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

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 16 (Resident #149, Resident #99, and Resident #5) residents reviewed for infection control, 1.The facility failed to ensure Resident #149's IV dressing was labeled on 08/10/2026. 2. The facility failed to ensure CNA G and CNA H performed proper hand hygiene, bed bath procedure, and proper doffing of PPE after exiting Resident 99's room. 3. The facility failed to ensure Resident #5's oxygen tubing was changed. These failures could place residents at risk for healthcare associated cross-contamination and the spread of infection. 1.Record review of Resident #149's face sheet, dated 08/12/2026, reflected an [AGE] year-old male with an admission date of 08/06/2026. His pertinent diagnosis included Cellulitis (a bacterial infection of the deeper layers of the skin and the tissues just beneath it). Record review of Resident #149's MDS revealed it was in progress. The BIMS form dated 08/07/2026 reflected a score of 15, which indicated cognitively intact. Record review of Resident #149's order summary, dated 08/10/2026, reflected ceftriaxone sodium intravenous solution reconstituted 1 GM. Use 1 application intravenously one time a day for Cellulitis for 7 days. Start date 08/07/2026. End date 08/14/2026. Record review of Resident #149's care plan, date initiated 08/07/2026, reflected Resident #149 Goal: The resident will have not have any complications related to IV therapy through the review date. Interventions: IV Dressing (change dressing prn) Observe dressing (qshift). Monitor/document/report PRN s/sx of infection at the site: Drainage, inflammation swelling, redness, warmth. Monitor/document/report PRN s/sx of leaking at the site. Record review of Resident #149's MAR, dated 08/12/2026, reflected orders for ceftriaxone use 1 gram intravenously one time a day for Cellulitis (a bacterial infection of the deeper layers of the skin and the tissues just beneath it) for 7days. Start date: 08/07/2026. Flush peripheral IV line (pushing a safe, clear saltwater liquid through the small plastic tube in the arm to clean it out and keep it from getting blocked) with 10 ML of NS before and after each medication administered every shift for IV patency (IV line is open clear and working correctly so that fluids and medicine can flow smoothly into the vein without any blockages). Start date: 08/07/2026. D/C date: 08/14/2026. Flush peripheral IV line with 10 ML of NS every shift for IV patency maintenance. Start date: 08/07/2026. D/C date: 08/14/2026. Monitor peripheral IV site for redness, tenderness, edema(swelling), excessive bleeding and any other abnormalities on right hand. Notify MD as needed every shift. Start date: 08/06/2026. Change peripheral IV site and dressing as needed for infiltration (fluid or medication from an IV accidentally leaks into the tissue under the skin instead of flowing directly into the vein) right hand. Start date: 08/06/2026. During an observation on 08/10/2026 at 9:50 a.m., revealed Resident #149 had a peripheral IV dressing on his right wrist that was not labeled with the date, time, or initials. No redness or swelling noted at the IV site. In an interview on 08/10/2026 at 9:51 a.m., revealed Resident #149 stated he had IV for a few days at the same site. He denied experiencing any pain or discomfort at the IV site. In an interview on 08/10/2026 at 10:22 a.m., RN J stated the facility's process for labeling an IV dressing was to date and sign the dressing. He stated that peripheral IV sites should be checked daily and the site should be rotated every 72 hours but would need to verify the facility's specific process with management. RN J stated that the IV dressing needed to be labeled so staff could determine when the IV was inserted and whether the IV site required rotation. He stated that he received an in-service on infection control and IV medication about a week ago. RN J stated the negative outcome of not having the IV dressing labeled was that staff would not know the date the IV was inserted, which could increase the risk for infiltration and infection at the IV site. RN J verified that Resident #149's IV dressing was not labeled. He stated that he had checked it this morning for signs and symptoms of infiltration and infection but did not notice that the dressing was not labeled. RN J stated that he was not the one who inserted the IV. In an interview on 08/12/2026 at 3:35 p.m., the DON stated the facility's policy regarding labeling peripheral IV dressings was that the dressing was to be labeled at the time of the dressing change. She stated the dressing was to be labeled with the date and staff initials and title, and that including the time would be ideal. The DON stated the IV dressing used to be expected to be changed every 72 hours, but she would need to verify the current requirements. She stated that nurses had been in-serviced on the facility's requirements for labeling IV sites and were expected to inspect the IV site. She stated if an IV dressing was not labeled, staff were instructed to do another dressing change, as PRN orders for dressing changes were in place. The DON stated the potential negative outcome of the IV dressing not being labeled was an increased risk for infection. 2. Record review of Resident #99's face sheet, dated 8/12/2026, reflected a [AGE] year-old female with an admission date of 2/20/2026. Her pertinent diagnoses included functional quadriplegia (inability to move the arms and legs or walk due to extreme physical weakness or advanced disease, rather than direct physical damage to the spinal cord), neuromuscular disfunction of bladder (bladder control problem caused by nerve damage that prevents the brain and spinal cord from communicating correctly with the bladder), muscle wasting and atrophy (the shrinking, thinning, and loss of muscle mass and strength), and contracture of muscle, right and left ankle and foot (a severe, permanent tightening and shortening of the muscles and tendons on both sides that prevents the joints from moving normally). Record review of Resident #99's quarterly MDS assessment, dated 5/26/2026, reflected a BIMS score of 5, which indicated severe cognitive impairment. Section K- Swallowing/Nutritional Status, indicated Resident #99 had a feeding tube. Section H- Bladder and Bowel, indicated Resident #99 had an indwelling catheter. Section GG- Functional Abilities, indicated Resident #99 was dependent on staff for shower/bath. Record review of Resident #99's care plan, date initiated 2/22/2026, reflected Resident #99 has an ADL self-care performance deficit r/t generalized weakness has a community acquired infection. Interventions: Bathing/Showering: The resident is totally dependent on (1) staff to provide bathing. Resident #99's care plan, revised date 1/14/2026, reflected Resident had the need for Enhanced Barrier Precautions due to: (PEG tube [soft plastic tube placed directly through the skin of the abdomen into the stomach to deliver food, fluids, and medicine], Foley catheter [thin, flexible plastic tube placed into the bladder to drain urine into a collection bag when a person cannot urinate on their own]). Interventions: .Gown and gloves only for high-contact resident care activities (bathing/showering, personal hygiene) . During an observation on 8/12/2026 at 8:29 a.m., revealed CNA G and CNA H performed a bed bath on Resident #99. During the bed bath, CNA G removed her gloves, did not sanitize her hands and applied clean gloves. CNA H did not change gloves throughout the bed bath procedure and continued using the same gloves as she cleaned Resident #99's vaginal area and buttocks area. At the conclusion of the bed bath procedure, both CNA G and CNA H exited Resident #99's room and did not perform hand washing. CNA H did not remove her PPE, including her gown and gloves. During an interview on 8/12/2026 at 9:20 a.m., CNA G said she received monthly in-services on hand hygiene. She said hand sanitizer was available in the residents' rooms and hallways. She said she knew how to perform hand hygiene in between glove changes and had forgotten to wash her hands when she finished providing the bed bath for Resident #99. She said it was important to perform handwashing and hand hygiene to avoid spreading germs to the residents and staff. During an interview on 8/12/2026 at 9:26 a.m., LVN I said she observed CNAs providing care during her rounds. She said she provided them with reminders as needed on handwashing and hand hygiene. She said the last in-service on hand hygiene and hand washing was in July 2026. During an interview on 8/12/2026 at 9:45 a.m., the DON said hand hygiene, including hand washing was done before and after any procedure. She said PPE needed to be removed before leaving the resident's room. She said staff should not leave the resident's room with gloves on. The DON said quarterly and PRN in-services were done on hand hygiene and handwashing to prevent the transmission of infection to staff and residents. During an interview on 8/12/2026 at 10:15 a.m., CNA H said the process during a bed bath included changing gloves and performing hand hygiene during glove changes. She said it was important to follow infection control measures to avoid spreading germs to the residents and everyone else. CNA H said donning and doffing (putting on and taking off) PPE was done in the resident's room and realized she had walked out of the room wearing the gown and gloves. She said donning and doffing PPE in the resident's room was done to prevent spreading germs. She said Resident #99 was on EBP because of her feeding tube and required PPE to be worn when providing care to her. CNA H said she received an in-service in July 2026 on handwashing. 3. Record review of Resident #5's electronic face sheet dated 08/12/2026 reflected the resident was a 75 -year-old female admitted to the facility on [DATE]. Resident #5 had diagnoses which included the following: Cerebral Infarction Unspecified (stroke), Chronic Obstructive Pulmonary Disease Unspecified (lung condition that blocks airflow and makes it hard to breathe), Essential (Primary) Hypertension, Type 2 Diabetes Mellitus (high blood sugar levels), and Other Artificial Openings of Gastrointestinal Tract Status. Record review of Resident #5's Comprehensive MDS assessment, dated 06/07/26, reflected that she scored a 6 on her BIMS which reflected severely cognitively impaired. Record review of Resident #5 Physician's Order Summary dated 08/12/26 reflected orders for oxygen at 4LPM via nasal cannula every shift and oxygen saturation – check every shift. Observation and interview on 08/12/26 at 11:10 a.m. revealed Resident #5 had oxygen tubing labeled 08/02/26 and appeared soiled. Resident #5 said they had not changed her tubing recently and did not remember when the last time was that they changed it. During an interview on 08/12/26 at 11:14 a.m. with RN K, said she checked Resident #5's oxygen setting and tubing every shift. She said she checked the O2 setting earlier during her shift but had not noticed that the tubing should have been changed. RN K said it should have been changed at least weekly or when it was soiled. She said if it was not changed, it could cause the resident to have an infection. During an interview on 08/12/26 at 5:09am the DON said if there were orders to change Resident #5's tubing weekly, it should have been changed. She said it's changed if it's visibly soiled. Record review of the facility's policy titled Catheter Insertion and Care; Peripheral IV Dressing Changes, dated 05/01/2020, reflected Policy: Peripheral IV dressings will be changed when needed to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site. Procedure: 8. Label dressing with date, time, and initials. Record review of the facility's policy titled Infection Prevention and Control Program, dated 5/13/23, reflected 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. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and acted national standards. 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Record review of in-service sheet titled Infection Control: hand hygiene, PPE, don and doff, transmission-based precautions and enhanced barrier precautions dated 7/31/26, 8,4,26 and 8/7/26, indicated Handwashing: perform hand hygiene before and after resident care and after glove removal. EBP: Remove PPE before leaving resident room. Perform hand hygiene before and after PPE use. Record review of Lippincott Nursing Procedure, 9th edition, titled Bed Bath Procedure, dated 2022, stated For bathing with water, skin cleanser, and washcloth: Wash, rinse, and dry the patient's abdomen and then the groin and perineum. Remove and discard your gloves. Perform hand hygiene. Put on a new pair of gloves. Completing the procedure: Remove and discard your gloves and other personal protective equipment, if worn. Perform hand hygiene. Record review of facility's policy titled Oxygen Administration with a revised date of 07/2015 reflected; Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure 5. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. a. Date and initial tubing b. Change equipment every (7) seven days.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation and for two of two nutritional storage rooms. 1.The facility failed to ensure 1 one-gallon bottle of corn syrup with vanilla was labeled and dated in the dry food storage. 2. The facility failed to ensure expired nutritional supplement drinks in the nourishment rooms were disposed of. These failures could place residents who consumed food from the kitchen at risk for food borne illness. Findings included: 1. During observation in kitchen's dry storage room on 8/10/2026 at 8:40a.m., revealed a one-gallon bottle of corn syrup stored without a date. During an observation and interview and observation with DM N on 8/10/2026 at 8:50a.m., the DM was observed as she checked the one-gallon bottle of corn syrup and acknowledged there was no label on the bottle. The DM stated that the kitchen staff labeled food items as soon as they received them. The DM stated the facility's protocol was to label all food items to notify staff when it was received and to prevent foodborne illnesses. DM N stated she regularly in-serviced all kitchen staff on the topic of food storage and labeling. DM N stated that residents can get sick of food borne illness if they consume products that are expired. During an interview with DA O on 8/12/2026 at 10:08a.m., DA O said she had received in-service on the topic of food storage and labeling regularly. DA O said as soon as a food shipment was received, the food needed to be labeled and dated before it was stored. DA O said the negative outcome of having a food item not labeled would be that they would not know when the item was received and to prevent food-borne illnesses. During an interview with DA P on 8/12/2026 at 10:16a.m., she stated that it was important that all food was labeled to ensure that it was not expired. DA P stated that she received in-services on food storage and labeling on a monthly basis. DA P stated that if a resident were to consume expired food it could result in food borne illness. 2.During observation in the nutritional storage room on 8/12/2026 at 2:00p.m., revealed a 33.8 fluid ounce bottle of nutritional supplement was found with a Use Before 1 [DATE], date on it. During observation in a second storage nutritional room on 8/12/2026 at 2:12p.m., revealed four bottles of 33.8 fluid ounces of nutritional supplement were found with a Use Before 1 [DATE], date on them. During an interview with ADON F on 8/12/2026 at 2:05p.m., the ADON stated that that staff were in-serviced on checking expiration dates on products monthly and on a quarterly basis. ADON F stated that the Central Supply employee was responsible for checking nutritional room storage and disposing of expired products. ADON F was unable to answer what could happen to a resident if they consumed expired nutritional supplements. During an interview with ADON C on 8/12/2026 at 2:16p.m., she stated that nutritional supplements were given to patients that were fed through their peg tube (a flexible feeding tube placed through the skin of the abdomen directly into the stomach. It delivers liquid food, fluids, and medicines when a person cannot swallow safely). ADON C stated that staff are in-serviced and told to discard expired products. ADON C stated Central Supply employee were responsible for checking nutritional room storage and disposing of expired products. ADON C that if residents consumed expired nutritional supplements, they could get sick. During an interview with LVN Q on 8/12/2026 at 4:05p.m., she stated she gave nutritional supplements to residents that used it. LVN Q stated that she checked the expiration date on the nutritional supplement prior to using it. LVN Q stated that she received in-services monthly, and that staff were told to discard expired products. LVN Q stated a negative consequence of a resident consuming expired nutritional supplement would be that they could get sick with food borne illness. During an interview with the DON on 8/12/2026 at 4:12p.m., she stated that Central Supply was responsible for inspecting the items in the nutritional room storage and responsible for disposing of expired products. The DON stated staff are often in-serviced on disposing of expired products such as nutritional supplements. The DON was unable to say what negative consequences could occur if a resident consumed expired nutritional supplement. During an interview with CS R on 8/12/2026 at 4:45p.m., he stated he was responsible for the storage rooms. CS R stated that he stocked up the supplies such bandages and enteral supplies (medical devices, formulas and tools used to deliver nutrition and hydration and directly into a person's intestine when they cannot eat by mouth) such as nutritional supplements. CS R stated during inspections he disposes of expired products. CS R stated he attended in-services on food storage on a regular basis. CS R stated he did not know what could happen to residents if they consumed expired nutritional supplements. Record review on 8/12/2026 of policy labeled Food Storage dated 6/1/2019, revealed: Policy: To ensure that all food is served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and U.S. Food Codes and HACCP (Hazard Analysis Critical Control Point) guidelines: Procedure: 1. Dry storage room d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 7 residents (Resident #14) reviewed for unnecessary medications. The facility failed to ensure LVN B correctly documented Resident #14's behavior monitoring for Klonopin on 08/01/26, 08/04/26, 08/07/26, 08/08/26, and 08/11/26; Olanzapine on 08/03/26, 08/08/26, and 08/10/26; Lurasidone on 08/01/26, 08/08/26, 08/11/26, and 08/12/26. During the 6:00 a.m. to 2:00 p.m. shift. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Record review of Resident #14's admission record, dated 08/12/26, reflected a [AGE] year-old female readmitted on [DATE] and an original admission date of 12/27/2017. Her relevant diagnoses included major depressive disorder (a mental health condition causing lasting sad mood, loss of joy in daily life, and low energy for at least two weeks), schizoaffective disorder ( a chronic health condition that combines symptoms of schizophrenia, such as hallucinations or delusions-with a major mood disorder, like depression or bipolar mania), and dementia ( an umbrella term for a decline in mental ability severe enough to interfere with daily like, affecting memory, communication, and problem-solving). Record review of Resident #14's quarterly MDS assessment, dated 06/09/26, reflected a BIMS score of 15, which indicated her cognition was intact. Her active diagnoses included depression, major depressive disorder, and psychotic disorder. High-risk drug classes used during the last 7-days.antipsychotic, antianxiety, antidepressant, and anticonvulsant. Resident #14 had no behavioral symptoms.Record review of Resident #14's quarterly care plan assessment, dated 06/15/26, reflected: Problem: [Resident #14] uses antipsychotic medications (Latuda, Olanzapine, and clonazepam.) related to depression, schizoaffective disorder. Date initiated 12/12/23 and revised on 11/15/24. Interventions included administered mediation as ordered by MD, date initiated 04/14/24, and monitor behaviors. Notify MD of new or worsening behaviors. Date initiated 12/12/23. Record review of Resident #14's active physician order summary, dated 08/12/26, reflected an order for: Behavior Monitoring - Antianxiety Klonopin behavior codes: 0. None 1. Restlessness 2. Pacing 3. Continuous cry for help 4. Afraid/panic 5. Repetitious movements 6. Verbalizations of anxiety 7. Other (Document in PN) interventions(s): Document in PN every shift. Start date 04/14/24. Behavior Monitoring - antipsychotic (Olanzapine) behavior codes: 0. None 1. Mania 2. Auditory hallucinations 3. Visual hallucinations 4. Delusions 5. Paranoia 6. Grandiosity 7. Biting 8. Danger to self 9. danger to others 10. smearing feces 11. kicking 12. pinching 13. extreme fear 14. striking out/ hitting 15. other (document in PN) intervention(s): document in PN every shift for Prophylactic (a measure, medicine, or device intended to prevent disease, infection before it happens). Start date 02/07/25. Behavior Monitoring - lurasidone antipsychotic behavior codes: 0. none 1. mania 2. auditory hallucinations 3. visual hallucinations 4. Delusions: 5. Paranoia 6. Grandiosity 7. biting 8. danger to self 9. danger to others 10. smearing feces 11. kicking 12. pinching 13. extreme fear 14. striking out/ hitting 15. Other (document in PN) intervention(s): Document in PN every shift related to schizoaffective disorder, bipolar type. Start date 12/09/23. Record review of Resident #14's August 2026 MAR reflected: Behavior Monitoring - Antianxiety Klonopin behavior codes: 0. None 1. Restlessness 2. Pacing 3. Continuous cry for help 4. Afraid/panic 5. Repetitious movements 6. Verbalizations of anxiety 7. Other (Document in PN) interventions(s): Document in PN every shift. LVN B entered an X under code on 08/01/26, 08/04/26, 08/07/26, 08/08/26, and 08/11/26 during the 6:00 a.m. to 2:00 p.m. shift Behavior Monitoring - antipsychotic (Olanzapine) behavior codes: 0. None 1. Mania 2. Auditory hallucinations 3. Visual hallucinations 4. Delusions 5. Paranoia 6. Grandiosity 7. Biting 8. Danger to self-9. danger to others 10. smearing feces 11. kicking 12. pinching 13. extreme fear 14. striking out/ hitting 15. other (document in PN) intervention(s): document in PN every shift. LVN B entered an X under code on 08/03/26, and 08/08/26, 08/10/26 during the 6:00 a.m. to 2:00 p.m. shift. Behavior Monitoring - lurasidone antipsychotic behavior codes: 0. none 1. mania 2. auditory hallucinations 3. visual hallucinations 4. Delusions 5. Paranoia 6. grandiosity 7. biting 8. danger to self-9. danger to others 10. smearing feces 11. kicking 12. pinching 13. extreme fear 14. striking out/ hitting 15. Other (document in PN) intervention(s): Document in PN every shift related to schizoaffective disorder, bipolar type. LVN B entered an X under code on 08/01/26, 08/08/26, 08/11/26 during the 6:00 a.m. to 2:00 p.m. shift. During a telephone interview on 08/12/26 at 5:14 p.m., LVN B said she was Resident #14's charge nurse. LVN B was asked if her MAR signature was XXXX and she said yes to the first three characters but said she did not remember her last character. LVN B was asked if she had monitored Resident #14's behaviors for Klonopin, Olanzapine, and lurasidone on 08/01/26, 08/04/26, 08/07/26, 08/08/26, 08/10/26, 08/11/26, and 08/12/26. the month of August 2026 and she said yes, I did. LVN B said she I would not be able to tell you why I put an X instead of a numerical code. LVN B said she had been in-serviced in the past on the topic of medication administration and was not able to say if there were any negative outcomes to Resident #14 for entering an X on the MAR. During an interview and observation on 08/12/26 at 5:30 p.m., ADON C was observed as she reviewed Resident #14's electronic medical record and said LVN B had signed of behavior monitoring for Klonopin, olanzapine, and lurasidone on 08/01/26, 08/04/26, 08/07/26, 08/08/26, 08/10/26, 08/11/26, and 08/12/26. ADON C said LVN B called her after being interviewed by this surveyor and told her that she was not sure why she had entered an X instead of a numerical code as ordered. ADON C said LVN B told her, she would sometimes put an X for no behaviors. ADON C was asked if there were any negative outcomes to Resident #14 for not entering the correct behavior code when she was being monitored for Klonopin, olanzapine and lurasidone and she answered, I don't know. ADON C said nursing staff were regularly in-serviced on the topic of medication administration and documentation. During an interview on 08/12/26 at 6:13 p.m., the DON said she was very familiar with Resident #14. She said Resident #14 had several mental disorders that she was being treated for. The DON said nursing staff and medication aides should follow the residents' orders. She said she was not sure why Resident #14's electronic medical record (MAR) would accept an alphabetical code when it required a numerical code. She said she would be contacting their IT department to look into it. The DON said Resident #14 had not had any behaviors in a while. She said Resident #14 was doing well with the medications she was taking for her mental illness. The DON said the negative outcome to Resident #14 for not entering the correct code would be negative behaviors would not be addressed immediately. The DON said nursing staff were regularly in-serviced on the topic of medication administration and documentation. Record review of the facility's Documentation in Medical Record policy, implemented on 10/24/22, reflected: Policy: Each residents' medical record shall contain an accurate representation in the actual experiences of the resident and including enough information to provide a picture of the residents' progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 of 4 (Resident #145) reviewed for notifying the LTC Ombudsman of the residents' discharge.Resident #145 was discharged home on [DATE] without a notice to the LTC state ombudsman.This failure could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.Findings were:Record review of Resident #145's admission Record dated 08/12/26 revealed a [AGE] year old female with an admission date of 05/15/26. Resident #145 had a diagnoses of Post-laminectomy Syndrome ongoing back, neck, or radiating limb pain, Anemia (body does not have enough healthy red blood cells to carry oxygen to body tissue), Muscle Wasting and Atrophy (muscle shrinkage and loss of strength), and Need for assistance with Personal Care.Record review of Resident #145's MDS discharge date d 05/16/26 revealed Resident #145 was Independent in Cognitive Skills for daily Decision making. Resident #145 was discharged home on [DATE].Record review of Resident #145's electronic medical record revealed a progress note dated on 05/16/26 which stated Resident #145 planned to be discharged to home AMA.Record review of the Discharge Summary & Post-Discharge Plan of Care dated 03/20/26 revealed Resident #145 was discharged home on [DATE].In an Email communication on 08/12/26 at 9:50 AM, the Ombudsman revealed that she had not received a resident discharge notice for Resident #145 from the facility.During an interview on 08/12/26 at 2:15 PM LVN M said she sent notifications to Ombudsman via email every 2 weeks notifying them of residents who had been discharged for the month. She said she did not know why notification of Resident #145 was not sent. LVN M said Ombudsman should have been notified of Resident #145's discharge. LVN M said she wouldn't know how to answer if there had been any negative outcomes for this resident. During an interview on 08/12/26 at 5:04 PM, the DON said they notify Ombudsman monthly on all residents that have been discharged for the month. She said she didn't know how Resident #145 was missed and not sent. She said it should have been sent as well.On 08/12/26 at 2:25 PM a copy of the facility policy regarding notification to Ombudsman upon a resident discharge was requested but was informed by LVN M that the facility did not have a policy specifically on notifying Ombudsman upon a resident discharge.

Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for 1 of 6 (Resident #40) residents reviewed for comprehensive care plan revisions. The facility failed to ensure Resident #40's care plan reflected a diagnosis of PTSD. The facility failed to ensure Resident #40's care plan reflected that he could not use his pad light. These failures could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #40's admission record, dated 08/10/26, reflected an admission date of 02/13/23. His relevant diagnoses included post-traumatic stress disorder (a mental health condition that can develop after you go through or see a scary, dangerous, or life-threatening event), Alzheimer's disease (a progressive brain disorder and the most common cause of dementia), and dementia (a decline in memory, language, problem-solving, and other thinking skills that interferes with daily life). Record review of Resident #40's quarterly MDS assessment, dated 06/29/26, reflected a BIMS score of 03, which reflected his cognition was severely impaired. Resident #40's active diagnoses include post-traumatic stress disorder. Record review of Resident #40's quarterly care plan, dated 06/16/26, reflected: Problem: [Resident #40]is at risk for falls, r/t history of falls, dementia, weakness. Date initiated: 02/15/23 and revised on 03/28/24. Interventions: be sure [Resident #40's] call light is within reach and encourage the resident to use it for assistance. Dated initiated 05/15/23. Record review of Resident #40's medical diagnoses included Post-Traumatic Stress Disorder, Unspecified. Effective 01/02/2025. Resident #14's care plan did not address his PTSD diagnosis that was effective 01/02/2025.During an observation and interview on 08/10/2026 8:58 a.m., Resident #40 was observed lying in bed awake and his call light was observed in his trashcan. Resident #40 could not answer questions regarding his call light. During an interview and observation on 08/10/26 at 8:55 a.m., CNA A said she was assigned to Resident #40's hall. CNA A said Resident #40 had just been brought back from the dining room. CNA A was observed removing Resident #40's pad light out of the trash can. She said she must have dropped the pad light in the trash can while she was assisting Resident #40 back to bed. CNA A said Resident #40 was known to being unable to use his pad light due to his dementia and required frequent monitoring. CNA A said in the past, she had informed Resident #40's charge nurse of he was unable to use his pad light. She said Resident #40's family member would visit him several times a day and if he needed anything, she would call them. She said Resident #40's door was kept open and whenever she would walk by his room, she made sure she glanced over to check on him. CNA A said she had been in-serviced on the topic of call lights. CNA A said she was not aware Resident #40 had PTSD. She could not say what the negative outcomes of not having Resident #40's care plan include was not able to use his pad light or that he had a diagnosis of PTSD. During an interview on 08/10/2026 at 10:40 a.m., LVN B said Resident #40 was a veteran and required frequent monitoring due to him not being able to use his pad light. LVN B said any staff that would enter Resident #40's room were responsible to ensure his pad light was within reach even though he was not able to use it due to his diagnosis of dementia. LVN B said Resident #40 had a diagnosis of PTSD but could not identify any of his triggers. LVN B said she had been in-serviced on the topics of call lights and PTSD. She said there were no negative outcomes to Resident #40 not having his care plan include that he was not able to use his pad light because staff would round on him frequently, kept his door open, and his family member would visit several times a day. LVN B could not say if there were any negative outcomes to Resident #40's care plan not including his diagnosis of PTSD. During an interview on 08/10/2026 at 10:51 a.m., ADON C said Resident #40 was a veteran and had a diagnosis of dementia and PTSD. She said all staff who entered Resident #40's room were responsible to ensure his pad light was within reach. She said she had not been informed Resident #40 was unable to use his pad light; she would have care planned it. ADON C could not identify Resident #40's PTSD triggers. ADON C said a negative outcome to Resident #40 not having his care plan include that he was unable to use his pad light could be that new staff would not know he was unable to use it. She said the facility provided in-services on the topic of call lights and PTSD to all direct care staff. During an interview and observation on 08/11/26 at 2:29 p.m., MDS D said Resident #40 was a veteran. She was observed as she reviewed Resident #40's electronic medical record and said he was diagnosed with PTSD on 01/02/25. MDS D said Resident #40's diagnosis of PTSD had not been care planned. She said a negative outcome for Resident #40 not having his diagnosis of PTSD care planned could be that staff would not know his triggers and unintentionally expose him to a situation that might trigger a trauma response. MDS D said she was not aware Resident #40 could not use his pad light. She said the facility's protocol would be to have the CNAs inform the resident's charge nurse of any changes and then the charge nurse would discuss the change during their IDT meetings. She said once the change had been discussed, proper interventions would be implemented and care planned. MDS D said a negative outcome to Resident #40's care plan include he was unable to use his pad light would be staff would not be aware of him not using it and would not get the proper assistance when rounding. During an interview and observation on 08/11/26 at 3:00 p.m., ADON E (acting DON) said Resident #40 was a veteran. She was observed as she reviewed Resident #40's electronic medical record and said he had a diagnosis of PTSD which should have been care planned. She said the importance of care planning Resident #40's PTSD would be for staff to know his triggers. She said residents with a diagnosis of PTSD had certain triggers that needed to be avoided in order to escalate the symptoms of PTSD. ADON E said a negative outcome for Resident #40 not having his PTSD care planned would be that he could be exposed to his triggers and could experience behaviors. ADON E said Resident #40's care planned did not include he was unable to use his pad light, and a negative outcome could be he would not be able to get the assistance he may need. ADON E said all direct care staff were in-serviced on the topic of call lights and PTSD/trauma. Record review of the facility's policy Care Plan Revisions Upon Status Change, dated implemented 10/24/22 reflected: Policy: 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. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2.Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDs Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. Record review of the facility's Trauma Informed Care, date implemented 10/13/22, reflected: Policy: It is the policy of this facility to provide care and service which, in addition to meeting professions standards, are delivered using approaches which are culturally competent, account for experiences and preference, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Policy explanation and compliance guidelines.6. The facility will identify triggers which may re-traumatize residents with history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents' care plan.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents reviewed for PASRR. (Resident #13).The facility failed to refer Resident #13 for PASRR Level II assessment when Resident #13, after her admission, was later diagnosed with a mental illness of Major Depressive Disorder.This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning. Findings were:Record review of Resident #13's electronic face sheet dated 08/12/26 reflected the resident was a 93 -year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included the following: Anxiety Disorder (ongoing, excessive fear, worry or panic) with an onset date of 08/08/25, Major Depressive Disorder, Recurrent, Mild (experienced at least two major depressive episodes separated by a period of normal mood, and symptoms causing minor impairment in daily life) with an onset date of 12/23/25, and Essential (Primary) Hypertension (high blood pressure) with an onset date of 08/08/25.Record review of Resident #13's quarterly MDS assessment dated [DATE], reflected she scored a 14 on her BIMS which indicated cognitively intact. Record review of Resident #13's quarterly care plan dated 05/21/26 reflected Resident #13 has Major Depressive Disorder, Panic Disorder, date initiated 05/21/26.Record review of Resident #13's Order Summary Report dated 08/12/26 revealed Resident #13 was not on medication for Major Depressive Disorder.During an interview on 08/11/26 at 10:20 AM Resident #13 said she was treated well at the facility. She said sometimes she felt nervous but she did not know why.During an interview on 08/11/26 at 3:34 PM MDS D said Resident #13 was diagnosed with Major Depressive Disorder in December 2025 and said she had completed the form 1012 for further evaluation. She said she had not submitted it on the LTC Online Portal because it needed a physician signature. She said she had tried for about a month to obtain the signature but was not able to meet with the physician to have it signed. She said she did not document when completed the 1012 form or when she had made attempts to obtain physician's signature. MDS D said Resident #13 possibly won't receive proper services that she might qualify for if she is not evaluated for them. As per MDS D, the facility did not have a policy for PASRR Evaluations.

Based on 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, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #137) reviewed for care plans.The facility failed to ensure Resident #137's care plan included her triggers for a diagnosis of Post Traumatic Stress Disorder (PTSD).This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included:Review of Resident # 137's admission Record dated 8/12/2026, reflected a [AGE] year-old female with an admission date of 10/05/2025. Her relevant diagnoses included major depressive disorder (clinical depression, common mental health condition), paranoid personality disorder (mental health condition where a person lives with a constant, extreme distrust and suspicion of everyone around them, even when there is no clear reason to feel that way.), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), and post-traumatic stress disorder (mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, or violent crime).Record of Resident # 137's quarterly MDS assessment, dated 8/01/2026, reflected her BIMS score of 12, which indicated moderate cognitive impairment. Section I - Active Diagnoses, included a diagnosis of post-traumatic stress disorder.Review of Resident # 137's quarterly care plan, date revised 2/20/2026, revealed Resident #137 has been identified as having positive PASRR status related to mental illness: PTSD, major depression dx with history of suicidal ideations. Interventions included: Specialized services Coordination - provided by the LMHA. Coordinate services with a representative from the LMHA. Resident #137 quarterly care plan, date revised 5/19/2026, revealed Resident #137 uses psychotropic medications (buspirone, sertraline, doxepin) r/t anxiety, depression, PTSD, bipolar disorder. Interventions included: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q shift.Review of Resident # 137's care plan revealed there were no triggers for a diagnosis of PTSD addressed.During an interview on 8/11/2026 at 3:35 p.m., Resident #137 said she had a history of PTSD and was receiving counseling services. She said she was very happy and the counseling services and had been doing well.During an interview on 8/12/2026 at 4:00 PM MDS D said PTSD triggers were not included in Resident #137's care plan. She said, generally, the IDT discussed PTSD and identified resident's triggers which were added to goals and interventions in the resident's care plan. MDS D said examples of triggers were loud noises and coming up to a resident from behind. MDS D said not knowing a resident's triggers could accidentally trigger a behavior and potentially cause the resident distress. She said in-services on trauma informed care were done yearly.During an interview on 8/12/2026 at 4:30 p.m., the DON said PTSD diagnoses should have included triggers in the care plan. She said the care plan provided guidance to the staff and informed them of potential triggers to prevent the residents from having a behavioral episode. The DON said the staff had mandatory yearly training on trauma informed care. She said negative outcomes from not including triggers in a care plan included not having met the resident needs and potential for re-traumatizing. Record review of the facility policy title Trauma Informed Care, dated 10/13/22, stated Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards are delivered using approaches which are culturally competent, account for experience and preferences and address the needs of trauma survivors by minimizing triggers and / or re-traumatization. Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: . 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan.Record review of facility policy titled Comprehensive Care Plan dated 10/4/22, stated, Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: .g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident. As well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (West Wing Medication Storage room) of two reviewed for pharmacy services.The facility failed to dispose of a bagged IV antibiotic medication, which was labeled Daptomycin (medication used to treat bacterial infections) and had an expiration date of 8/07/2026. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The findings included: During an observation on 8/11/2026 at 2:11 p.m. of the [NAME] Wing Medication Storage room, revealed that a refrigerated bagged IV antibiotic of Daptomycin 350 mg/ 50 mL had an expiration date of 8/07/2026.During an interview on 8/11/2026 at 2:30 p.m., ADON F said the expired IV medication should have been placed in the locked cabinet used for discontinued medication. He said the antibiotic regimen had been completed on 7/19/2026. ADON F said the nurses were responsible for removing discontinued and/or expired medication and placing it in the designated locked cabinet. He said the pharmacy consultant was at the facility on 8/07/2026 and checked for expired medication. ADON F said there were no negative outcomes for Resident #1 because he had completed the course of antibiotics in July 2026 and had not received the medication in August 2026. He said an in-service on medication storage was done but could not remember the date.During an interview on 8/12/2026 at 10:25 p.m., the DON said she and the ADONs were responsible for checking the medication storage rooms and removing expired medication and medications belonging to residents that had been discharged from the facility. She said nurses were also responsible for checking and removing expired medication. The DON said there was no negative outcome for the resident because he did not receive the medication. She said the five rights of medication administration had to be followed to avoid potential risk of medication errors. The DON said the expired medication should have been processed for destruction. She said that on 8/06/26, the facility had performed drug destruction and should have included the expired bagged IV antibiotic. The DON said the last in-service on medication administration was done in June 2026.Record review of the facility policy title Expiration Dating and Expired Medications, dated 10/01/19, revealed Policy- Drugs which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. The facility is to strictly adhere to the expiation dating. Procedure- .8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medication will not be administered in the Facility. All expired medications will be disposed of per Facility policy.

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 (Residents #1), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1's Morphine orders included pain parameters for when the medication should be given. This failure could place residents at risk for not receiving medication as ordered. Findings included: Record review of Resident #1's admission record, dated 07/02/26, reflected a[AGE] year-old male who was re-admitted on [DATE] and an original admission date of 05/20/26. His relevant diagnoses included Parkingson's disease (a progressive neurological disorder that primary affects movement), dementia (a decline in mental ability severe enough to interfere with daily life), and abnormalities of gait and mobility (any irregular walking pattern or difficulty moving). Record review of Resident #1's 5-day Medicare MDS assessment, dated 06/08/26, reflected a BIMS score of 07, which indicated his cognition was moderately intact. Record review of Resident #1's comprehensive care plan, dated 06/16/26, reflected:Problem: [Resident #1] is on pain medication therapy morphine r/t hip surgery. Date initiated:07/01/26. Interventions: Administer analgesic ( any medication designed to relieve pain without causing a loss of consciousness) medications as ordered by physician. Record review of Resident #1's physician order summary, dated 07/02/26, reflected 3 morphine orders: Morphine Sulfate (concentrate) oral solution 20 mg/ml (morphine sulfate) give 0.75 ml by mouth every 1 hours as needed for pain/sob. Start date 07/02/26. Morphine Sulfate (concentrate) oral solution 20 mg/ml (morphine sulfate) give 0.50 ml by mouth every 1 hours as needed for pain/sob. Start date 07/02/26. Morphing Sulfate (concentrate) oral solution 20 mg/ml (morphine sulfate) give 1 ml by mouth every 1 hours as needed for pain. Start date 07/02/26. Record review of Resident #1's July 2026 MAR, reflected Morphine Sulfate oral solution 20 mg/ml had not yet been administered. Record review of Resident #3's vital pain history reflected he had not been in pain since re-admission [DATE]. During an observation on 07/02/26 at 10:58 a.m., Resident #1 was observed lying in bed asleep. No facial grimacing was observed and no signs of distress were noted during the observation. During an interview and record review on 07/02/26 at 11:50 a.m., LVN A said Resident #1 was re-admitted on [DATE] after a short hospital stay. She said Resident #1 had been placed under hospice services while hospitalized and upon readmission, the hospice agency ordered prn morphine for pain and sob. She reviewed Resident #1's electronic medical record and said he had 3 PRN orders for morphine and all 3 were missing pain parameters. LVN A said it was the facility's protocol to have an order for each dose of narcotics for monitoring purposes. LVN A said Resident #1 was non-verbal and nursing staff relied on facial grimacing to determine his pain level. She said Resident #1's prn morphine order required pain parameters to know much to administer. She said Resident #1 had not been administered morphine since he was re-admitted . She said she was familiar with the pain management parameters and the appropriate morphine dose to administer based on Resident #1's facial grimacing. She said she would administer 0.50 ml of morphine for a pain level of 1-3, 0.75 ml for a pain level of 4-7, and 1 ml for a pain level of 8-10. LVN A said there were no negative outcomes to Resident #1 not having his morphine order include pain parameters because he had not been administered morphine yet and she would know who much to give. During an interview and record review on 07/02/26 at 12:10 p.m., the ADON said Resident #1 had a diagnosis of dementia and had difficulty verbalizing his pain. She said nursing staff relied on his facial grimacing to determine his level of pain. The ADON reviewed Resident #1's electronic medical record and said Resident #1 was readmitted on [DATE] after a short hospital stay. She said Resident #1 had been placed under hospice services while hospitalized and upon readmission to the facility, the hospice agency ordered prn morphine for pain and sob. The ADON said Resident #1's morphine orders were missing pain parameters. She said pain parameters were important to determine how much medicine to give. She said it was the responsibility of the admitting nurse to ensure all orders were clear and complete. The ADON said Resident #1 had not yet been administered morphine since his readmission. The ADON said one of her morning responsibilities was to review all re/admitted residents orders to ensure they were written and followed correctly. She said she had not had time yet to review any orders today (07/02/26). She said nursing staff were frequently in-serviced on physician orders and medication administration. She said a negative outcome for Resident #1 not having pain parameter on his morphine order would be that he could be over sedated. During an interview and record review on 07/02/26 at 12:50 p.m., the DON was observed as she reviewed Resident #1's electronic medical record and said Resident #1 had been readmitted to the facility on [DATE] after a short hospital stay. She said Resident #1 had been placed under hospice care while hospitalized and upon admission, the hospice agency had ordered prn morphine for pain and sob. She said Resident #1 had a diagnosis of dementia and had difficulty communicating his pain level. She said nursing staff relied on Resident #1's facial grimacing to determine his pain level. The DON said upon his readmission, Resident #1 had not yet been administered morphine. She said Resident #1's morphine orders were missing pain parameters. She said it was the facility's protocol to have pain scale for residents who had dementia or have difficulty verbalizing pain. The DON said it was the responsibility of the admitting nurse to ensure all orders were clear and complete. She said Resident #1 had just been admitted last night and said as soon as the ADON or herself reviewed Resident #1's order, they would have determined the pain parameters were missing but state surveyor saw it first. The DON said a negative to Resident #1 not having pain parameters on his morphine orders would be the potential of being under or over dose and not given the adequate dose to meet his needs. Record review of the facility's Medication Orders policy, revised on 10/01/2019, reflected: Policy: Medications are administered only upon clear, complete, and signed order of a person lawfully authorized to prescribe.Procedure: 1. Elements of the medication orderMedication orders specify the following.c. dosage.

Based on record reviews and interviews, the facility failed to ensure that a medication was properly labeled for 1 of 2 residents (Resident #1) that were reviewed for pharmacy services.The facility failed to ensure that a tube of Permethrin External Cream 5% (a topical medication primarily used to treat scabies (skin rash)) was labeled with Resident #1's name.This failure could place residents at risk of not receiving prescribed medications as ordered and adverse effects of medications due to incorrect labeling.Findings included:Record review of Resident #1's admission Record, dated 05/07/26, revealed an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE] with an original admission date of 10/19/24. Record review of Resident #1's Diagnosis Report, reflected a primary diagnosis of vascular dementia (result from conditions that damage the brain's blood vessels), muscle wasting and atrophy (partial or complete wasting away of a part of the body), Type 2 diabetes (condition where the body develops insulin resistance, causing high blood sugar levels), hemiplegia paralysis affecting one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and heart disease (conditions affecting the heart's structure and function).Record review of Resident #1's Quarterly MDS assessment, dated 04/20/26 revealed Resident #1 had a BIMS score of 01, which indicated she was severely cognitively impaired. Record review of Resident #1's Completed Orders for October 2025 revealed an order for Permethrin External Cream 5% dated 10/27/25: Apply to affected area topically for one time only for Rash for 1 day.Record review of Resident #1's MAR for October 2025, revealed Permethrin External Cream 5% had been administered on 10/28/25 by LVN B.Record review of Resident #1's Progress Note by LVN B dated 10/28/25 stated, Permethrin treatment done today at 7:15pm.During a record review on 05/05/26 at 8:42am of a photograph that was submitted for review from Resident #1's RP. The photograph was time-stamped Tuesday October 28, 2025, 7:17pm. The photograph revealed a tube of Permethrin External Cream 5% that did not have Resident #1's name on the label. During an interview on 05/05/26 at 8:42am with Resident #1's RP revealed she was aware that Resident #1 received a topical medication that did not have Resident #1's name on the label. The RP stated Resident #1 received the order for Permethrin in late October of 2025 but Resident #1's name was not on the label. RP stated she was in the room when LVN B administered the medication. RP stated when LVN B was not looking, she took a photograph of the medication tube when she noticed it did not have Resident #1's name on it. RP stated she did not alert LVN B that the medication tube did not have Resident #1's name on it because it was still the correct medication ordered.During an interview on 05/07/26 at 2:15pm, LVN B stated he remembered that he administered Permethrin once to Resident #1. LVN B stated he did not recall seeing Resident #1 name on the label. LVN B stated it was important to check the name on the label because the medication could be used for a different purpose. LVN B stated results of that could have caused an allergic reaction.During an interview on 05/07/26 at 5:03pm, the DON stated she was not aware that the medication administered did not have Resident #1's name on the label. She stated had she known, she would have addressed it right away. DON stated facility nurses were educated to ensure that the medications were given to the correct resident. DON stated it was important to ensure that medications indicated were to treat whatever it was indicated for.Review of the facility's Labeling of Medications with revision date of 10/01/19 revealed: Policy: All drugs and biological in the Facility are labeled in accordance with all Federal and State regulations.Procedure: 2. Prescription medications will be labeled with the following informationB. Name of Resident

Based on record review and interviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for administration.The facility failed to document skin integrity findings into the skin assessments for continued monitoring.This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care to meet their needs.Findings included:Record review of Resident #1's admission Record, dated 05/07/26, revealed an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE] with an original admission date of 10/19/24. Record review of Resident #1's Diagnosis Report, reflected a primary diagnosis of vascular dementia (result from conditions that damage the brain's blood vessels), muscle wasting and atrophy (partial or complete wasting away of a part of the body), Type 2 diabetes (condition where the body develops insulin resistance, causing high blood sugar levels), hemiplegia paralysis affecting one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and heart disease (conditions affecting the heart's structure and function).Record review of Resident #1's Quarterly MDS assessment, dated 04/20/26 revealed Resident #1 had a BIMS score of 01, which indicated she was severely cognitively impaired. Record review of Resident #1's Total Body Skin assessments dated 06/06/25, 06/13/25,06/20/25,06/21/25, 06/27/25, 07/04/25, 07/11/25, 07/19/25, 17/26/25,08/02/25, 08/11/25, 08/13/25 and 08/20/25 indicated no new skin findings.Record review of Resident #1's skin checks dated 09/11/25, 09/18/25, and 09/29/25 indicated no new skin findings. Record review of Resident #1's progress note dated 07/10/25 revealed a nursing note by ADON A. Under the skin section, the following was noted: Skin: Skin Color: Normal for ethnic groupSkin Temperature: Warm/drySkin Turgor: NormalSkin intact: YesDuring an interview on 05/05/26 at 8:42am with Resident #1's RP, RP stated she notified staff in June of 2025, that resident had developed a rash on her legs. RP stated rash was not properly addressed until October of 2025. RP stated she was aware that Resident #1 had a skin scrape test (a quick, minimally invasive diagnostic test where a healthcare provider gently scrapes the surface of a skin lesion to collect skin cells. It is primarily used to check for fungal infections like parasites such as scabies) done and the results were negative, but RP insisted Resident #1 needed to be treated. RP stated the rash had since resolved.During an interview on 05/07/26 at 11:48am with ADON A stated he would round with the Wound Care NP and would document wound progressions, changes, and new skin issues. ADON A stated he was aware that resident had something on her skin in June of 2025. ADON A stated that what he saw on resident was not a rash but more like petechiae (tiny, non-raised red, purple, or brown spots caused by small broken blood vessels leaking blood under the skin). ADON A stated he did not document the finding because it was being monitored weekly by the NP and himself while doing wound care rounds. ADON A stated it was not until October of 2025 that Resident #1 received an order for a skin scrape test. ADON A stated he was the one that performed the test and results came back negative for scabies. ADON A stated that even though the results were negative, Resident #1's RP insisted for Resident #1 to be treated for scabies. ADON A stated a few weeks after the treatment, the rash resolved. ADON A stated Resident #1 did not have a rash at this time. ADON A stated it is important to document all new skin findings because it established a baseline to track changes over time and diagnose underlying diseases.During an interview on 05/07/26 at 5:38pm, the NP stated she did not remember if Resident #1 had a rash or skin issue in June or July of 2025. The NP also stated she did not remember if she had documented it or not. The NP stated that if Resident #1 had a skin issue, she would have expected ADON A to document it on his notes for continued monitoring.Review of the facility's Documentation in Medical Record policy, dated 10/24/22, reflected: Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

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 13 of 13 residents reviewed for infection control practices. The facility failed to ensure all EBP residents in the facility had PPE available immediately near the residents' rooms. This failure could place residents at risk for cross contamination and infection.Findings included: Record review of the list of residents on precautions, from the ICN, dated 08/20/2025, revealed 13 residents in the facility were on EBP, and 4 residents were on contact precautions. In an observation on 11/17/2025 at 1:45 PM, it was observed multiple rooms, to include rooms on Halls 100, 300, 400, 500, 600 and 700, had EBP signage which revealed providers and staff must wear gloves and gown for the following high contact activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and/or wound care. The rooms that were on EBP had appropriate signage located on the doors, but there was no PPE located on the doors or next to the rooms. It was observed the rooms which had contact precaution signs on the doors had PPE located on the doors or next to the rooms. In an interview on 11/19/2025 at 3:05 PM, ADON-A stated only residents on contact precautions had PPE on their doors or next to their rooms because it had to be utilized every time someone entered that room, but PPE for residents on EBP was kept in the supply closet located on each unit, as well as on the linen carts, since it only had to be utilized for high contact activities. After reviewing all of the linen carts on each hall, ADON-A stated there was no PPE on the carts, only in the supply closets located on the 200 hall on Unit A, and the 800 hall on Unit B. ADON-A stated she knew EBP required PPE for high contact activities for residents with wounds, indwelling medical devices, or certain contagious illnesses, but was not sure about policies, guidelines, or recommendations for where it should be kept or placed for residents on EBP. In an interview on 11/19/2025 at 3:15 PM, ADON-B stated PPE was not kept next to any of the EBP rooms or on their doors; he stated PPE was only kept on the door of or next to residents' rooms on contact precautions. ADON-B stated there was a supply closet located on the 200 hall in Unit A and the 800 hall in Unit B which had PPE in it, and the staff knew to go to these closets to get PPE prior to going into the EBP rooms to provide care. ADON-B stated visitors knew which PPE to utilize in rooms on EBP because the signage on the door notified visitors to check with the nurses' desk prior to entering the room, and they were then instructed on and provided the appropriate PPE to use if they were going to provide any care. Upon looking at the signage on the door, ADON-B stated it did not reveal visitors were to come to the nurses' station prior to entering the room. ADON-B stated he was not sure what the recommendations were for the facility infection control policy or enhanced barrier policy in regard to placing or storing PPE for EBP rooms, as well as he was not sure what the CDC guidelines or recommendations for placing or storing PPE for EBP rooms were other than it should be made available and utilized with high contact activities for residents with draining wounds, certain infections, and/or indwelling medical devices. In an interview on 11/19/2025 at 4:05 PM, LVN-E stated EBP precautions were used for high contact on residents with draining wounds, certain infections, and indwelling medical devices, and the PPE involved was typically gown, gloves, and sometimes face shields. LVN-E stated the PPE for residents on EBP was located in the supply closet on the 300 hall, and it was tedious to go back and forth to the area to grab supplies for the EBP rooms. She stated she believed the PPE was supposed to be kept right outside of the residents' rooms which were on EBP just like residents on contact precautions, but she was not sure. In an interview on 11/19/2025 at 4:13 PM, CNA-F stated EBP precautions were used for residents with wounds or things such as foley catheters or g-tubes to keep from spreading infection to these residents. She stated she had to go to the supply room on the 300 hall to get PPE supplies each time she went in to care for a resident on EBP. She stated it was difficult to go back and forth so much to get new PPE supplies every time she had to provide care. She was not sure where they were supposed to be kept, but the supply room on the 300 hall was where they were kept on her side of the facility. CNA-F stated the residents who were on contact precautions had the PPE located on the door of their room, and it was much easier to grab it at the door to put on prior to entering their room for anything. In an interview on 11/19/2025 at 4:44 PM, the DON stated residents who were on EBP did not have PPE kept at or close to their room since it was only required for staff rendering high contact activities. The DON stated staff knew they had to go to the supply room to grab PPE prior to going into a resident's room which was on EBP. The DON also stated families of these residents were in-serviced over EBP as to what PPE was required for which activities. She stated there were 2 supply rooms, so one on each unit, and they were kept locked, but the staff knew the codes to be able to go in and get PPE. If family, friends, or caregivers needed PPE, the staff obtained it for them. The DON stated if she were a CNA, she would grab enough PPE to keep it handy on the linen carts so as to not have to go back and forth between all the residents' rooms on EBP and the supply closets. The DON stated the facility was not required to have the PPE for residents on EBP in any specific location as long as it was available in the facility. The DON defined the word immediately as meaning fast or readily available, but felt like the definition of the word immediately was meant differently for the EBP PPE protocol than for contact precautions PPE protocol. She stated for contact precautions immediately means you had to have it ready right then and there, but for EBP immediately means you just needed to have PPE readily available in the facility, and she stated down a separate hall to the supply closet could have constituted as immediately near or outside an EBP room. In an interview on 11/19/2025 at 5:11 PM, the ICN stated she was the person responsible for placing precautions signs and PPE, and PPE was only kept next to the residents' rooms which were on contact isolation, but the CNAs knew to go to the supply rooms on each unit and grab PPE prior to going into a resident's room on EBP. She stated as long as PPE was made available in the facility residents on EBP, it did not matter where it was located. The ICN stated the CDC guidelines and the facility's infection control policy just stated to make PPE available but did not state where it had to be located. After reading the infection control policy, and enhanced barrier policy, the ICN stated PPE needed to be located immediately near or outside the residents' rooms. The ICN stated immediately means right away. The ICN stated the supply room down the hall did constitute immediately since the staff were able to get to the supplies and get what's needed. Immediately availability for PPE for EBP and Contact precautions, even if worded the same in the policy and CDC regulations, was not the same, even if stated make PPE available immediately. The ICN continued to state immediately did not mean the same for residents on EBP as immediately did for residents on contact precautions. The ICN also stated the facility used CMS guidelines, as well as HHSC's infection prevention and control guidelines for residents on precautions. Record review of the facility's Infection Prevention and Control policy, dated 05/13/2023, revealed 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. 13. A. Resident, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and the conditions for which to notify the nursing staff. Record review of the facility's Enhanced Barrier policy, dated 04/05/2024, revealed 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provided jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure all alleged violations or allegations involving abuse for Resident #1 were reported to the proper entities immediately or as required by law on 08/19/2025. This failure could place residents at risk for abuse or further potential for abuse due to unreported allegations of abuse and neglect.Findings include: Record review of Resident #1's face sheet, dated 11/19/2025, revealed an [AGE] year-old male who was originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE]. Resident #1's pertinent diagnoses included PTSD (a mental health condition which was caused by an extremely stressful or terrifying event), Dyspnea (commonly known as shortness of breath, or the sensation of not being able to get enough air into the lungs), Depression (a mood disorder which causes a persistent feeling of sadness and loss of interest and could interfere with daily living), and Chronic Systolic Heart Failure (a condition in which the left ventricle of your heart was weak and cannot pump blood efficiently). Record review of Resident #1's change of condition note, dated 08/19/2025, revealed Resident #1 reported another resident wandered into his room and hit him on the right side of his forehead when he told him to leave. No injuries were noted. Record review of Resident #1's progress note, dated 08/19/2025 at 3:00 AM, revealed LVN-C heard Resident #1 yelling help, get him out of my room. Upon arrival to the room, LVN-C noticed Resident #2 standing at the foot of Resident #1's bed. Resident #1 told LVN-C he hit me. Resident #2 appeared to be confused, and was escorted back to his room by CNA-D. Record review of Resident #1's Provider Investigation Report, CNA-D's Investigation Statement, dated 08/19/2025, revealed she was the CNA primarily assigned to the 100 hall at the time of this incident, and when she entered Resident #1's room, Resident #2 was standing at the end of Resident #1's bed. Resident #1 yelled get him out of here, he already hit me one time. Record review of Resident #1's annual MDS assessment, dated 10/07/2025, revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #2's face sheet, dated 11/19/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's pertinent diagnoses included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Anxiety (intense, excessive and persistent worry and fear about everyday situations), Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), PTSD (a mental health condition which was caused by an extremely stressful or terrifying event), Depression (a mood disorder which causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes). Resident #2's face sheet also revealed he had been discharged to another nursing facility on 08/28/2025. Record review of Resident #2's quarterly MDS assessment, dated 08/20/2025, revealed a BIMS score of 03, which indicated severely impaired cognition. The MDS also revealed Resident #2's active diagnoses of Anxiety, Depression, PTSD, Alzheimer's and Dementia. MDS section P0100 revealed wander/elopement alarm used daily. Record review of Resident #2's care plan, dated 03/06/2025, revealed Resident #2 was an elopement risk and wanderer. Interventions included the use of a wander guard, identify patterns of wandering and intervene as appropriate, provide structured activities, as well as distract Resident #2 by offering pleasant diversions, structured activities, food, conversation, television, and/or books. Interventions revealed the facility was working on finding appropriate placement in a secured unit for Resident #2. Resident #2 had a care plan dated 08/19/2025, which revealed Resident #2 had an episode of wandering into another resident's room and allegedly hitting him on the right side of his forehead. Care Plan revealed it was suspected Resident #2 thought he was in his room since it was directly across the hall from his room. Interventions included placing a picture of Resident #2 and his motorcycle outside of his room to help him identify the room, psychiatric consult to review medication regimen, lab work ordered, to include CBC and CMP, and continue to monitor Resident #2 for increased wandering episodes. Record review of PIR revealed the incident between Resident #1 and Resident #2 occurred on 08/19/2025 at 2:00 AM but was reported to state survey agency on 08/20/2025 at 1:37 PM. The PIR also revealed Resident #2 struck Resident #1 on the right side of the head. The assessment section of the PIR revealed no physical injuries were noted. In an interview on 11/18/2025 at 2:30 PM, the Administrator stated Resident #2 entered Resident #1's room in the middle of the night around 2:00 or 3:00 AM on 08/19/2025; Resident #1 was still awake and on his computer and yelled at Resident #2 to get out of his room, which startled Resident #2. The staff responded and got Resident #2 out of Resident #1's room. The Administrator and the DON were not made aware of the incident until their morning meeting on 08/19/2025. The Administrator stated he went and spoke with Resident #1, and it was explained to Resident #1 during the night Resident #2 got confused while getting up to use the restroom, and he had entered the wrong room by accident, and Resident #1 had told him nothing physical had occurred, but the Administrator stated Resident #1 later changed his story and stated Resident #2 got startled and hit him in his head, and Resident #1 felt anxious and upset by the event after the fact. The Administrator stated Resident #1 changed his story multiple times from no physical aggression was involved to being hit in the head and feeling anxious and upset. The Administrator stated he did not initially report the incident because he was not made aware of any physical contact between the residents, and when he questioned Resident #1 about physical contact, Resident #1 initially denied any physical contact during the incident. The Administrator also stated that Resident #1 denied feeling scared or intimidated by Resident #2. The Administrator stated he reported abuse per the HHSC LTCR provider letter, which was to report any instance of abuse immediately or no later than two hours, and since he was not notified initially, and then Resident #1 denied any physical altercation, as well as denied and physical or psychosocial injuries when he was interviewed, he did not feel it was a reportable incident at that time. In an interview on 11/18/2025 at 3:05 PM, Resident #1 stated Resident #2 came into his room in the middle of the night because he was confused and trying to find the bathroom. Resident #1 stated he told him to get out of his room, but he was grumbling, cursing and arguing with him; he then stated Resident #2 hit him on the side of his head with a closed fist. Resident #1 stated Resident #2 did not hit him hard enough to have any bruising or redness from the incident. Resident #1 stated Resident #2 did not scare him or worry him, but Resident #2 made him a little nervous that he would walk into his room without him knowing it because he is on his computer frequently, and he had already seen him hold one of the nurses down on the floor and choke her, but now Resident #2 was gone to a different facility which had a place for people like him with confusion, so he was not nervous and did not need to keep his door closed all the time. In an interview on 11/18/2025 at 4:45 PM, CNA-D stated she remembered hearing Resident #1 yelling at Resident #2 to get out of his room. When CNA-D went into the room, Resident #1 stated Resident #2 had hit him once before. CNA-D did not remember seeing any redness, bruising or otherwise, but stated LVN-C did skin assessments on both residents after the incident. CNA-D stated she was supposed to notify her charge nurse when there was resident to resident physical aggression, but the charge nurse was already aware because they entered the room at the same time. She stated Resident #2 was confused and had gone into the wrong room by accident. In an interview on 11/18/2025 at 4:13 PM, LVN-C stated she was covering for the charge nurse for the 100 hall around 3:00 AM on 08/19/2025, and she was at nurses station doing reports and heard a scream yelling for help; walking down 100 hall, LVN-C saw Resident #2 in Resident #1's room standing at end of the bed, but he was heading toward the door, like he had been startled. CNA-D came in and helped escort Resident #2 back to his room and restroom. Resident #1 stated he hit him on the right side of his face. LVN-C stated skin assessments were done on both residents, and neither resident had any changes, redness, bruising, swelling, or marks otherwise. LVN-C stated Resident #2 would typically get up during the night when he needed to go to the bathroom and would sometimes get confused and walk into the wrong room. LVN-C stated she reported the incident and the fact there were no injuries to the charge nurse for the 100 hall when she came back from break, but she did not notify the Administrator or DON. She assumed the charge nurse would notify the Administrator, but she now realized she should have notified the Administrator and DON of the incident when it happened so the incident could be further investigated or reported for abuse. In an interview on 11/18/2025 at 4:57 PM, the DON stated the staff do not always contact her during the night if there was not a significant injury, so she and the Administrator were not notified of the incident until they got to the facility the morning of 08/19/2025 and went to their morning meeting. The DON stated the nurse did not call the administrator or the DON during the night (early morning hours) to report a resident had been hit in the face, but she should have. The DON stated HHSC was not notified until 08/20/2025 at 1:27 PM due to the fact Resident #1 denied any physical altercation or aggression at first. The DON stated counseling was done with LVN-C for not notifying the Administrator and DON when the incident happened as it could have been considered abuse. The DON stated the facility reported abuse per the HHSC LTCR provider letter, which was to report any instance of abuse immediately or no later than two hours, and the night nurse should have notified the Administrator and DON immediately when it was known to her Resident #2 entered Resident #1's room and hit him in the head. Record review of the facility's Employee Counseling Report, dated 08/23/2025, revealed LVN-C was counseled on level two offenses to include failure to report an incident and failing to meet job expectations. Incident description revealed on 08/19/2025, LVN-C, responded to a call for help from a resident and found Resident #2, who had dementia, had wandered into Resident #1''s room. LVN-C and another staff immediately redirected Resident #2 out of the room. Resident #1 stated he had been hit. LVN-C notified the primary nurse of the allegation when she returned from break, but she failed to notify her supervisors immediately after finding out of the allegation. Record review of the facility's Abuse Prevention Policy, implemented 08/15/2022, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Record review of the HHSC LTCR Provider Letter, issued 08/29/2025, 2.4 Reportable Incidents and Timeframes, Do Report: abuse (with or without serious bodily injury) immediately, but not later than two hours after the incident occurs or is suspected.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #123) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to obtain the physician's signature on the OOH-DNR form for Resident #123 dated [DATE]. This deficient practice could affect residents who require care and monitoring and place them at risk of receiving or not receiving advanced directives to meet their needs. Findings included: Record review of Resident #123's electronic admission Record dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #123's OOH-DNR form dated [DATE] was not completed with the physician's signature. Record review of Resident #123's baseline care plan dated [DATE], reflected the following: FOCUS: o Resident is a full code Date Initiated: [DATE] GOALS: o Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o If resident has a cardiac arrest, initiate CPR ad call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] LN o Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] LN. Record review of Resident #123's physician order dated [DATE], reflected an order for DNR (Do Not Resuscitate). Record review of Resident #123's Quarterly MDS dated [DATE] reflected he had a BIMS score of 05, indicating Resident #123's cognition was severely impaired. Record review of Progress Notes dated [DATE] revealed Resident #123 was discharged to the hospital on [DATE] related to a fall with right side head trauma. In an interview on [DATE] at 03:06 PM LVN A stated for an OOH-DNR form, she would make sure there was a provider's signature. In an interview on [DATE] at 03:46 PM LVN B stated the admitting nurse was responsible for contacting the physician for the signature if one was not on the OOH-DNR form. She said the code status was given by the hospital. In an interview on [DATE] at 04:09 PM ADON C stated if any resident or RP said they wanted a DNR code status, she would notify the doctor. In an interview on [DATE] at 04:25 PM the DON stated an OOH-DNR form for any resident would be honored with a doctor's verbal order. Record review of the facility's Documentation in Medical Record policy date implemented [DATE] reflected the following: Policy: 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. Record review of the facility's Residents Rights Regarding Treatment and Advanced Directives policy date implemented [DATE] revealed: 1.On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. 3.On admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #123) of 6 residents reviewed for baseline care plan completion. The facility failed to complete the advance directive section in the baseline care plan dated [DATE] for Resident #123 within the required 48-hour timeframe when the physician order was dated [DATE]. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures. Findings included: Record review of Resident #123's OOH-DNR dated [DATE] was not completed with the physician's signature. Record review of Resident #123's baseline care plan dated [DATE], revealed: FOCUS: o Resident is a full code Date Initiated: [DATE] GOALS: o Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o If resident has a cardiac arrest, initiate CPR ad call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] LN o Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] LN. Record review of Resident #123's physician order dated [DATE], revealed an order for DNR (Do Not Resuscitate). Record review of Resident #123's electronic admission Record dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #123's Quarterly MDS dated [DATE] revealed he had a BIMS score of 05, indicating Resident #123's cognition was severely impaired. Record review of Progress Notes dated [DATE] revealed Resident #123 Resident #123 was discharged to the hospital on [DATE] related to a fall with right side head trauma. In an interview on [DATE] at 03:06 PM LVN A stated the ADONs update the Care Plans. LVN A stated code status would be in the report before the resident arrived for admission so it could be input code status in the computer during admission. In an interview on [DATE] at 03:46 PM LVN B stated when a resident was admitted the code status was immediately put in the computer. She said code status was reported before resident arrived. She said the code status was given by the hospital. LVN B stated the care plan was put in by the nurses. In an interview on [DATE] at 04:09 PM ADON C stated the admitting nurse would be the one who added the code status on admission. In an interview on [DATE] at 04:25 PM the DON stated the admitting nurse was responsible for putting a resident's code status in the computer. The DON stated the admitting nurse or Social Services would put the code status in PCC (electronic resident chart) Care Plan whether the code status was full code or DNR. Record Review of the facility policy subject titled, Baseline Care Plan date implemented [DATE], revealed policy statement The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: a. The baseline care plan will: a. Be developed within 48 hours of a resident admission. b. Include the minimal healthcare information necessary to properly care for a resident including, but not limited to: ii. Physician's orders

Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, including the opened date on over the counter (OTC) medications in 1 of 23 medication carts (700 hallway Medication Cart) and one of two residents Resident#106. reviewed for medication storage in that: 1. The OTCs in the 700 hallway Medication Cart did not have an opened date written on the bottle. 2.On 06-12-2025 LVN G failed to administer Resident #106's medications and left a cup containing Resident #106's medication on her bedside table. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The findings included: 1. Observation on 06/10/25 at 4:39 p.m., of the Medication Cart 700 hallway with LVN B, revealed one over the counter (OTC) medications which did not have an opened date written on the bottle (Folic Acid 1000 micrograms). In an interview on 06/10/25 at 4:45 p.m., LVN B stated the OTCs should have an open date written on them. She said they were still within the expiration date but should have had an open date written on them. She said it was important to write the open date to know for how long the bottle had been opened. In an interview on 06/12/25 at 4:18 p.m., LVN E stated OTC medication should always have an opened date written on it that way everyone knows what date it was opened and possible contaminated to air or losing effectiveness or strength. In an interview on 6/12/25 at 5:00 p.m., ADON C stated that it was important to write the open date on the medication bottle to know for how long had been opened. ADON C said that nurses and medication aids were responsible to check the medication bottles, and to write an open date on a new medication bottle. In an interview on 06/12/25 at 5:47 p.m., DON stated that she knew the medication bottle was still within the expiration date. DON stated that she would make sure the bottles found (without an open date written on them) were disposed of because they did not know when the bottles were opened and she did not want residents to get medication that they did not know when it was opened. 2. Review of Resident #106's face sheet, dated 6/12/25, revealed a [AGE] year-old, female, with the diagnosis of Gastrostomy Status (the presence of a surgically created opening, called a gastrostomy, in the stomach, which is accessed via the abdominal wall.), Post gastric Surgery Syndromes (complications that can arise after stomach removal (gastrectomy) or surgery on the stomach). Record review of Resident #106's care plan dated 4/2/25, revealed The resident requires enteral feedings via Gastrostomy tube related to history of post gastric surgery with (dumpling) syndrome and surgical complications. History of benign neoplasm of the colon with partial resection of colon; she was unable to tolerate PO feedings without adverse outcome (nausea, vomiting). Interventions: Flush feeding tube with 10mL of water before and after medication administration as ordered. Review of Resident #106's MDS assessment, dated 4/4/25, revealed a BIMS of 15, a cognitive score indicating no impairment. Feeding tube while not a resident and while a resident. Observation of Resident #106's medication administration on 6/12/25 at 7:03 a.m. revealed a medication cup was left on the bedside table. The cup contained Tramadol (ordered for treatment of pain), while LVN G went into the restroom to wash her hands. An interview with LVN G on 6/12/25 at 8:20 a.m. who stated she did not normally leave medications at a resident's bedside, but she went to wash her hands and left the medication with Resident #106. She added that medication was to be administered to the resident and the nurse should stay with the resident while the medication was administered because if medication left unattended could get lost, thrown away or another resident could grab it. An interview on 6/12/25 at 5:06 p.m. with ADON C who confirmed medications to be administered should not be left at the bedside. When asked if the practice of leaving medication at bedside was common, he replied, 'No, we never do that. She said the nurse should have taken the medication with her while washing her hands because another resident could get the medication. An interview on 6/12/25 at 6:00 p.m. with DON who stated that medications should not be left unattended because another resident could grab it accidentally and could have an adverse reaction. Review of the facility policy and procedure titled House Stock Medications dated 10/01/2019 revealed: The Facility maintains a supply of commonly used over-the-counter (OTC) medications considered as house stock or floor stock medications (not resident-specific), as permitted by state regulations, to be administered only upon receipts of an order form an authorized prescriber

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #346) of 3 residents reviewed who were in isolation. CNA F did not don PPE before entering Resident #346's. Resident #346 was under contact isolations 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: Record review of Resident #346's face sheet dated 06/11/25 revealed a [AGE] year old female admitted to the facility on [DATE], with the diagnosis of hypertension (high blood pressure), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should), and heart failure (a condition where the heart does not pump enough blood to meet the body's needs). Review of Resident #346 Physician Orders dated 6/6/2025 revealed Contact Precautions Dx: ESBL (bacteria that make them resistant to a broad range of antibiotics, including penicillin's and cephalosporins.) to the urine every shift until 6/13/2025. Review of Resident #346's care plan dated 6/7/2025 revealed the resident has infection of the urinary tract related to ESBL. Interventions: Contact isolation precautions as indicated by the physician. Review of Resident #346's MDS dated [DATE] revealed BIMS score of 12 which means moderate cognitive impairment. Observation on 06/11/25 4:50 p.m. revealed Resident #346 was on contact isolation precautions. Outside Resident #346's room was an isolation sign, personal protective equipment on the door that had masks, gloves and gowns available. Certified Nurse Aide (CNA) CNA F entered Resident #346 (contact isolation precautions) room up to the foot of the bed without any personal protective equipment. In an interview on 06/11/2025 at 4:52 p.m., CNA F stated when there were isolation precautions in place for Resident #346, the staff needed to put gloves, and gown before entering room. CNA F stated she went into the room really quick because the call light was on. CNA F stated it was important to wear personal protective equipment before entering the room to prevent the spread of germs to other residents. In an interview on 06/11/2025 at 5:05 p.m., Licensed Vocational Nurse (LVN) LVN B stated the isolation cart should contain gown, gloves, and mask outside of room and available to staff and family that enter the rooms when a resident was diagnosed with contact isolation precautions for ESBL to the urine. LVN D stated that all staff and visitors should have worn personal protective precautions before entering rooms to prevent the spread of infection to other residents. In an interview on 6/12/25 at 5:03 p.m., ADON C 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. In an interview on 06/12/25 at 5:15 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 the key to prevent this to happen again. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Isolation Protocol (Transmission-Based Precautions): a. 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.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 (Resident #63, Resident #345) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #63's oxygen was administered at the correct setting of 3 liters per minute on 06/10/2025 as ordered by the physician. 2. The facility failed to ensure Resident #345's oxygen was administered at the correct setting of 2 liters per minute on 06/10/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #63's admission record dated 06/10/2025 reflected a [AGE] year-old male with an admission date of 05/27/2025 and with an initial admit date of 04/18/2025. Pertinent diagnoses included Shortness of Breath, Acute Kidney Failure, Muscle Wasting and Atrophy (loss of muscle tissue), Type 2 Diabetes Mellitus, and Hypertension (high blood pressure). Record review of Resident #63's person-centered care plan, initiated date 4/21/2025 reflected Resident #63 used oxygen therapy related to hypoxia. Intervention included oxygen settings: Oxygen via nasal cannula at 3 liters per minute continuous. Record review of Resident #63's physician order dated 06/10/2025, reflected oxygen at 3 LPM via nasal cannula for Shortness of breath every shift. Record review of Resident #63's Quarterly MDS assessment, dated 06/23/2025 reflected it was in progress. During an observation of Resident #63 on 06/10/2025 at 11:15 a.m. revealed the oxygen level on the oxygen concentration machine was at 2.5Liters Per Minute via nasal cannula. Observation of Resident #63 revealed the resident was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. 2. Record review of Resident #345's admission record dated 06/10/2025 reflected he was a [AGE] year-old male admitted on [DATE]. His relevant diagnoses included end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (relying on a process to filter waste and excess fluid from the blood, as the kidneys were no longer functioning properly), and Hypertension (high blood pressure). Record review of Resident #345's care plan dated 06/10/25 reflected in progress. Record review on 06/10/25 of Resident #345's order summary dated 06/10/25 reflected an active order of Oxygen at 2 liters via nasal cannula every shift for hypoxia. During an observation on 06/10/25 2:35 p.m. revealed Resident #345 was observed laying on bed in his room. Resident #345 was sleeping. Resident #345's oxygen concentrator revealed it was set at 1.5 Liters Per Minute. In an interview on 06/10/2025 at 11:25 a.m. LVN D stated she was the nurse for Resident #63. LVN D agreed that the O2 setting was set at 2.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 3 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN D stated that she checked Resident #63's oxygen tubing and saturation in the mornings. She stated that she usually checked the oxygen once a day. LVN D stated that the negative outcome of keeping Resident# 63's oxygen setting at 2.5 Liters Per Minute was that the resident could go to respiratory distress. In an interview on 06/11/25 at 4:56 p.m. with the ADON C who stated that the nurse was responsible for checking the oxygen settings. She stated the nurse was supposed to check it every shift, whenever the patient comes back from doctors' appointments, and as needed. She stated the negative outcome of keeping it at a low setting would be that the patient would have hypoxia (low levels of oxygen), or respiratory distress. In an interview on 06/12/2025 at 4:00 p.m. with the DON, stated that the nurses assigned to that hall were responsible for checking the Oxygen settings. She stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome could be that the resident could have a respiratory distress and hypoxia (low oxygen levels). In an interview on 6/12/2025 at 4:45 p.m. with the DON who stated that the facility did not have a policy on oxygen.

Based on interview and record review, the facility failed to ensure each resident's drug regimen must be free of unnecessary drugs for one (Resident #74) of six resident reviewed for medications. The facility failed to have an adequate indication for the use of the medication Rexulti (brexpiprazole- atypical antipsychotic) for Resident #74. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings were: Record review of Resident #74's Admission Record dated 04/17/24 indicated Resident #74 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of end stage renal disease (condition in which the kidneys can't filter waste from the blood), hypertensive heart disease with heart failure (is a long-term condition that develops over many years in people with high blood pressure), white matter disease (damage to the white matter in the brain that can lead to problems with thinking, problem solving and balance), dependence on renal dialysis and encounter for screening examination for other mental health and behavioral disorders. The Admission Record did not include a diagnosis of dementia. Record review of Resident #74's quarterly MDS assessment dated [DATE] indicated Resident #74 was able to understand others, was understood by others and had moderate cognitive impairment. Resident #74 had verbal behavioral symptoms directed toward others and had other behavioral symptoms not directed toward others. Resident #74 did receive antipsychotics. Record review of Resident #74's Physician's Orders for April of 2024 revealed an order dated 04/16/24 for Rexulti Oral Tablet 0.5 mg (Brexpiprazole), give one tablet by mouth in the evening for dementia with agitation and psychosis for 30 days with start date of 04/17/24 and end date of 05/17/24, side effect monitoring for Rexulti every shift with start date of 04/17/24 and behavior monitoring-antipsychotic for Rexulti every shift with start date of 04/17/24. Record review of Resident #74's e-MAR dated April of 2024 revealed the medication Rexulti oral tablet 0.5 mg was administered to Resident #74 on 04/17/24 and 04/18/24. Record review of Resident #74's care plan dated 04/16/24 revealed that Resident #74 used anti-anxiety medications r/t anxiety disorder and has attention seeking behavior and will start yelling when staff passed by her room. The interventions were to administer the anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift and monitor/document/report PRN any adverse reactions to anti-anxiety therapy. Record review of the care plan did not reveal any care plan for dementia with agitation and psychosis. In an interview on 04/17/24 at 4:50 PM, Resident #74 said she had anxiety and took medication for the anxiety. Resident said if she did not have the anxiety medication, she would feel restless, nervous and her heart would beat faster. Resident said she would take antianxiety medications when she was at home. Resident said her doctor prescribed the medications. Resident #74 said the staff provided her the medications as scheduled. Resident said she did recall having any episodes of yelling. Record review of Resident #74's electronic medical record did not reveal a diagnosis of Dementia, or a progress note from the physician or the NP providing an explanation for the prescription and the administration of the drug Rexulti to Resident #74. In an interview on 04/18/24 at 10:53 AM, CNA D said Resident #74 has been more tired than usual. CNA D said Resident #74 is usually alert and oriented times three (alert and oriented to time, place and person) but at times she will yell out for her family member or call the CNAs family member. CNA D said Resident #74 does refuse care at times when she is unusually tired, and she will yell when she is anxious. Resident will ask to be transferred to the chair and then she will say she is tired and for them to place her in bed. Resident #74 will do this multiple times. In an interview on 04/18/24 at 1:43 PM, LVN E said there was a change in Resident #74's behavior lately. Resident #74 had become very anxious, asking to be put to bed then getting up to her chair every few minutes. LVN E said Resident #74 has exhibited yelling and anxiousness the last few weeks. In an interview on 04/18/24 2:00 PM LVN E said it was the in-house Psychiatric NP who ordered the Rexulti for Resident #74. In an interview on 04/18/24 at 2:25 PM, ADON F said Resident #74 had episodes of yelling and at times it was non-stop. The NP came to see Resident #74. The NP left an order for the Rexulti. The ADON said there should be a progress note written by the nurse indicating the nurse did not administer the medication. In an interview on 04/18/24 at 2:50 PM, the DON said that Resident #74 had been having episodes of yelling due to anxiety. The NP gave the order for the Rexulti because she believes that Resident #74 had dementia with agitation and psychosis. The DON said they decided to order it because they had tried other medications and they did not work. The DON said she spoke to Resident #74 and asked her if they obtained the medication if she would take it and the resident agreed to take the medication. The DON said she made a late entry progress note and it should be in PCC today. Record review of Resident #74's electronic medical record revealed a progress note written by the DON with an effective date of 04/16/24 at 05:18:00 PM and a created date of 04/17/24 at 12:19:45 AM revealed that the NP was called, and the NP gave order for Rexulti for 30 days to manage current behavioral issues of episodes of severe agitation/panic attacks. NP stated that Resident #74 did not have a psychiatric or mental illness such as bipolar, that it (Rexulti) was for dementia with behavioral issues of severe agitation. In an interview on 04/19/24 at 10:01 AM, LVN G said he administered the Rexulti because he had an order and the consent form. LVN G said if he does not have an order and a consent form, he would not administer a psychotropic medication. LVN G said the past few months Resident #74 had deteriorated mentally with behaviors. LVN G said Resident #74 would start yelling without stopping. LVN G said they have tried music, aroma therapy, and food without success. LVN G said he did not notice that the dementia diagnosis was not in PCC. The consent for the Rexulti was on PCC and he usually did not look at the diagnosis. In an interview on 04/19/24 at 10:30 AM, the NP said she prescribed the Rexulti because Resident #74 was in distress. Resident #74 had been having episodes of yelling off and on and lately had hallucinated. Resident #74 had been anxious and very forgetful, and her recall had declined. The NP said when she asked Resident #74 questions, she was unable to recall the words given to her at the beginning of the interview and unable to recall the month or date. The NP said she would never prescribe a medication if the patient did not need it. The NP said she only prescribed the Rexulti for a brief period of time and at the end of that period she would re-evaluate the patient and make sure her diagnosis was correct. If Resident #74 regains her recall and emotional stability, then the medication would be discontinued, and the diagnosis of dementia with agitation and psychosis would be removed. The NP said sometimes when a patient was under emotional distress and depressed their cognition was affected but once they were on the correct medication, they felt better, and their cognition improved. In an interview on 04/19/24 at 1:45 PM, the DON said as soon as she had the paperwork from the physician, she would upload the diagnosis onto PCC. The DON said she did all the psychotropic medications. The DON said she should have uploaded the progress note right away and input the diagnosis on PCC, but she had been terribly busy lately and she just got behind. The family did not want Resident #74 to be on many antipsychotics. The DON said she had noticed the resident having different behavior. She had episodes of yelling and screaming. The DON said they tried a one dose of Zyprexa, but it did not help Resident #74 with her anxiety and yelling. The DON said she did not see any negative outcome for Resident #74 because the medication has helped her. Record review of progress note provided by DON on 04/19/24 and signed by NP on 04/18/24 revealed the NP assessed Resident #74 on 04/08/24 for frequent panic attacks, bouts of anxiety and occasional hallucinations. Patient is difficult to console and requiring at times 1:1 person intervention. Patient requires frequent redirection. When patient was asked for the reason for anxiety, she is unable to explain the reason why. Hallucinations onset was a few weeks ago. Her BIMS was a 12 last 03/09/24 but patient had moments of confusion and agitation, worst in the evening. ASSESSMENT & PLAN: Vascular dementia, unspecified severity, with psychotic disturbance. (new) Plan: start with Rexulti 0.5 mg PO QHS. Other mode of modalities and medications have failed. Signed by NP on 3:20 PM April 18, 2024 Record review of Facility's undated policy revealed: Upon noting an order for psychoactive medication on admission or initiation of therapy: 1. Complete the Psychoactive Medication Evaluation at the initiation of psychoactive medication therapy. 2. Complete the Consent for Use of Psychoactive Medication therapy with the resident and/or the resident representative at the initiation of psychoactive medication or off label use of a medication (i.e., Klonopin) educate on the benefits, potential negative outcomes, alternatives, and outcomes of psychoactive medication use. 3. Implement the behavior monitoring/side effects monitoring in PCC on the MAR for psychoactive medications with the targeted behavior for why the resident is receiving the medication as ordered. Initial appropriate observed behaviors or no behaviors observed. 4. Complete baseline Abnormal Involuntary Movement Scale (AIMS) at the initiation of psychoactive medication therapy. 5. Care plan the targeted behavior for why the resident is receiving the medication.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 6 residents (Residents #84 and Resident #90) reviewed for respiratory care. The facility failed to ensure Resident #84 received oxygen at the prescribed rate. He received oxygen at a rate less than prescribed. The facility failed to ensure Resident #90 received oxygen at the prescribed rate. He received oxygen at a rate higher than prescribed. This failure could place residents receiving oxygen at risk for respiratory distress. The findings included: Record review of Resident #84's Quarterly MDS assessment dated [DATE] revealed resident with a BIMS score of 9 which suggests a moderate cognitive impairment and received oxygen therapy under special treatments/respiratory treatments. Record review of the Face Sheet dated 4/17/24 for Resident # 84 revealed the following diagnosis: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and vascular dementia (brain damage caused by multiples strokes which causes memory loss in older adults). Record review of the Care Plan for Resident #84 revealed resident has oxygen therapy r/t short of breath, hypoxia. Date initiated 8/15/22. Record review of the Doctor's Order Summary revealed Resident # 84 was prescribed O2 at 2LPM via Nasal Cannula Continuous DX: Hypoxia every shift related to COPD Active 03/29/2024. On 04/16/24 at 10:58 AM observed Resident #84 with O2 via nasal cannula at 1.5LPM. On 04/16/24 at 11:05 AM interviewed LVN B and she confirmed that Resident #84's order is for O2 at 2 LPM via nasal cannula continuous. She said that all nurses are responsible for ensuring O2 rates are set correctly. LVN B stated she usually checks the rates when she comes on shift. On 04/17/24 at 03:05 PM interviewed LVN H and she stated that all nurses are responsible for ensuring the rates for O2 are correct. LVN H said the O2 setting should be checked every shift. She said that the lack of oxygen could cause a resident to struggle to breathe and not get enough oxygenated blood to the body. LVN H said that she has not seen Resident #84 displaying any adverse symptoms today. On 4/17/24 at 3:35 pm interviewed ADON M and she said that the respiratory therapist has a training for facility staff every year. She said that if O2 is not given as ordered, the resident can have respiratory distress, dizziness, or SOB. On 04/17/24 at 05:37 PM interviewed ADON C and she stated that the nurses are responsible for ensuring the oxygen rates are correct. ADON C said that the nurses should check every shift and every time they enter a resident's room as best practice. ADON C said if a resident receives less oxygen than prescribed, their O2 saturation can go low, and they can experience SOB. ADON C said that she is unaware of Resident # 84 displaying any adverse effects. She said that they have a respiratory therapist that comes to the facility and gives training and certification in O2 therapy every year. On 04/17/24 at 05:45 PM interviewed DON and she said that licensed nurses are responsible to ensure O2 rates are accurate every shift. As best practice, nurses should check every shift, and every time they go into a resident's room. She said that if a resident is receiving O2 that is less than prescribed, the resident's oxygen saturation will go low, or they can have SOB or experience respiratory distress. On 4/19/2024 at 3:00 pm interviewed RT via telephone, and she stated that she completed the Respiratory Training/Certification for the nurses at the facility on 11/29/2023. The RT provided documentation via email. Record review of Resident #90's MDS comprehensive assessment dated [DATE] revealed resident with a BIMS score of 15 which suggests a cognitively intact mental status. Record review of the Face Sheet dated 4/17/24 for Resident # 90 revealed the following diagnosis: Chronic systolic (congestive) heart failure, Obstructive sleep apnea, Chronic Obstructive pulmonary disease, morbid obesity, and muscle weakness. Record review of the Care Plan for Resident #90 revealed resident has congestive heart failure that requires an intervention of the following oxygen settings: O2 via (nasal prongs) @ 2 LPM every shift, as needed for SOB and Hypoxia date initiated 2/28/24, and the resident has oxygen therapy r/t COPD with interventions of the oxygen settings: O2 via nasal cannula at 2 LPM for hypoxia initiated 3/31/24. Record review of the Doctor's Order Summary revealed Resident # 90 was prescribed O2 at 2 LPM via nasal cannula PRN DX: SOB every shift r/t hypoxia started on 04/15/2024. On 04/16/24 at 03:30 PM observed Resident # 90 with O2 at 3LPM via Nasal Cannula. On 4/17/24 at 03:32 PM interviewed RN L and she read Resident #90's orders at 2 LPM via nasal cannula PRN and states the current O2 rate reads 3 LPM and resident's O2 saturations are 93-94%. When asked by RN L, resident denied any symptoms. RN asked resident #90 if he moved the rate and the resident denied. RN L corrected the O2 rate by lowering it to 2 LPM. RN L said that the nurses are responsible for ensuring the O2 rates are correct. RN L states that she usually checked resident oxygen rates at the beginning of her shift, during completing her rounds. RN L said that if a resident with COPD receives too much O2, they may not be able to get rid of CO2 (carbon dioxide) and could have respiratory issues. RN L said resident #90 is not her patient for this hallway. On 4/17/24 at 03:40 PM interviewed LVN G, she said that she is Resident #90's current floor nurse. LVN G said that it is the nurse's responsibility to ensure O2 rates are accurate. She said that she usually checks the O2 rate during her morning rounds. LVN G said that if a resident with COPD receives O2 higher than prescribed, the resident could get over oxygenated, the COPD can worsen, or they can have respiratory distress. LVN G said that to her knowledge, resident #90 has not exhibited any symptoms. On 04/17/24 at 03:44 PM interviewed LVN K and she said that nurses are responsible for ensuring O2 rates are accurate, but that Resident #90 at times is non-compliant and changes the flow rate. LVN K said that if the oxygen flow rate is above 2 LPM, the resident can desaturate (low blood oxygen saturation). LVN K said he checks everyone's O2 rates when he enters his shift. On 04/17/24 at 03:50 PM interviewed RN F and he said that nurses are responsible to ensure O2 flow rates are accurate every shift when they come in. RN F said that if a resident receives more oxygen than prescribed, they could retain CO2 and experience SOB or other complications. RN F said they have annual in-services done by the Respiratory Therapist. RN F said he remembered the last in-service early this year or late last year. On 04/17/24 at 05:37 PM interviewed ADON C and she stated if a resident receives more O2 than prescribed, they can have too much oxygen in the body and the negative effect is they can experience elevated pulse and respiration rates and experience respiratory distress. ADON C said that she is unaware of Resident # 90 displaying and adverse effects. On 04/17/24 at 05:45 PM interviewed DON and she said if a resident received more O2 than prescribed to it could cause SOB and can cause the resident to receive in excess the oxygenation needed. Record review of In-service for Respiratory Education Training revealed the training is completed annually. The staff trained are checked of on assessment, oxygen administration, basic treatments, suctioning, pulse oximeter, respiratory assist devices and delivery systems skills. A certification test is administered, and the staff receive a certificate for Successful completion of Respiratory Therapy. The last annual training is dated 11/29/24 - 11/30/24 . Record review of the Oxygen Administration policy date revised 7/2015 revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure 6. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. 8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.