection control in-service was held about three weeks ago. Topics reviewed were hand washing and sanitizing, transferring of linens, and trash. Record Review of Resident # 3's face sheet dated 12/05/2023 revealed an [AGE] year-old female with a diagnosis of Alzheimer's Disease, Hypertension, and Atrial Fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly). Record Review of Resident # 3's Physician Order dated Effective 8/21/2025 Contact Precautions due to Scabies with PPE including gloves, and disposable gowns, all supplies available on entry. Record Review of Resident # 3's Quarterly MDS Assessment, dated 6/25/2025 revealed she had a BIMS Score of 01 which means severe cognitive impairment. Observation on 8/26/2025 at 12:04 p.m. Resident # 3 was on contact isolation precautions. Outside Resident #3's room was a sign indicating contact precautions, personal protective equipment outside the door that had masks, gloves, and gowns available. RN/ADON B walked into Resident 3's room (Contact Precautions) without donning PPE and delivered her meal tray. Interview on 8/25/2025 at 12:31 p.m. RN/ADON B said he did not need to don PPE because he was not touching the resident and did not render care. Record Review of Resident # 12's face sheet dated 1/07/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction (stroke), Hemiplegia Left Side (left side paralysis), and Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause ongoing breathing problems). Review of Resident # 12's physician order dated 8/26/2025 revealed Contact Precautions due to Suspected Scabies. All staff/visitors to follow Contact Precautions with PPE including gloves, and disposable gowns, all supplies available on entry. Review of Resident # 12's MDS assessment dated [DATE] revealed a BIMS score of 09 which means moderate cognitive impairment. Observation on 8/26/2025 at 1:50 p.m. housekeeper B was inside Resident # 12's room mopping wearing gloves and no gown. Contact precaution signage on the resident's door. Gowns, gloves, and face mask were outside of the resident's room. Interview on 8/26/2025 at 1:55 p.m. Housekeeper B said she has been employed at the facility for three days and had training on housekeeping and laundry topics. She said her co-workers told her there was only one room where she had to wear a gown. She said she was not sure why she had to wear a gown. Housekeeper B said that she had watched education videos on basic topics such as falls and when and to whom she should report incidents. Interview on 8/28/25 at 4:48 p.m., RN/ADON B stated all staff and visitors should wear personal protective equipment before entering the isolation rooms because this prevents the spread of infection to other residents. He is the Infection Preventionist and that staff trainings on infection control are done as needed, during orientation for newly hired employees, and quarterly. Interview on 08/28/25 at 5:13 PM, DON stated contact Isolation precautions should be followed by all staff because of the potential for spreading infections to other residents. DON stated that in-services (training) on infection control were done on an annual basis and as needed. She said all staff gets trained on Transmission Based Precautions (TBP) and Infection Control is addressed monthly during their QAPI (Quality Assurance and Performance Improvement) committee review. 2) Record review of Resident # 34's face sheet dated 12/06/2024 revealed an [AGE] year-old male with a diagnosis of Malignant Neoplasm of Bladder (bladder cancer), Secondary Malignant Neoplasm of Liver and Intrahepatic Duct (liver cancer), Displacement of Nephrostomy Catheter (tube that acts as a temporary detour for urine, allowing urine to drain directly from the kidney into a bag outside the body) Record review of Resident # 34's person-centered care plan, initiated date on 8/20/2025 revealed he was on IV (intravenous) antibiotic therapy related to Sepsis (condition in which the body responds improperly to an infection). Record review of Resident # 34's MDS assessment dated [DATE] revealed a BIMS score of 12 which is moderate cognitive impairment. Observation on 8/26/2025 at 2:09 p.m. Resident # 34's IV access to left forearm covered with a clear dressing was not labeled and tape coming off the sides. Dried blood noted under the clear dressing. Observation on 8/27/2025 at 5:45 p.m. Resident # 34's IV site unlabeled, tape adhesive coming off and dried blood seen under clear dressing. Interview on 8/27/2025 at 5:50 p.m. Licensed Vocation Nurse (LVN) E said Resident # 34 returned from the hospital two to three days ago with the IV access and that the dressing will be changed tonight. Interview on 8/28/2025 at 9:14 a.m. LVN F said that a physician's order was received on 8/20/25 for IV antibiotic to be administered every eight hours for nine days and that she redressed the dressing on 8/24/25. She said that if IV site is not cleaned there can be a risk of infection to the area. LVN F said she had a training on PPE and infection control this past week. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Isolation Protocol (Transmission-Based Precautions): A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. 3) Record review of Resident #10's admission record dated 06/04/25 revealed an [AGE] year-old female with diagnosis of Colle's' fracture of right radius (type of wrist fracture that occurs when the distal radius ((the lower end of the radius bone in the forearm)) breaks and bends backward), other fractures of lower end of right radius, unspecified protein-calorie malnutrition, major depressive disorder, and dysphagia (difficulty swallowing food or liquids). Record review of Resident #10's quarterly MDS assessment revealed resident #10's BIMS score was a 2 which indicates severe cognitively impaired. Section O - Special Treatments, Procedures, and Programs revealed Resident #10 was receiving IV medications. Record review of Resident #10's Order Summary Report dated August 2025 revealed Resident #10 had an order for Dextrose Intravenous Solution 5 % (Dextrose) Use 80 ml/hr intravenously every shift for IV hydration for 2 Days with 2 Liters in total, start date 08/20/25. Observation on 08/26/25 at 8:53 a.m. revealed Resident #10 was in her room lying in bed. She had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on her left hand. There were no signs or symptoms of infection or infiltration noted at the IV site. In an interview on 08/26/25 at 9:35 a.m. LVN N stated he was the nurse for Resident #10. He stated that the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN N stated that it was important to label the IV site to know when the IV was placed or the last time it was changed. He stated that if the IV was not changed within the ordered time, then it could cause an infection. He stated that the last time he had checked the resident's IV site was this morning, at the beginning of his shift. LVN N stated that the IV site should be checked at every shift. The site was to be checked for any signs of infection, the date and signature on the dressing, and check that the saline lock cap was in place. He stated he could not recall when the last training was he had received on IV administration. LVN N confirmed the resident had a peripheral IV lock on her left hand covered with a transparent dressing that was not labeled or dated. In an interview on 08/27/25 at 9:25 a.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated that the nurse that had inserted the IV should have dated and initialed the dressing that was over the IV site. The DON searched through orders on their computer system to verify who had placed the IV, however, she was not able to find the progress note indicating placement. The DON stated that labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated that the negative outcome of not labeling the dressing was that it could go over the recommended standard time of every 72 hours and could cause infection. She stated that IV administration class was done annually and as needed. Record review of the facility's Infection Prevention and Control Program Policy date implemented 05/13/23 revealed: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident # 11) reviewed for accidents and supervision.The facility failed to ensure Resident # 11's door handle remained unlocked from the outside when the door was closed.This failure could place residents at risk for accidents and injuries.Findings included:Record review of Resident # 11 face sheet dated 07/24/24 revealed an [AGE] year-old male admitted to the facility on [DATE], with the diagnosis of Dementia (brain disorder that causes a gradual decline in cognitive abilities), Gastro-Esophageal Reflux Disease (Condition where stomach acid flows back into the esophagus, causing symptoms of heartburn), Hypertension (high blood pressure), Muscle Wasting and Atrophy.Review of Resident # 11's MDS assessment dated [DATE] revealed a BIMS score of 06 which means severe cognitive impairment.Review of Resident # 11 Care Plan date revised 6/24/2024 reveals Resident has limited physical mobility r/t physical limitations such as weakness, dementia. Interventions: The Resident was NON-WEIGHT BEARING and requires assistance by one staff for locomotion using wheelchair as needed.Observation on 8/26/2025 at 9:15 a.m. survey attempted to enter Resident # 11's room but was unsuccessful due to the door being locked. The surveyor asked LVN G if there was a Resident in the room and he said yes and attempted to open the door. He then called Maintenance A to unlock the door and within a minute and a half the door was unlocked. LVN G said he did not know the door handle had a lock. The surveyor entered the room and Resident 11 was lying in bed, covered. He said he was fine and there were no concerns. The call light was within reach. Resident 11 demonstrated how to use call light. Observation on 8/26/2025 at 9:17 a.m. Maintenance A was changing the door handle.Interview on 8/26/2025 at 9:20 a.m. Maintenance A said that room A was used as a show room (facility model of resident room) and the door handle differed from the rest of the resident's door handles. The door handle for room A had a lock/key system and the rest of the handles did not. He said he did not notify the staff that the door handle differed from the regular handles. He said the showroom and storage room had locks to prevent residents from having accidents. He said he should have changed it on Monday but forgot. He said Resident 11 was moved Sunday evening to that room due to the outbreak. Interview on 8/26/2025 at 1:35 p.m. CNA D said she had not entered Resident 11's room but noticed his door was always cracked open. She said she had worked the previous day, and his door stayed opened all day. CNA D said she had training on Abuse, Neglect, and Exploitation (ANE) and gave examples of ANE and said she would immediately notify the administrator of ANE concerns.Interview on 8/26/2025 at 1:44 p.m. CNA H said she had seen Resident at 6:20 a.m. during her rounds, at 7 a.m. to drop off breakfast tray, and again sometime after 8 a.m. to pick up his tray. She demonstrated how she closed the door completely after walking out of the room with his tray.Interview on 8/26/2025 at 1:55 p.m. LVN I said he had been in Resident # 11's room around 6:40 a.m., 7 a.m., and 8:47 a.m. for rounds. He said he had always seen the door cracked open and at times fully open. Interview on 8/26/2025 at 3:41 p.m. CMA J said she went into Resident # 11's room to administer meds and his door was halfway open. She said she worked a double shift on 8/25/2026 and never saw his door completely closed. She said she did not know the door handle was different from the rest. CMA J said that the administrator is always talking to the staff about ANE and providing education. She said the last training on ANE was done last week.Interview on 8/27/2025 at 8:30 a.m. Maintenance A said he was notified by LVN F on Sunday (8/24) to unlock and prepare to have room [ROOM NUMBER] ready for a resident because they were in the process of moving some residents due to contact precautions. He said he moved the furniture out and prepared the room. Maintenance A said the door locked from the outside but remained unlocked from the inside.Interview on 8/27/2025 at 11:34 a.m. LVN I said He received report at the beginning of his shift and was informed that Resident # 11 was moved to room [ROOM NUMBER]. He said the door was not completely closed at the beginning of his shift and that he was unaware that the door locked from the outside. He said nothing like this has happened before.Interview on 8/27/2025 at 12:00 p.m. LVN N said he worked on Sunday (8/24) and a couple of residents were going to be moved to the back and one to the front. He said that LVN G had notified him that some residents were going to be moved that day including Resident # 11, but no specific room was assigned. LVN N said he had no knowledge of showroom, or the door handles being different. He said he never had a Resident with a locked door.Interview on 8/27/2025 at 1:02 p.m. via telephone call LVN L said she worked the night shift (10pm-6 am) on Sunday (8/24) and received report that Resident # 11 was moved to room [ROOM NUMBER]. She said she checked up on him during the night and liked to keep the door open to hear the resident. She said Resident # 11 does voice his needs and is able to use the call light but does not get up. LVN L said she did not pay attention to the door handle.Interview on 8/27/2025 at 1:31 p.m. via telephone call LVN F said she worked on Monday (8/25) the day shift (6am-2pm) and had received report at the beginning of her shift regarding Resident # 11 moved to room [ROOM NUMBER] due to contact precautions and that there was no mention about the door handle. She said Resident # 11 was stable and no changes in condition and that his door was always open despite contact precautions. LVN F said she had spoken to Maintenance A on Sunday to get the rooms ready and generalized all rooms not specifically room [ROOM NUMBER]. She said she did not know about the lock on the handle in room [ROOM NUMBER].Interview on 8/27/2025 at 2:25 p.m. LVN E said he worked the afternoon shift (2pm-10pm) on Monday (8/25) and received report at the beginning of his shift regarding residents being moved. He said he knew Resident # 11 was in room [ROOM NUMBER] and he made sure his door was open because he is one of the few residents that has difficulty verbalizing need. LVN E said he made rounds every hour to make sure everyone was okay. He said that at the end of his shift he reported no concerns throughout the day and that the door handle to room [ROOM NUMBER] was movable inside and out and kept the door open all day. He said it was never completely closed.Interview on 8/27/2025 at 2:34 p.m. via telephone call, Registered Nurse (RN) M said he worked the afternoon shift on Sunday (8/24) and that Resident # 11 was moved from room [ROOM NUMBER] to 211. He said resident would be in the room alone due to the contact precaution and that room [ROOM NUMBER] was the only room available. RN M said that room [ROOM NUMBER] was a showroom and that keys were available with nurses at both sides of the facility. He said he did not know that the door handle had a lock and that he gave report to the incoming shift to leave the door open.Interview on 8/28/2025 at 4:48 p.m. RN/ADON B said he knew the door handle to room [ROOM NUMBER] had a lock and knew where the key was, which was at the front lobby. He said he did not recall if the door was fully closed and that an in-service was done by Maintenance A regarding locks.Interview on 8/28/2025 at 5:13 p.m. DON said she had forgotten that the door handle to room A was different and that the door was always kept open. She said that if staff were providing care, the door was able to open from the inside and that rounds are done throughout the day to check in on the residents.Interview on 8/28/2025 at 5:27 p.m. Administrator said she was made aware of Resident #11 moving into room A on Monday (8/25). She said that she was his ambassador and did rounds and his door was opened throughout the day. She said his door was open or cracked open but not fully closed. Administrator said that the manager on duty and all staff know where to access key to the showroom. She said the facility did not have any policies for locks.Review of facility's Proof of Education dated 8/26/25: All Resident's Door Must Remained Unlock. Topic: Resident Doors. Summary of Training: Resident Door, All Resident doors to remain unlocked, Refer all issues to maintenance supervisor. Conducted by RN/ADON B. Forty-one employee signatures on In-service sign-in sheet.Review of facility's census sheet dated 8/26/25 at 2:32 p.m. Maintenance A checked all doors and identified room [ROOM NUMBER], 214, and 218 as storage locked. A notation on checklist made of All doors checked 100%, Visual examination and inspection of resident's doors, and, all doors checked for resident's room, No door handles with locks or locked doors.

Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident # 15) reviewed for quality of care. The facility failed on 08/27/2025 to ensure Residents # 15's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings included: Record review of a facility face sheet dated 8/28/25 for Resident # 15 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), and malfunction, dislodgement, and/or obstruction (distinct issues that can block the flow of urine, potentially causing severe pain, infection, and kidney damage). Record review of a comprehensive care plan dated 8/28/25 for Resident # 15 indicated that she had an indwelling catheter and had an intervention that read: . monitor that collection bag is off the floor and hung below bladder level . Record review of a physician's order summary report dated 8/28/25 for Resident # 15 indicated that she had the following order dated 8/18/25: . May change with Foley Catheter 16F with 10mL bulb as needed. every 24 hours as needed for Malfunction, Dislodgement, and/ or Obstruction **Document reason for re-insertion, size of Foley, and if tolerated well. Document in PCC as indicated During an observation on 8/27/25 at 10:14 am Resident # 15 received catheter care by CNA H. Resident #15 had an indwelling catheter present in a privacy bag and the tubing was not secured with a securement device. During an interview on 8/27/25 at 10:14 am, CNA H said that Resident #15 had a strap applied to secure his foley catheter earlier this morning by the nurse. CNA H said that not having a securement strap could cause harm or pain to the resident from the pulling or weight of the drainage bag pulling on the urethra. During an interview on 8/27/25 at 11:00 am, LVN K said that the nurses were responsible for the securement devices on residents that had indwelling catheters. LVN K said that residents that had an indwelling catheter should have a securement device to prevent dislodgement or trauma to the resident. During an interview on 8/28/25 at 09:05 am, the DON said the nurses were responsible for assessing residents with indwelling catheters to ensure there was a securement device in place. She stated the charge nurse should also assess the securement device on each shift to ensure the resident was not having any discomfort from tension or pulling of the tubing. The DON stated she expected every resident with an indwelling catheter to have a securement device. The DON said she would be in servicing the staff. During an interview on 8/28/25 at 11:00 am, the administrator said that there was no policy on foley catheters.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents psychosocial needs for one (Resident#11) of two residents reviewed for comprehensive person centered care plan. The facility did not have interventions in place for Resident #11's behavior of removing peg tube. Resident #11 had removed his peg tube on 2 separate occasions and was sent to hospital. This failure could affect residents and place them at risk of not receiving appropriate interventions. The findings were: Record review of Resident 11's Admission Record dated 09/19/24 revealed a [AGE] year-old male with an original admitted [DATE] and diagnoses of Alzheimer's Disease Unspecified (brain disorder that slowly destroys memory and thinking skills), Gastrostomy Status (surgical procedure that creates an opening in the abdomen & into the stomach to provide nutritional support), Displacement of other gastrointestinal (organs that process food and liquid) Prosthetic Devices (device designed to make a part of the body work better), Chronic Kidney Disease Stage 5, Anxiety Disorder Unspecified, Restlessness and Agitation, and Muscle Wasting and Atrophy. Record review of Resident #11's Quarterly MDS dated [DATE] revealed Resident #11 was severely impaired in cognitive skills, rarely/never makes self-understood, rarely/never understands others. Resident #11 was also coded as having a peg tube in place as a nutritional approach. Record review of Resident #11's Care plan dated 06/28/24 revealed Resident #11 requires tube feeding r/t Dysphagia. Record review of Resident #11's progress note dated 07/26/24 documented by LVN D revealed facility nurse had found Resident #11 had removed his peg tube and was sent to the hospital for reinsertion. Record review of Resident #11's progress note dated 09/13/24 documented by LVN C revealed that Resident #11 had pulled out his peg tube and was sent out to hospital for reinsertion. Record review of Resident #11's Care plan dated 09/03/24 found no documentation of interventions for Resident #11's behavior of removing peg tube. In an interview on 09/17/24 at 4:00 pm, the RP stated Resident #11 had previously removed his peg tube before being admitted into the facility. She said she had told the facility about it when he was first admitted to the facility and that's why she and her family take turns staying with Resident #11 and decided to hire private pay sitters as well. In an interview on 09/18/24 at 10:39 am, LVN C said on 09/13/24 CNA L told her that Resident #11 had removed his feeding tube. LVN C said she immediately went in to assess the resident and had Resident #11 sent out to the hospital to have peg tube reinserted. LVN C said it was not his first time that he had done that, however, she was not working that day it happened. LVN C said those were the only times Resident #11 had done that. LVN C said Resident #11's family private pays a sitter to be with him throughout the afternoon and sometimes at night. She said the family also takes turns staying with him to monitor his behavior. In an interview on 09/18/24 at 11:23 am the MDS nurse said Resident #11's care plan stated that resident removes peg tube. He said he did not know why any interventions were not care planned specifically for that. He said it should have been care planned and said he was responsible for care planning this but did not know why it wasn't but would be reviewing it. In an interview on 09/18/24 at 2:24 pm, the DON said Resident #11 had removed the peg tube on 2 different occasions. She said the family takes turns staying with him and monitoring him. She said the family has hired private pay sitters to stay with him as well. The DON said Resident #11 also has an abdominal binder to prevent him from removing it. The DON said that interventions for Resident #11 removing his peg tube were not documented because the family was providing the monitoring of the resident. A care plan policy was requested on 09/18/24, however was not provided.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals in 1 of 1 medication room review for medication storage . The facility failed to ensure that all medical supplies in the main medication storage room located in the in the front of the building were not past their expiration date. The facility's failure could result in residents receiving expired medical supplies, such as formula, as well as those supplies not being maintained at their best therapeutic level. The findings included: An observation on 07/22/2024 at 2:00 PM of the main medication storage room revealed 6 Aztreonam 500 MG/50 ML NS IV antibiotic medication with an expiration date of 07/18/2024 and 2 Azithromycin 250 MG/250 NS IV antibiotic medication with an expiration date of 07/19/2024 along with non-expired IV medication. In an interview/observation on 07/22/2024 at 2:05 PM, LVN B who witnessed the medication storage and labeling review of the main medication room on 07/22/24 at 2:00 pm first stated expired medication was kept in the refrigerator until they would take them for disposal. The Surveyor then observed LVN B remove the 8 expired IV medication bags and place them in a red bin where he said expired medications were temporarily placed until they were taken to the DON's office. LVN J said a negative outcome of storing expired medication with non-expired medication could results in residents being administered expired medication(s) if nursing staff failed to check expiration dates. An interview on 07/22/24 at 4:00 PM, the DON said expired medications should not be stored with non-expired medications. She said expired non-narcotic medications were stored in a red bin located in the main medication storage room. The DON was not able to say what a negative outcome was for storing expired and non-expired medications together. On 07/24/2024, the Surveyor requested the facility's policy on labeling and storage from the DON but only received a Labeling of Medication policy.

Based on observation interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #23) reviewed for care plans, in that: The facility failed to ensure Resident #23's comprehensive care plan dated 06/06/24 identified him as a one or two person assist for ADL's. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and no having personalized plans developed to address their specific needs. The Findings included: Record review of Resident #23's face sheet dated 07/24/2024 reflected an [AGE] year-old male with an admitted [DATE]. Resident 23's relevant diagnoses included Parkinsonism (disorder of the central nervous system that affects movement, often including tremors), stiffness of right elbow, vascular dementia (brain damage caused by multiple strokes), hemiplegia of left nondominant side (paralysis of one side of the body), age related physical debility, osteoarthritis (when flexible tissue at the ends of bones wears down) on left hand, muscle weakness and atrophy( decrease in size of tissue; wasting) multiple sites, repeated falls, and reduced mobility. Record review of Resident #23's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02, which indicated he was severely cognitively impaired. Section GG identified Resident #23 as being dependent for the following ADL's: eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking of footwear, personal hygiene, roll left/right, sit to lying, sit to stand, chair/bed-to-chair transfer, toiler transfer, and tub/shower transfer. The MDS definition of dependent was that resident did none of the effort to complete the activity or, the assistance of 2 or more helpers was required for the resident to complete the activity. Record review of Resident #23's quarterly care plan reflected 06/06/2024 reflected: Problem: [Resident #23] had an ADL self-care performance deficit r/t immobility, cognitive deficit, parkinsonism. Dated initiated 01/04/2024 and revised on 01/09/2024. Interventions: Bathing/Showering: The resident requires assistance by (1-2) staff with bathing/showering, as necessary. Date initiated/revised 05/22/2024. Bed mobility: The resident requires dependent assistance by (1-2) staff to turn and reposition in bed every two hours and as needed. Date initiated 01/04/2024 and revised on 01/09/2024. Dressing: The resident requires assistance by (1-2) staff to dress as needed. Date initiated/revised 05/22/2024 Personal Hygiene: The resident requires assistance by (1-2) staff with personal hygiene as needed. Date initiated/revised 05/22/2024. Toilet using: The resident is fully dependent on 1-2 staff for toileting. Date initiated 01/04/2024 and revised on 01/09/2024. Transfer: The resident requires complete dependence by 1-2 staff to move between surfaces, as necessary. Date initiated: 01/04/2024 and revised on 01/09/224. An attempted interview and observation on 07/21/2024 at 12:08 p.m., revealed Resident #23 was not interviewable. Resident #23 was asked if he was able to open his left hand, but he just starred at it and not able to answer. Resident #23 was asked if he was able to use his right hand and he managed to take it out from under his head, but it started shaking and he quickly put it back under his head. Resident #23 was asked if he received assistance in feeding and he nodded yes. An interview and observation on 07/22/2024 at 8:30 a.m., CNA C said due to Resident #23's legs being contracted and him not being able to assist, he required a 2 person assist for bathing, transfer Hoyer lift (the resident is placed in a sling that acts like a hammock raising them up in a cradled position , and allows them to be maneuvered to their new surface), and peri-care and a 1 person assist for feeding. She said she knew to check the Kardex to see if he was a 1 or 2 person assist for ADL's. The Surveyor observed CNA C check Resident #23's electronic record (Kardex) under ADL's it reflected that he was a 1-2 person assist for ADL's with the exception of eating and transfer (Hoyer Lift). She said even though the Kardex indicated he was a 1-2 person assist, she knew he required a 2 person assist for bathing and transfer because she had been caring for him since he was admitted to the facility. CNA C said newly hired CNAs shadowed tenured CNAs for two weeks to become familiar with their residents' needs. She said during those 2 weeks, they were able to observe all ADL's for their residents. CNA C showed the Surveyor a list she carried behind her name badge which indicated all the residents who required a Hoyer Lift for transfer and Resident #23's name was on the list. She said if a resident required a Hoyer Lift for transfer that meant a 2 person assist. An interview on 07/22/2024 at 8:49 a.m., LVN D said Resident #23 was a 2 person assist for bathing, transfers, and peri-care. He said for newly hired CNAs he would make sure they became familiar with their residents' needs before he would allow them to go on their own. He said newly hired CNA's shadowed tenured CNAs for 2 weeks. He said he would also make sure newly hired CNAs knew where to check to see if resident required a 1 or 2 person assist. CNA C said even though Resident #23's care plan reflected 1-2 person for ADL's she knew he was a 2 person assist due to his contractures. An interview and observation on 07/23/2024 at 10:16 a.m., the MDS-LVN said he was in charge of completing the MDS and Care plan assessments for the facility. He was observed checking Resident #23's electronic record and said his care plan indicated he required a 1 to 2 person assist for ADL's; however, most of the time he would require a 2 person. The MDS-LVN said the CNAs would determine whether Resident #23 would be a 1 or 2 person assist. He said if the CNA did not feel safe in performing a certain ADL task, then they asked for assistance. He said that was the reason he had indicated a 1 to 2 person assist for ADL's was to allow the CNAs to make that decision. The MDS-LVN said there were several factors a CNA would consider when determining if Resident #23 would be a 1 or 2 person assist. He said their experience was one factor, if the CNA felt they could do it on their own they were allowed. Another factor the CNAs would consider would be their CNAs stature. He said if the CNA were petite and didn't feel safe performing an ADL task on their own, they could ask for assistance. He said there was always someone to assist if the CNAs requested assistance with a resident's ADL's. MDS-LVN said Resident #23's the MDS indicated he was dependent for all ADL's which coincided with a 2 person assist. The MDS-LVN said CNA's did not receive training on how to determine if a resident was a 1 or 2 person assist. He said no training was needed. He said, What determined if a [Resident #23] would be a 1- or 2-person assist was how confident the CNA felt. An interview on 07/23/2024 at 10:52 a.m., the DON said Resident #23 was coded as dependent on his MDS assessment for ADL's, which meant he was dependent on the CNAs for assistance. She said what would determine if Resident #23 was a 1- or 2-person assist was if he were having a good day or not If he were having a good day, which meant he was able to help with his ADL's then he would require a 1 person assist. She said if he were not having a good day then he would require a 2 person assist. The DON said the CNAs already knew Resident #23 and they were able to determine if he was having a good day or not. She said if a there's a new CNA, they would shadow tenured CNAs for 2 weeks to be shown what each resident required. The DON said there were no specific trainings for CNAs to help them determine if a resident was a 1 or 2 person assist. She said, Just personal experience, they gain from working with each other. An interview on 07/23/2024 at 5:00 p.m. the Administrator said the reason Resident #23's care plan said 1 to 2 person assist for his ADL's was to allow the CNAs to determine if they felt safe performing a specific task on their own or ask for assistance. She said a resident was not always going to be a 1 or 2 person assist because it would depend on the CNAs experience and whether or not the resident was able to assist on that particular day. She said if a resident was on a ventilator, then they would always be a 2 person assist. The Administrator said there was no risk in allowing CNAs to determine whether or not a resident would be a 1 or 2 person assist. Record review of the facility's Comprehensive Care Plan policy dated 10/24/2022 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs that identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlines by the comprehensive care plan, shall be culturally competent and trauma informed. 2. All Care Assessments Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #23) of four residents reviewed for call light. The facility failed to ensure Resident #23 had a padded call light as indicated on his care plan. This failure could place residents at risk of not having their needs met. Findings were: Record review of Resident #23's face sheet dated 07/24/2024 reflected an [AGE] year-old male with an admitted [DATE]. Resident 23's relevant diagnoses included Parkinsonism (disorder of the central nervous system that affects movement, often including tremors), stiffness of right elbow, vascular dementia (brain damage caused by multiple strokes), hemiplegia of left nondominant side (paralysis of one side of the body), age related physical debility, osteoarthritis (when flexible tissue at the ends of bones wears down) on left hand, muscle weakness and atrophy( decrease in size of tissue; wasting) multiple sites, and reduced mobility. Record review of Resident #23's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02, which indicated he was severely cognitively impaired. Section GG 0115 Functional Limitation in Range of Motion indicated impairment on one side for upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). Section GG functional abilities and goals identified Resident #23 as being dependent for the following ADL's: eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking of footwear, personal hygiene, roll left/right, sit to lying, sit to stand, chair/bed-to-chair transfer, toiler transfer, and tub/shower transfer. MDS definition of dependent was that resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #23's quarterly care plan reflected 06/06/2024 reflected: Problem: [Resident #23] has an ADL self-care performance deficit r/t immobility, cognitive deficit, parkinsonism. Date initiated 01/04/2024 and revised on 01/09/2024. Interventions: Pad call light in place. Date initiated 03/25/24. Problem: [Resident #23] has limited physical mobility r/t parkinsonism, generalized weakness. Date initiated and revised on 01/10/2024. Interventions: Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/10/2024 An observation on 07/21/2024 at 12:05 p.m., revealed Resident #23 was lying awake in bed. His bed was set to the lowest position and his push button call light was within reach. Resident #23's left hand was contracted (closed in a fist), and he had his right hand under his head. An attempted interview and observation on 07/21/2024 at 12:08 p.m., revealed Resident #23 was not interviewable. Resident #23 was asked if he was able to open his left hand, but he just starred and did not answer. Resident #23 was asked if he was able to use his right hand, and he managed to take it out from under his head, but it started shaking and he quickly put it back under his head. An observation on 07/22/2024 at 8:24 a.m., revealed Resident #23 was lying awake in bed, his bed was set to the lowest position and his non-padded call light was within reach. An interview on 07/22/2024 at 8:30 a.m., CNA C said Resident #23 was not able to use the call light due to his left hand being contracted and his right hand would shake a lot. She said as far as she could remember, Resident #23 had never used the call light. CNA C said she would make sure she checked on Resident #23 at least every 30 minutes to see if he needed anything because he was not able to talk or press the call light. CNA C said Resident #23 was a 2 person assist for bathing and was a Hoyer lift assist transfer (the resident is placed in a sling that acts like a hammock raising them up in a cradled position , and allows them to be maneuvered to their new surface). She was not able to say if Resident #23 had ever had a padded call light. An interview on 07/22/2024 at 8:49 a.m., LVN D said Resident #23 was not able to use a regular call light. LVN D said he and the CNAs would check on Resident #23 frequently to see if he needed anything. He said if Resident #23 needed anything he would grunt. LVN D said Resident #23 would benefit from having a padded call light. LVN D was not able to say what the negative outcome for Resident #23 would be if he was not able to use the non-padded call light. An observation on 07/22/2024 at 9:00 a.m., revealed LVN D was observed checking Resident #23's electronic record (care plan) to verify what type of call light he needed. LVN D said he was having difficulty in finding they type of call light Resident #23 required on his care plan, so he called MDS-LVN to assist. They both said Resident #23's care plan indicated he needed a padded call light. An interview and observation on 07/22/2024 at 9:08 p.m., the MDS-LVN said he Resident #23 had a padded call light and proceeded to walk to Resident #23's room to check. The MDS-LVN walked into Resident #23's room and said he should have had a padded call light. He said, Last week he had a padded call light; they must have changed it this week. The MDS-LVN said he was going to immediately meet with the nursing staff, ADON, DON to assess and determine what type of call light Resident #23 needed. An interview of on 07/22/2024 at 9:20 a.m., the MDS-LVN said after Resident #23 was assessed by himself, the ADON and DON on 07/22/2024, and it was determined Resident #23 was able to press the regular call light, therefore, he no longer needed a padded call light. He said he was not sure why the care plan indicated he required a padded call light. The MDS-LVN said, Resident #23's care plan had been updated. An interview on 07/23/2024 at 3:00 p.m., the ADON-RN said he was present for Resident #23's call light assessment on 07/22/2024. He said Resident #23 was able to press the regular call light when asked and it was determined that he would benefit from a regular call light. An interview on 07/23/2024 at 3:30 p.m., the DON said she was present for Resident #23's call light assessment on 07/22/2024 and said Resident #23 was able to press the regular call light. She said the call light assessment done on Resident #23 was a visual assessment and it had not been documented. Record review of the facility's Call Lights: Accessibility and Timely Response policy dated 10/13/2022 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: 3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.

Based on interview and record review the facility failed to ensure resident who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for two Residents (R#46, R#16) of 5 residents reviewed for unnecessary medications. The facility failed to ensure that: 1) Resident #46 had an appropriate diagnosis for Risperidone (an antipsychotic used to treat schizophrenia and bipolar disorder). 2) Resident # 16, with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety received antipsychotic medication Lurasidone without an additional diagnosis indicating the use for antipsychotic medication. This failure puts residents at an increased risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status from receiving unnecessary antipsychotic medications. The findings included: 1. Review of Resident #46's Face Sheet dated 7/24/24, revealed she was a [AGE] year-old female originally admitted to the facility 3/25/22 with a most recent admitted [DATE]. She had diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance; major depressive disorder, recurrent, mild; anxiety disorder, unspecified; type 2 diabetes mellitus; and had a need for assistance with personal care. Review of Resident #46's Quarterly MDS Assessment, dated 7/13/24, Section B - Hearing, Speech, and Vision, B0200 revealed resident had minimal difficulty hearing, B0600 revealed resident had unclear speech, B0700 revealed resident is rarely/never understood, B0800 revealed resident rarely/never understands, and B1000 revealed resident has impaired vision - sees large print, but not regular print in newspapers/books. Section C - Cognitive Patterns, C0700 revealed resident had short term memory problem, C0800 revealed resident had long-term memory problem, and C1000 revealed resident severely impaired - never/rarely made decisions. Section GG - Self-Care, GG0130 revealed the resident required maximum assistance or dependent for ADL's except for oral hygiene and eating. Section N - Medications, N0415 revealed resident received antipsychotic, antidepressant, anticoagulant and hypoglycemic medications; and N 0450 revealed an antipsychotic GDR was reflected on 7/3/24 not documented by a physician as clinically contraindicated. Review of Resident #46's most recent Care Plan, revealed the following: Problem: Resident #46 uses antipsychotic medication (Risperidone) r/t episodes of verbal and physical aggression and diagnosis of dementia. Resident #46 is currently under psychiatric services of Psych MD. Date Initiated: 04/05/2024 Revision on: 04/29/2024. Interventions include the following: o 7/3/24. Gradual Dose Reduction Risperidone 1mg/ mL PO BID to 0.5mL PO BID by Psych MD's P.A. Date Initiated: 07/03/2024. o Administer anti-psychotic medication(s) as ordered by physician. Monitor/document side effects, and effectiveness every shift. Date Initiated: 04/05/2024 Revision on: 04/05/2024. o Educate the Family/ Caregivers about risks, benefits, and the side effects and/ or toxic symptoms of anti-psychotic medication on consent. Date Initiated: 04/05/2024 Revision on: 04/05/2024. o Monitor/ Document/ report adverse reactions to anti-psychotic therapy that include stiff neck, confusion, muscle rigidity, involuntary movements, drooling, tremors, restlessness, sleep disturbance, dry mouth blurred vision, constipation, and/ or sedation as condition warrants and notify physician/ psychiatric consultant. Date Initiated: 04/05/2024 Revision on: 04/05/2024. o Monitor/ Record occurrence of improving/ worsening target behavior symptoms of verbal and physical aggression to Supervisor as indicated. Notify MD/psychiatrist and follow up on any new orders. Date Initiated: 04/05/2024 Revision on: 04/05/2024. o Refer to Psychiatrist/ Psychologist consult per MD order. Follow up on any new orders. Date Initiated: 04/05/2024 Revision on: 04/05/2024. Record review of Resident #46's most recent Care Plan revealed: Risperidone Black Box Warning: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 04/29/2024. Review of Resident #46's Order Summary Report, dated 7/24/24, revealed: Side effect monitoring for stiff neck, confusion, muscle rigidity, involuntary movements, drooling, tremors, restlessness, sleep disturbance, dry mouth, blurred vision, constipation, and sedation every shift for anti-psychotic use related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Risperdal Oral Solution 1 MG/ML (Risperidone) Give 0.5 ml by mouth two times a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Start date 7/3/24. Review of Resident #46's MAR on 7/24/24 revealed: From July 1st to July 2nd, 2024, she received Risperidone Solution (1 MG/ML) 1 mg by mouth two times a day related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. From July 3rd to July 23rd, 2024, she received risperidone 0.5 mg twice a day as related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. This was the most recent order for risperidone which was reduced and started on 7/3/24. Record review of the Gradual Dose Reduction Report for June 2024 revealed that the Pharmacy Consultant made recommendation to the facility that Resident #46 had an improper diagnosis of Dementia in regards the antipsychotic Risperdal she was prescribed. On 7/23/24 at 4:19 pm interviewed LVN A. She said that she worked for the facility as an LVN for 6 months. She said that previously she was an MA for [AGE] years. She said that the Risperidone is being given for Resident #46's Dementia. She said that she knew the resident prior and she was displaying psychotic episodes before, but the medication is helping with those symptoms. She said that the dementia is not an appropriate diagnosis for the Risperidone. She said that an anti-psychotic is not appropriate for a diagnosis of dementia. She said that it is for psychosis or mood disorders. She said that a resident could have an adverse effect from a medication they didn't need. On 7/23/24 at 4:34 pm interviewed the ADON. He said that for Resident #46, Risperidone was not an appropriate medication to be prescribed for her diagnosis of Dementia. He said that she never used the medication before and that it was prescribed to manage her behaviors. He said that Resident #46 was confused, incoherent, and trying to get out of bed on her own. He said that she was initially started on Zyprexa, then changed to liquid Risperdal due to Resident #46 spitting out the tablets. He said that if an antipsychotic was given to a resident without the appropriate diagnosis, they could experience adverse reactions that may be permanent. He said that they used the medication as a last resort and that Resident #46 was already started on a gradual dose reduction. He said that dementia was not treated with an antipsychotic. He said that the Care Plan stated it has a black box warning for an increased risk of death. On 7/24/24 at 2:56 pm interviewed the Pharmacist Consultant. She said that she had noticed that the psychiatrist placed a diagnosis of Dementia and used them for the behaviors. She said that she is aware that the state does not allow for those diagnosis. She said that she does ask the psychiatrist for another diagnosis, but she goes by whatever the doctor writes on her recommendations page. She said that she cannot just stop the medication abruptly. The Pharmacist Consultant said that she places residents on a GDR as soon as possible once the behaviors have subsided. On 7/24/24 at 3:12 pm interviewed the DON. She said that she agreed that Risperidone was not an appropriate medication to be prescribed for a diagnosis of Dementia. She said that if an antipsychotic is given to a resident without the appropriate diagnosis, they could experience adverse reactions that may be permanent. She said that Resident #46 is being given the medication for previous behaviors that are not reflected on the prescribed diagnosis for that medication. 2) Record review of Resident #16's Admission Face Sheet, dated 07/24/24, revealed he was a [AGE] year-old male admitted to the facility 09/15/27, with the following diagnoses: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety(a condition characterized by progressive or persistent loss of intellectual functioning resulting from organic disease of the brain); major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest); cognitive communications deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions); anxiety disorder (any group of mental conditions characterized by excessive fear or apprehension about real or perceived threats, leading to altered behavior); and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Record review of Resident #16's quarterly MDS assessment, dated 06/19/24, indicated Resident #16 was sometimes understood by others, would sometimes understand others, had severe cognitive impairment, did not have any behaviors and was antipsychotic medication was received on a routine basis. Record Review of Resident #16's care plan dated 06/10/24 revealed Resident #16 uses antipsychotic medication (Lurasidone) relating to bipolar disorder that included the interventions of Black Box Warning of increased mortality in elderly patients with dementia related to psychosis. To monitor/document/report adverse reactions antipsychotic therapy that includes stiff neck, confusion, muscle rigidity, involuntary movements, drooling, tremors, restlessness, sleep disturbance, dry mouth, blurred vision, constipation, and/or sedation as condition warrants and notify physician/psychiatric consultant. Record review of Resident #16's Physician's Orders, dated July 2024, revealed an order for Lurasidone (antipsychotic medication) 40 mg by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, the order start date was for 06/08/24. Record review of Resident #16's Medication Administration Record, for July 2024 revealed Resident #16 received the antipsychotic medication lurasidone HCl 40 mg by mouth at bedtime from 07/01/24 through 07/23/24 related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of the Gradual Dose Reduction Report dated June of 2024 revealed the Pharmacy Consultant made a recommendation to the facility that Resident #16 had an improper diagnosis of dementia for the Lurasidone . In an interview on 07/23/24 at 4:18 PM LVN A said the medication for Resident #16 was used for unspecified dementia. LVN A said she did not think the medication should be given for dementia. LVN A said the antipsychotic should be given for psychosis, schizophrenia, bipolar disorder or any mood disorder. LVN A said Resident #16 did have behaviors, but the medication should be administered to residents with psychosis, or another mood disorder. LVN A said if a resident did not have psychosis, or another mood disorder and he was given an antipsychotic it could cause an adverse effect. In an interview on 07/23/24 at 4:32 PM the ADON said Resident #16 was confused and was hallucinating. Resident #16 was on Zyprexa for yelling out, and calling for his spouse several times a night. Resident #16 had a diagnosis of bipolar. The ADON said dementia was not treated with antipsychotics. ADON said the diagnosis for the Lurasidone was not an appropriate diagnosis for the medication Lurasidone. The ADON said he would speak with the physician and ask if the diagnosis could be changed to be given for bipolar disorder. In an interview on 07/24/24 at 8:35 AM, Resident #16 said he did not know what medications he was taking. Resident #16 said the nurse came in and gave him his medications. Resident #16 said he was visually impaired and could not see the medications given to him. Resident #16 said that the nurse might have told him what the medications were for, but he did not remember what the names of the medications were. In an interview on 07/24/24 at 2:56 PM the Pharmacy Consultant said the psychiatrist uses the diagnosis of dementia for residents with behaviors. The Pharmacy Consultant said she was aware that state did not allow the diagnosis of dementia when prescribing antipsychotic medication. The Pharmacy Consultant said she would ask for a different diagnosis, but it is the doctor's decision to write the diagnosis on her recommendation letter. The Pharmacy Consultant said she would request a GDR as soon as possible. In an interview on 07/24/24 at 3:12 PM the DON verbalized she agreed that an antipsychotic was not an appropriate medication to be prescribed for the diagnosis of dementia. The DON said that if an antipsychotic was given to a resident without the appropriate diagnosis, they could experience adverse reactions that may be permanent. The DON said the resident was being given the medication for previous behaviors that were not reflected on the prescribed diagnosis for that medication. Record review of the facility policy Psychotropic Medication implemented 8/15/22 revealed: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 49301

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 1 of 2 residents (Resident #20) reviewed for infection control practices, in that: LVN C failed to utilize appropriate hand hygiene during wound care and skin treatment to Resident #20 This failure could place residents at risk for infection, slow wound healing and or a decline in health. The findings were: Record review of Resident #20's face sheet, dated 4/12/23 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included elevated white blood cell count (also known as leukocytosis; usually occurs because of an infection or inflammation in the body), cutaneous abscess of left lower limb (localized collection of pus in the skin), heart disease and respiratory failure with hypoxia (not enough oxygen in the blood). Record review of Resident #20's most recent annual MDS assessment, dated 1/20/23 revealed the resident was severely cognitively impaired for daily decision-making skills and had a Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer). Record review of Resident #20's comprehensive care plan, revision date 4/11/23 revealed the resident had been receiving treatment with antibiotic therapy for wound infection effective 4/7/23 with interventions that included to administer treatments as ordered and observe for effectiveness. Further review of Resident #20's comprehensive care plan revealed the resident had a rash to the face with interventions to apply/administer anti-pruritic medication/topical as ordered by the physician. Record review of Resident #20's Order Summary Report, dated 4/12/23 revealed the following orders: -Hydrofera Blue Foam Dressing External Pad (Wound Dressings) apply to left hip topically every day shift for wound care for 30 days, cleanse wound with Dakins 0.25% and gauze, dry with gauze, apply skin prep to peri wound, apply Santyl and gentamycin 0.1%, place Hydrofera Blue Foam, cover with gauze and secure with tape, with order date 4/8/23 and no end date. -Ketoconazole External Cream 2%, apply to face topically every day and evening shift for fungal infection of face for 14 days. Apply topically to face and LOTA (left open to air), with order date 4/7/23 and end date 4/21/23. Observation on 4/12/23 at 8:55 a.m., after completing wound care to Resident #20, LVN C applied skin prep to the perimeter of Resident #20's left hip wound, took off his gloves, did not perform hand hygiene and put on a new pair of gloves. LVN C then took the clean adhesive bandage with a dry gauze and placed it over Resident #20's left hip wound. LVN C then, with the same gloves, applied the Ketoconazole cream to Resident #20's face. During an interview on 4/12/23 at 9:33 a.m., LVN C revealed he realized he had not performed hand hygiene between glove changes because he did not have any hand sanitizer with him. LVN C stated he did not want to leave Resident #20's bedside to get hand sanitizer and decided to keep going. LVN C stated not sanitizing or washing his hands between glove changes was considered an infection control issue and cross contamination and could result in the resident being exposed to infection. During an interview on 4/13/23 at 10:53 a.m., the DON revealed, it was best practice to either sanitize or wash hands between glove changes otherwise it was considered cross contamination. Record review of the policy and procedure titled, Administering Topical Medications, revision date 7/15 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of topical medications .1. Perform hand antisepsis by either washing with soap and water or applying alcohol-based hand rub .Remove gloves. Wash and dry hands thoroughly . Record review of the Wound Care Procedure for Major Wounds competency, dated 4/6/23 for LVN C revealed in part, .17. Remove gloves .wash hands .18. Put on new gloves .

Based on observation, interview and record review the facility must ensure that a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #20) reviewed for pressure sores in that: LVN C failed to utilize appropriate wound care treatment during wound care to Resident #20 This failure could affect residents with pressure injuries and wounds and could place the residents at risk for worsening of pressure ulcers. The findings were: Record review of Resident #20's face sheet, dated 4/12/23 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included elevated white blood cell count (also known as leukocytosis; usually occurs because of an infection or inflammation in the body), cutaneous abscess of left lower limb (localized collection of pus in the skin), heart disease and respiratory failure with hypoxia (not enough oxygen in the blood). Record review of Resident #20's most recent annual MDS assessment, dated 1/20/23 revealed the resident was severely cognitively impaired for daily decision-making skills and had a Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the bottom layer of skin in the body). Record review of Resident #20's comprehensive care plan, revision date 4/11/23 revealed the resident had been receiving treatment with antibiotic therapy for wound infection effective 4/7/23 with interventions that included to administer treatments as ordered and observe for effectiveness. Further review of Resident #20's comprehensive care plan revealed the resident had a Stage 2 pressure wound (skin is broken, leaves an open wound, or looks like a pus-filled blister) to the left hip with interventions that included to perform wound care treatments as ordered. Record review of Resident #20's Order Summary Report, dated 4/12/23 revealed the following wound care order: -Hydrofera Blue Foam Dressing External Pad (Wound Dressings) apply to left hip topically everyday shift for wound care for 30 days, cleanse wound with Dakins 0.25% and gauze, dry with gauze, apply skin prep to periwound, apply Santyl and gentamycin 0.1%, place Hydrofera Blue Foam, cover with gauze and secure with tape, with order date 4/8/23 and no end date. Observation on 4/12/23 at 8:55 a.m., during wound care, LVN C applied Gentamycin to Resident #20's wound bed on the left hip. LVN C then took a pre-cut piece of Hydrofera Blue antibacterial Foam to place over Resident #20's wound bed on the left hip but dropped the Hydrofera Blue antibacterial Foam onto Resident #20's bed linens. LVN C then picked up the same pre-cut piece of Hydrofera Blue antibacterial Foam and placed it over the resident's wound. During an interview on 4/12/23 at 9:33 a.m., LVN C stated, the Hydrofera Blue antibacterial Foam used on Resident #20 was used to help with wound healing. LVN C revealed he was aware he had dropped the Hydrofera Blue antibacterial Foam intended for Resident #20's wound bed on the left hip and at that point should have discarded it because it was considered dirty. LVN C revealed he was waiting for the surveyor to call him out on it but since that did not happen LVN C revealed he continued with the treatment. During an interview on 4/13/23 at 10:53 a.m., the DON stated, LVN C should have discarded the Hydrofera Blue antibacterial Foam because it was considered contaminated after it was dropped on Resident #20's bed linens and it would not be good for the resident because you can't use something contaminated because it's not usable. Record review of the competency training document titled, Wound Care Procedure for Major Wounds, dated 4/6/23 revealed in part, .PURPOSE: To provide guidelines for appropriate technique in completing wound care .NOTE: Clean technique is used. Sterile technique would be used per physician orders, such as with fresh surgery wounds. Care must be taken to prevent contamination of the supplies and surfaces used in wound care . Further review of the competency training document revealed LVN C had satisfied the requirements for appropriate technique in completing wound care.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #57) and 1 of 4 medication carts (200 hall medication cart) reviewed for medication administration and storage, in that: 1. Certified Medication Aide (CMA) D used her ungloved right index finger to take a pill from a medication bottle intended for Resident #57 2. LVN C had a loose pill in a medication cup inside the top drawer of the medication cart intended for Resident #14 These deficient practices could affect residents who received medication and place them at risk of infection, not receiving the appropriate amount of medication and drug diversion. The findings were: 1. Record review of Resident #57's face sheet, dated 4/13/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic long lasting health condition that affects how your body turns food into energy) with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), moderate protein-calorie malnutrition, Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) of sacral region and acute kidney failure. Record review of Resident #57's admission MDS assessment, dated 3/27/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and had a wound infection. Record review of Resident #57's Order Summary Report, dated 4/13/23 revealed an order for multivitamin with minerals, 1 tablet by mouth one time a day for supplement/risk for malnutrition, with order date 4/12/23 and no end date. Observation on 4/13/23 at 7:14 a.m. revealed CMA D, during the medication pass, placed 9 different medications into a medication cup and then took a stock bottle of multivitamin with minerals from the medication cart, opened the bottle and placed her right ungloved index finger into the bottle to retrieve one multivitamin with minerals pill. CMA D then took the multivitamin with minerals pill and placed it in the medication cup with the other 9 pills and administered to Resident #57. During an interview on 4/13/23 at 7:26 a.m., CMA D revealed the bottle of multivitamin with mineral pills used for Resident #57 was a stock bottle and was also used for other residents. CMA D stated, I had a hard time taking the pill out so I scooped it out but should not have done that because it was considered cross contamination. During an interview on 4/13/23 at 10:39 a.m., the DON revealed, CMA D should have used clean gloves, a spoon or a clean straw to scoop the pill out instead of using her bare finger because it would cause the bottle of pills to be contaminated and needed to be tossed out. Record review of the Medication Pass Evaluation, dated 1/19/23 revealed in part, .Medication Administration: a. Meds are properly removed from container/blister pack . Further review of the Medication Pass Evaluation revealed CMA D had satisfied the requirements for administering medications. 2. Record review of Resident #14's face sheet, dated 4/13/23 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (any clinical symptom that entails a marked loss of contact with reality, notably including delusions, hallucinations, disorganized speech, or disorganized behavior) not due to a substance or known physiological condition and recurrent depressive disorders (mood disorder that affects how you feel, think and behave and can lead to a variety of emotional and physical problems). Record review of Resident #14's most recent quarterly MDS assessment, dated 2/8/3 revealed the resident was severely cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #14's comprehensive care plan, revision date 12/21/22 revealed the resident was treated with the anti-anxiety medication klonopin related to anxiety disorder with interventions that included to administer anti-anxiety medications, klonopin as ordered by physician. Record review of Resident #14's Order Summary Report, dated 4/13/23 revealed an order for klonopin 0.5 mg, give 0.25 mg by mouth in the morning related to anxiety disorder, with order date 3/8/23 and no end date. During an observation and interview with LVN C on 4/13/23 at 1:23 p.m., during inspection of the 200 hall medication cart revealed a loose pill in a medication cup inside the top drawer of the medication cart. Upon further inspection, the loose pill in the medication cup had Resident #14's name written in black marker on the cup. LVN C identified the loose pill in the medication cup as a klonopin pill intended for Resident #14. LVN C revealed he had taken the klonopin pill from the lock box in the 200 hall medication cart and documented in Resident #14's Individual Resident's Controlled Substance Record which indicated the pill was dispensed to the resident at 8:00 a.m. LVN C stated Resident #14 was scheduled to receive the klonopin pill at 9:00 a.m. but forgot to give it to the resident because Resident #14 was asleep at the time and did not want to wake him. LVN C revealed he got busy and forgot about the pill but had still intended on administering the klonopin pill to Resident #14 more than 4 hours after it was due. LVN C revealed he was not supposed to store medications in a cup inside the 200 hall medication cart because somebody else could take it by mistake or could potentially lead to a drug diversion. LVN C revealed, the klonopin pill, a controlled substance, would need to be wasted (disposed of) but had to be witnessed by a second nurse and then the incident needed to be reported to the DON. Record review of the Individual Resident's Controlled Substance Record for Resident #14 revealed LVN C documented he removed one klonopin pill from the blister package on 4/13/23 at 8:00 a.m. During an interview on 4/13/23 at 1:35 p.m., LVN A revealed, klonopin was a controlled medication stored in the lock box of the medication cart. LVN A stated, once the klonopin pill was removed from the package, there had to be documentation on the Individual Resident's Controlled Substance Record and immediately administered to the resident. LVN A revealed, the next step after administering the klonopin would be to document in the computer in Resident #14's electronic medication administration record. LVN A stated, controlled medications could not be taken out of the package and not administered because it could fall out and mistakenly be given to somebody else. LVN A revealed, controlled medications not tracked could result in a drug diversion. During an interview on 4/13/23 at 1:40 p.m., the DON stated, once pills are taken out of the package, they have to be administered otherwise then the pills need to be disposed. Medications need to be given on time to avoid a mistake. There could have been a drug diversion and to me it's a medication error. Record review of the Medication Pass Evaluation, dated 4/5/23, revealed LVN C had satisfied the requirements for performing the medication pass. Record review of the policy and procedure titled, Medication Administration, revision date 10/1/19 revealed in part, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .D. 10 Rights of Medication Administration .There is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication .harm to the person can occur and some reactions can be deadly .5. Right Time .the time a medication is given is important .check the frequency of the ordered medication .Double-check that you are giving the ordered dose at the correct time .Confirm when the last dose was given .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 2 of 2 dumpsters in that: 1. Dumpster #1 did not have a drain plug. 2. Dumpster #2 did not have a drain plug. These failures posed a sanitary and safety hazard that could result in the attraction of vermin and affect all resident residing in the facility by exposing them to germs and diseases carried by vermin and rodents. The findings were: During an interview and observation on 4/13/2023 at 8:01 a.m., while viewing the dumpsters, the Dietary Manager said the dumpsters are supposed to be closed everywhere. The Dietary Manager said, they do not have stoppers, they haven't had them that I know of and I think they ordered them but I am not sure. The Dietary Manger was unable to state or provide any additional information regarding how long the stoppers were missing from the dumpster drain hole. During an interview and observation on 4/13/2023 at 8:06 a.m., while viewing the facility dumpsters, the administrator said, the holes in the bottom of the dumpster are supposed to be closed so whatever we put in there does not run out of the dumpster and on the ground. The Administrator stated he did not know how long the plugs had been missing from the dumpsters . Review of facility policy Garbage Receptacles, (Revised June 1, 2019), revealed, Outdoor Receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle. All Shall be maintained in good repair. Review of the U.S. Public Health Service FDA U.S. Food & Drug Administration Food Code 2017, Section 5-501.114 revealed, Using Drain Plugs: Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.