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

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 to the State Agency) in accordance with State law through established procedures for one of three residents (Resident #1) reviewed for abuse and neglect.The facility failed to report Resident #1's unwitnessed fall with serious injury on 08/12/26 at 5:00 AM to the State Survey Agency within the required two-hour timeframe.This failure could place residents at risk of being highly vulnerable to ongoing patterns of potential oversight and neglect.Findings included:Record review of Resident #1's face sheet dated 08/27/26 revealed a [AGE] year-old male who had an original admission date of 10/19/21. Resident #1 had diagnosis which included; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side (weakness or paralysis on one side of the body, where the exact side and cause are not yet specified), dementia (loss of memory, language, problem-solving and other thinking abilities), aphasia (a disorder that affects how you communicate), contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes joints to become stiff and hard to move) to the right knee, left knee and right hand, muscle wasting and atrophy (wasting or thinning of your muscle mass), anxiety disorder (a health condition involving persistent, excessive fear of worry that interferes with daily life) and need for assistance with personal care.Record review of Resident #1's comprehensive care plan dated lats revised on 04/07/26 revealed [Resident #1] requires total assistance with daily care due to significant physical and cognitive impairments. The comprehensive care plan also revealed Resident #1 was dependent on facility staff for all ADLs. Record review of Resident #1's Quarterly MDS dated [DATE] revealed the resident was coded with impairment of both sides of upper extremity and lower extremity. On tasks such as; toileting hygiene, upper/lower body dressing, personal hygiene, roll left and right, sit to lying, chair/bed-to-chair transfer, and tub/shower transfer, resident was coded 01 which indicated Dependent - Helper does ALL of the effort. Resident did none of the effort to complete the activity.Record review of Resident #1 Quarterly BIMS assessment dated [DATE] revealed a score of 00 which indicated he had severe cognitive impairment.Record review of Resident #1's Pain Evaluation dated 08/12/26 at 5:26 AM performed by LVN C revealed section:A. Pain Evaluation3. Indicate on body diagram areas where resident experiences pain. Describe type of pain.Site - Other: goose egg (a bump due to swelling) to rt side of the head with skin tear Record review of Resident's #1 Change of Condition dated 8/12/26 at 5:28 PM performed by LVN C revealed section:R. Nurse Suggestion 2. Nursing notes: resident fell out of bed, hitting his head on the rt side causing skin tear and raised bump.Record review of Resident #1's progress notes dated 08/12/26 at 5:33 AM LVN B stated CNA called SN into patient's room due to patient being found on the floor. Patient found on the floor follow an unwitnessed fall. Upon assessment, raised/swelling noted to left forehead with active bleeding.NP and DON made aware. RP also made aware.Record review of Resident #1's [Hospital] records dated 08/14/26 revealed the resident had a diagnosis of an intraparenchymal hemorrhage of brain and a subdural hematoma.Record review of Texas Unified Licensure Information Portal (TULIP) on 08/27/26 revealed the incident of an unwitnessed fall regarding the allegation of neglect was reported on 08/12/26 at 8:49 AM via email.In an attempted interview on 08/26/26 at 1:47 PM, Resident #1 was unable to be interviewed due to cognitive impairment.In an interview on 08/26/26 at 3:20 PM LVN B stated on 08/12/26 at around 5:00 AM, CNA E notified him Resident #1 was on the floor. LVN B stated when he walked into Resident #1's room, the resident was on the floor, face down, with a gash bleeding from the right side of the head. LVN B stated he was unaware the resident could move because Resident #1 had contractures. LVN B stated Resident #1 had a raised area to the right side of the head. LVN B stated he last saw Resident #1 approximately 15-20 minutes prior to the incident and the resident was asleep in bed at that time. LVN B stated he notified the NP, the DON, and the RP within 15-30 minutes after the incident. LVN B stated he did not report it to the administrator because he had already notified the DON.In an interview on 08/26/26 at 10:45 PM LVN C stated she accompanied LVN B to assess Resident #1 after they were notified by CNA E the resident had fallen. LVN C stated they were notified of the fall around 5:00 AM. LVN C stated when they walked into Resident #1's room, resident was lying on the floor, to the left side of the bed. LVN C stated Resident #1 was checked for bruises and hematomas. LVN C stated Resident #1 had a bump on the right side of his head, that looked like a goose egg. LVN C stated LVN B had notified the appropriate parties regarding the incident. LVN C stated she did not know exactly who LVN B had notified but assumed the Administrator was notified.In an interview on 08/27/26 at 12:03 PM, LVN D stated when she came on shift, on 08/12/26 at around 6:00 AM, she was notified of Resident #1's fall. LVN D stated she saw Resident #1 had some swelling to the right side of the head. Regarding the swelling, LVN D stated, It was nothing to be sent out for, is what I thought. LVN D stated, about an hour later, she noticed an increase in swelling. LVN D stated she notified the NP, the DON, and the Administrator of the findings. LVN D stated she received an order from the NP to send Resident #1 to the hospital for evaluation.In an interview on 08/27/26 at 12:18 PM, CNA E stated he found Resident #1 on the floor around 5:00 AM. CNA E stated the last time he saw Resident #1 was around 4:00 AM while attending to Resident 1's roommate. CNA E stated Resident #1 was asleep at that time. CNA E stated when he returned to Resident #1's room around 5:00 AM, all he could see was Resident #1 was bleeding from the head. CNA E stated he asked another CNA in the hall, to notify the nurse about the fall while he stayed with Resident #1. CNA E stated after Resident #1 was assessed by the nurses, he and another CNA placed the resident back in bed. CNA E stated he noticed Resident #1 had a bump to the side of his forehead. CNA E stated he knew how to report to the nurse immediately when residents were found on the floor. CNA E stated he was instructed never to pick up a resident found on the floor because the resident could have a serious injury. CNA E stated that if he picked them up, he could cause a greater injury.In an interview on 08/27/26 at 1:07 PM, the DON stated she was notified early in the morning by phone of the fall by LVN B. The DON stated she informed LVN B to notify the appropriate parties; the doctor, the Administrator, and the RP. The DON stated that by LVN B's report, Resident #1 did not have a serious injury. The DON stated that she was not aware of the Administrator having been notified. The DON stated the Administrator was in charge of reporting incidents to the State Agency and she assisted the Administrator with gathering the staff for interviews.In an interview on 08/27/26 at 1:29 PM, the Administrator stated the fall happened around 5:00 AM when CNA E found him. The administrator stated the nurses did a skin assessment, a pain assessment and an incident report. The Administrator stated the nurses notified the family, the physician, the DON and herself. The Administrator stated that according to the findings, there was nothing unusual or any area of concern. The Administrator stated she did not talk to the nurse regarding the wording of goose egg on the Pain Evaluation. The Administrator stated she was not sure what a goose egg was but assumed it was a raised area. The Administrator stated she did not report to the State Agency sooner because LVN B had not specified that finding was a major injury. The Administrator stated LVN D noticed the increased swelling on 08/12/26 around 6:50 AM. The Administrator stated she was not notified of the increased swelling at 6:50 AM. The Administrator stated she entered the building on 08/12/26 at around 7:30 AM and that it was then she was notified of the increased swelling. The Administrator stated she did not report the fall to the State Agency until the swelling had increased. The Administrator retracted and admitted that she was not notified of the incident at the time the fall had occurred. The Administrator re-stated she was notified of the fall on 08/12/26 at 7:30 AM when she arrived at the facility. The administrator stated she reported the fall to the State Agency on 8/12/26 at 8:49 AM via email. The Administrator stated that when there is a major injury, it should be reported to the State Agency within 2 hours of the time of the incident. However, since she was not notified at the time of the incident, she did not report it.Review of the facility's Abuse, Neglect and Exploitation Policy with a date implemented on 07/11/25 revealed: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Serious Bodily Injury means an injury involving.substantial risk of death; . requiring medical intervention such as ., hospitalization.The facility will make efforts to ensure all residents are protected from physical. harm. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination.

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical record for 1 of 5 residents (Resident #2) reviewed for Privacy. The facility failed to ensure the privacy of Resident #2 by not locking the computer screen on a medication cart, leaving the resident's personal and medical information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.Findings included: Observation on 08/26/26 at 1:40 PM revealed a computer screen on a medication cart in front of the nurse's station was left unlocked. There was no one near the medication cart to indicate who the cart belonged to. The screen displayed Resident #2's personal and medical information. As the state surveyor stepped closer to the medication cart, RN A quickly approached the medication cart.In an interview on 08/26/26 at 1:40 PM, RN A stated, I know, I know. I should have locked my computer. RN A stated he left the medication cart to speak to the administrator who was seated close by. RN A stated he left the medication cart for just a brief second. RN A stated it was important to lock the computer screen when not in use because the screen displayed Resident #2's private personal and medical information. RN A stated exposing private personal and medical information was a HIPAA (a law that protects patient medical privacy) violation. RN A stated he was aware not to leave any resident information exposed but had just failed to do it this time. In an interview on 08/27/26 at 1:07 PM, the DON stated she had spoken to RN A. The DON stated RN A had never left the computer screen on the medication cart open but this one time. The DON stated RN A had stepped away from the medication cart to speak to the administrator. RN A stated all staff were regularly in-serviced (teaching) on resident rights and HIPAA compliance. The DON stated staff were also reminded daily to lock their computer screens. The DON stated RN A had been in-serviced again today, after the incident of leaving the computer screen unlocked. The DON stated it was important to lock the computer screen because it contained the unknown resident's patient information; if an unauthorized person saw the screen, that person could have had access to the unknown resident's patient information. In an interview on 08/27/26 at 1:29 PM, the Administrator stated there was no policy on locking the computer screen but followed the State Long-Term Care Ombudsman Program (federal program mandated to advocate with, and for, residents of long-term care facilities) regarding resident rights. Record review of RN A's employee files revealed RN A had completed the required annual HIPAA training on 06/25/26. Record review of the State Long-Term Care Ombudsman Program dated January 2025 revealed: Your Rights in a Nursing FacilityPrivacy and ConfidentialityYou have the right to: Have facility information about you maintained as confidential.

Based on observation, interviews, 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 3 of 4 residents (Resident #61, Resident #37 and Resident #57) reviewed for infection control. 1.The facility failed to ensure CNA A performed proper hand hygiene and indwelling catheter care during peri care (incontinent care) for Resident #61. 2.The facility failed to ensure Resident #37's white pillowcases were clean. 3.The facility failed to ensure Resident #57's portable urinal was hanging from his wheelchair's backrest. These deficient practices could place residents at risk of infections, healthcare associated with cross contamination, and the spread of infection. Findings include: 1.Record review of Resident #61's electronic face sheet, dated 07/16/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Obstructive and Reflux Uropathy (a condition in which the flow of urine was blocked) and Type 2 Diabetes Mellitus (a chronic condition where your body either resists the effects of insulin or does not produce enough of it to regulate blood sugar properly). Record review of Resident #61's comprehensive person-centered care plan, dated on 01/10/2025, reflected Focus [Resident #61] has a suprapubic catheter due to obstructive uropathy. Interventions: Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Enhanced Barrier Precautions practices as clinically indicated. Record review of Resident #61's quarterly MDS assessment, dated 05/26/2026, reflected a BIMS score of 08, which indicated Resident #61 was moderately cognitively impaired. Resident #61 had an indwelling catheter. During an observation on 07/14/2026 at 3:30 p.m. revealed CNA A during catheter care, CNA A entered Resident #61's room and placed supplies on the bedside table. CNA A washed her hands, donned gown, and gloves. CNA A removed the soiled brief and placed it in the trash can. CNA A removed the gloves from her hands and donned gloves sanitized her hands before donning new gloves. CNA A then cleaned Resident #61's peri-area, removed gloves, CNA A cleansed the catheter tubing line going upwards towards the suprapubic opening instead of downwards. CNA A washed her hands before and after the procedure and lathered her hands for 12 seconds. During an interview on 07/14/2026 at 3:45 p.m., CNA A stated she should have lathered her hands for at least 20 seconds. CNA stated that she was nervous. CNA A stated the potential negative outcome was infection. She stated they were to clean the indwelling catheter tube downward, away from the suprapubic opening to prevent infection. CNA A stated that she did not notice that CNA B cleaned the indwelling catheter upward. During an interview on 07/14/2026 at 3:50 p.m., CNA B stated she cleansed the indwelling catheter tubing upward towards the suprapubic opening instead of downward. CNA B stated proper cleansing of the indwelling catheter tubing was to prevent infection. CNA B stated that she did not notice that she cleaned the indwelling catheter upward. During an interview on 07/6/2025 at 11:05 a.m., the DON stated the proper way to cleanse indwelling catheter tubing was to start from the suprapubic opening and go downwards. This was important to keep infections away from the site. The DON stated the proper handwashing was to lather hands for at least 20 seconds. The DON stated if CNA A did not lather for at least 20 seconds this would put Resident #61 at risk for infections. The DON stated they had monthly infection control in-services. She stated they conducted sporadic skill check offs. Record review of the facility's policy titled Hand Hygiene with an implemented date 10/24/22 reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.4. Hand hygiene technique when using soap and water .c. rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Findings included: 2.Record review of Resident #37's admission record, dated 07/14/26, reflected a [AGE] year-old male with a readmission date of 08/08/25 and an initial admission date of 05/21/22. His relevant diagnoses included follicular disorder (conditions affecting hair follicles), colostomy status (living with a functional, surgically created opening in their colon), and unspecified sequelae of cerebral infarction (having long term effects from an ischemic stroke (cerebral infarction). Record review of Resident #37's quarterly MDS assessment, dated 06/13/26, reflected a BIMS score of 13, which indicated his cognition as intact. Record review of Resident #37's quarterly care plan assessment, dated 06/17/26, reflected: Problem: [Resident #37] has scabbed areas to the back of my neck and scalp. Resident #37 with dx of follicular disorder. Intervention included to monitor skin for increased spread or signs of infection and treatment as ordered. Date initiated 12/23/25. During an observation and interview on 07/14/26 at 10:15 a.m., Resident #37 was observed lying in bed watching television. He was observed resting his head on two pillows with white pillow cases. Both pillow cases had light and dark brownish/reddish stains. Resident #37 said those stains were dry blood. He said he had scabs on his head and when he scratched they bled. Resident #37 said he was being treated with medication. Resident #37 said the facility's CNAs would change his pillow cases at least twice a day but the last time they had changed them was yesterday (07/13/26 in the afternoon). During an interview on 07/14/26 at 10:20 p.m., CNA C said she was assigned to Resident #37 and she worked the 6 a.m. to 2 p.m. shift. CNA C said she was aware Resident #37 had scabs on his head that would bleed when he scratched them. She said whenever she would round and noticed his pillowcases stained, she would change them. She said today (07/14/26), she had not had time to make her rounds because she was busy showering other residents. CNA C said a negative outcome for Resident #57 lying in blood stained pillows would be an infection control issue. She said she was regularly in-serviced on infection control. During an interview on 07/14/26 at 10:26 p.m., RN D said he was Resident #37's charge nurse. He said he worked the 6:00 a.m. to 2:00 p.m. shift. RN D said he would round residents every two hours. He said Resident #37 had scabs on his head that were being treated with medication but bled when he scratched them. He said he had already checked on Resident #37 but had not noticed his pillowcases were stained. RN D said Resident #37 required his pillowcases to be changed at least twice a shift. RN D said it was the responsibility of everyone who entered his room to change his pillowcases if they were stained. RN D said a negative outcome for Resident #37 lying on blood stained pillowcases would be considered an infection control issue and bacteria. During an interview on 07/15/26 at 2:42 p.m., the DON said Resident #37 had scabs on his head that bled when he scratched that were being treated with medication but bled when he scratched them. She said any staff member who entered Resident #37's room and noticed his pillowcases stained had the responsibility to change them. The DON said all staff were regularly in-serviced on the topic of infection control. The DON said a negative outcome for Resident #37 lying in blood stained pillowcases would be unappealing and infection control. 3.Record review of Resident #57's admission record, dated 07/14/26, reflected an [AGE] year-old male with and admission date of 12/16/24. His relevant diagnoses included unspecified sequalae of cerebral infarction (long term, lingering effects from an ischemic stroke (cerebral infarction) and benign prostatic hyperplasia without lower urinary tract symptoms (the prostate is physically enlarged but not compressing the urethra or irritating the bladder). Record review of the Resident #57's quarterly MDS assessment, dated 07/14/26, reflected a BMS score of 10, which indicated his cognition was moderately impaired. During an observation on 07/14/26 at 10:35 a.m., Resident #57 was observed sitting on the side of his bed. His wheelchair was positioned next to the bed, and his portable urinal was hanging from the backrest of the wheelchair. The portable urinal had light yellow urine and was missing the cap. Resident #57 refused to answer any questions. During an interview on 07/14/26 at 10:40 a.m., CNA C said Resident #57 was ambulatory and was known to move his urinal around to ensure it was close to him. She said she had last seen Resident #57 earlier this morning (07/14/26) when she took him via his wheelchair to the shower room. She said Resident #57's urinal was not hanging from the backrest of his wheelchair when she took him to the shower room. CNA C said when she would make her rounds she would ensure all portable urinals were hanging from the side of the resident's bed. CNA C said a negative outcome to Resident #57 having his portable urinal with urine and uncovered hanging from his wheelchair's backrest would be an infection control issue. She said had been in-serviced on the topic of infection control frequently. During an interview and observation on 07/14/26 at 10:25 a.m., RN D said Resident #57's portable urinal was not supposed to be handing from his wheelchair's backrest. He was observed as he removed Resident #57's portable urinal from his wheelchair and flushed the urine and hung it on the side of his bed. RN D said a negative outcome for Resident #57 having his portable urinal hanging from his wheelchair's backrest would a fall risk since the portable urinal did not have a cap and possible contamination. RN D said it was the responsibility of all staff who entered Resident #57's room to check for any infection control issues. RN D said all staff were frequently in-serviced on the topic of infection control. During an interview on 07/15/26 at 2:42 p.m., the DON said Resident #57 was able to ambulate on his own and use a portable urinal. She said, it was inappropriate to have a portable urinal hanging from the backrest of a wheelchair. The DON said it was the responsibility of all staff who entered a resident's room to check for infection control issues. She said all staff were frequently in-serviced on the topic of infection control. The DON said a negative outcome to Resident #57 having his portable urinal, with urine, and uncovered would be a fall risk and an infection control issue. Record review of the facility's Infection Prevention and Control Program, dated 05/13/23, reflected: Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national stands and guidelines.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.1.The facility failed to ensure that there were no personal items belonging to staff stored in refrigerator #2.2.The facility failed to ensure 15 juice bags were stored without being dated in the dry food storage.3 The facility failed to ensure expired nutritional drinks were stored in the nourishment room. These failures could place residents at risk for food borne illness.Findings included: During an observation on 07/14/26 at 8:37 a.m. revealed: an ice cream sundae belonging to a staff member was stored in refrigerator #2.7 nectar juice bags, 4 water thickener bags, 3 cranberry juice bags, and 1 apple juice bag were not dated in the dry storage room. During an interview and observation on 07/14/26 at 8:45 a.m., the DM said personal food belonging to a staff members were not allowed to be stored in the refrigerators. She said she was not sure who had left the sundae in refrigerator #2 and was observed as she threw it in the trash. The DM said the 15 juice bags stored in the dry storage room were delivered on 07/13/26 and they had not had time to date them. The DM said a negative outcome of having undated food items in the dry storage room would be staff would not know when they arrived at the facility. She said a negative outcome of having personal food in the refrigerators would run the risk of serving them to the residents in error. She said it was her responsibility to ensure all food was labeled and dated and no personal food items were left in the refrigerators. The DM said all kitchen staff shared the responsibility of dating and labeling food items. The DM said she regularly conducted in-services on the topic of labeling and dating all food items to her kitchen staff. During an observation on 07/16/26 at 3:30 p.m., of the facility's nourishment room revealed, six 1-liter bottles of nutritional drinks were expired. All six had a use by date of June 1, 2026. During an interview and observation on 07/16/26 at 3:35 p.m., the DON was observed as she removed all 6 nutritional drinks from the nourishment room. The DON said all staff who entered the nourishment room along with the facility's Central Supply Manager shared the responsibility to ensure there were no expired supplements stored in the nourishment room. The DON said at moment there were no residents who were ordered that particular nutritional drink. She said there were no negative outcomes for having the 6 bottles of nutritional drinks in the nourishment room because no residents were taking it. The DON said the facility did not have a specific in-service on storing supplemental drinks, she said it's a common sense thing to discard expired supplements. The DON said it was the facility's protocol to date and label all food in the kitchen. She said it was the DM's responsibility to ensure all food was labeled and dated. She said a negative outcome of not dating or labeling food would staff would not know when to discard it. During an interview on 07/16/26 at 3:45 p.m., the Central Supply Manager said it was her responsibility to ensure no expired nutritional drinks were stored in the facility's nourishment room. She said she had assigned a hospitality aide to assist her in inspecting the facility's nourishment room for expired supplements, but he had quit on 06/30/26. She said she had not inspected the nourishment room since the hospitality aide had quit. She said there were no negative outcomes of storing expired supplements in the nourishment room because staff would check the expiration date before providing the nutritional drinks. Record review of the Food Storage policy, revised on 06/01/19, provided by their dietitian reflected: Policy: to ensure that all food served by the fecality is of good quality and safe for consumption, all food will be stored according to the stated, federal. guidelines: Procedure:1.Dry storage rooms d.All containers must be labeled and dated. Record review of Federal Food Code 2022, reflected:References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES' observations and periodically evaluating FOODS upon their receipt 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS(A) Except as specified in (B) of this section, an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection cannot result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Ch.3-403 Reheating 3-403.11 Reheating for hot holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based on observation, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 1 medication storage room reviewed for medication storage. The facility failed to ensure the Discontinued Medication cabinet was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them and place the facility at risk of drug diversion. Findings include: During an observation on 06/15/2026 1:56 p.m., in the medication storage room, a cabinet that had discontinued medications was not locked and secured. In an interview on 06/15/2026 at 2:05 p.m., the ADON stated she knew the cabinet that stored the discontinued medications was supposed to be locked. She stated the nurses and medication aides pulled the discontinued medications and put them in the discontinued cabinet. She stated she went in on Mondays to prepare them for destruction. The ADON stated if the discontinued medication cabinet was kept unlocked, anyone who went in would have access to the medications and they could fall into the wrong hands. In an interview on 06/15/2026 at 2:10 p.m., the DON stated she thought only the discontinued narcotic medications were required to be kept locked but not the discontinued medication cabinet. The DON stated the ADON was in charge of the discontinued medication destruction. The DON stated if the discontinued medication cabinet was to be kept unlocked, anyone could remove a medication from the cabinet or get the wrong medication. Record review of the facility's Medication Storage and Disposal: Discontinued Medication policy, dated revised 10/01/19, revealed Policy When medications are discontinued by physician order, a resident is transferred or discharged and does not take medication with him/her, or in the event of resident's death, the medications are marked appropriated and destroyed, unless unopened and/or are returnable to the pharmacy. Procedure 2 Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until disposed of, or returned to the pharmacy if credit is allowed. Medications are removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 4 residents (Resident #1) reviewed for pharmacy services. Facility failed to acquire and administer physician ordered anti-seizure medication phenytoin (Dilantin) to treat Resident #1's seizure disorder. Resident #1 suffered a seizure and was sent to hospital on [DATE] with impression of Status Epilepticus, Subtherapeutic phenytoin (Dilantin) levels, Active infection (UTI/Sepsis/Pneumonia). The noncompliance was identified as PNC. The IJ began on 3/12/26 and ended on 4/9/26. The facility had corrected the noncompliance before the survey began.These failures could place residents at risk of complications, as well as jeopardize their health and safety. Findings included: Record review of Resident #1's face sheet, dated 5/28/26, revealed a [AGE] year-old female with an admission date of 3/12/26. Resident #1's diagnoses included unspecified convulsions. Record review of Resident #1's admission MDS assessment, dated 3/16/26, revealed Resident #1 never/rarely made decisions due to severely impaired cognitive skills. The Brief Interview for Mental Status was skipped and not conducted. Resident # 1 had active diagnosis of seizure Disorder or Epilepsy and high-risk drug classes included anticonvulsant. Record review of Resident #1's care plan revealed Resident #1 had a seizure disorder initiated 3/30/26. Goal included: Resident #1 will be/remain free of seizure activity through review with a target date of 6/21/26. Interventions included: Give seizure medication as ordered by doctor.Record review of Resident #1's hospital record dated 3/11/26 reflected Resident #1's phenytoin level at 21.43 mcg/mL (normal range 10.00 - 20.00).Record review of Resident #1's physician's orders for discharge received from the hospital on 3/12/26 reflected continued medications:Phenytoin (phenytoin 25 mg/mL oral suspension) 4 mL, oral, daily, andPhenytoin (phenytoin 25 mg/mL oral suspension) 8 mL, oral QHSRecord review of Resident #1's physician orders reflected phenytoin oral suspension 100 mg/4mL give 4 mL (100 mg) by mouth one time a day with a start date of 3/12/26. The physician orders did not reflect the order for phenytoin 25 mg/mL oral suspension 8 mL (200 mg) oral QHS. Record review of Resident #1's March 2026 MAR revealed Resident #1's phenytoin oral suspension 100 mg/4mL give 4 mL by mouth one time a day for anticonvulsant was administered daily from 3/14/26 to 3/31/26. Record review of Resident #1's April 2026 MAR revealed Resident #1's phenytoin oral suspension 100 mg/4mL give 4 mL by mouth one time a day for anticonvulsant was administered daily from 4/1/26 to 4/8/26. Record review of Resident #1's March and April MAR did not reflect the order for Phenytoin (Dilantin) Oral Suspension 100 MG/4ML Give 8 ml by mouth QHS for anticonvulsant for a total of 27 days. Record review of Resident #1's progress note dated 4/8/26 revealed Resident #1 had a seizure that lasted approximately 4 minutes. NP, ADON and family member were notified. Orders from NP were carried out and Resident #1 was transferred to the hospital after. Record review of Resident #1's hospital record dated 4/9/26 revealed Resident #1's Impression:Status Epilepticus (life threatening medical emergency defined as either a continuous seizure lasting more than 5 minutes, or recurrent seizures without the person regaining full consciousness in between)- This presentation is most consistent with breakthrough status epilepticus in the setting of subtherapeutic antiseizure medication levels and systemic infection (UTI/sepsis).Subtherapeutic (dose, concentration, or level of a drug or treatment that is too low to produce the intended medical effect or to effectively treat a disease) phenytoin (anti-seizure medication) level (2.4)Active Infection (UTI/sepsis/? pneumonia)In an interview on 5/28/26 at 2:05 p.m., LVN A said Resident #1 received one dose of Dilantin at 5 p.m. daily. LVN A said she was informed by administration that she forgot to enter the hour of sleep Dilantin order. LVN A said she was also informed the order was reviewed by other staff and they missed it also. LVN A said she received 1 to 1 education on obtaining labs and verifying medication orders. LVN A said not providing Resident #1 her QHS Dilantin placed her at risk for seizures.In an interview on 5/28/26 at 4:00 p.m., the DON said upon admission of Resident #1 on 3/12/26 the admitting nurse forgot to place the correct order for Dilantin. The DON said as per hospital DC orders, Resident #1 should have been given 25mg/mL 4 mL (100mg) q day and 8 mL (200mg) QHS. The DON said Resident #1 only received Dilantin 4 mL (100mg) QD. The DON said Resident #1 did not receive the ordered 8 mL (200mg) QHS because it was not entered into the system by the admitting nurse. DON said that type of med error could cause a resident seizures. The DON said Resident #1 ultimately had a seizure on 4/8/26. The DON said they did an in-service for nurses, informed them there should always be baselines for certain medications, and conducted med competencies when it was discovered.In an interview on 5/29/26 at 8:35 a.m. the NP stated she reviewed Resident #1 medication list from the hospital, and she did not give any orders to DC Dilantin 8mL QHS. She said the adverse outcome of not receiving Dilantin as ordered was different in every case. The NP said Resident #1 had not had a seizure in a very long time, but omission of the nighttime Dilantin could potentially cause a seizure. The NP said she rounded with Resident #1 and she showed no changes, was pleasant, and doing well throughout her stay. The NP said she did not order Dilantin levels for Resident #1 since they were drawn on 3/11/26 at the hospital and did not indicate a need. The NP said if the level on Resident #1's Dilantin level on 4/8/26 showed 2.4 (low) it could indicate she was not receiving the proper dose. The NP said residents with a history of seizures would have had a seizure even with normal levels. The NP said Resident #1 was also started on Rocephin ABX for a UTI on 4/5/26 which could also affect the threshold and triggered the seizure. In an interview on 5/28/26 at 10:24 a.m., the Pharmacist stated there were many things that could cause a seizure. He said, Could that have directly contributed to the seizure, he said he did not think so. The Pharmacist said he did not know if a UTI would cause Dilantin levels to go low. The Pharmacist said there was no interaction between Dilantin and the ABX Rocephin, so it did not appear that it would have lowered the Dilantin levels.Record review of the facility's Medication Reconciliation policy implemented 4/10/23 reflected, Policy:This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. Definitions: Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. Policy Explanation and Compliance Guidelines: .4. admission Processes:a. Obtain current medication list from referral source (i.e. hospital, home health, hospice, or primary care provider).b. Compare orders to hospital records, etc. Obtain clarification orders as needed.c. Transcribe orders in accordance with procedures for admission orders.Record review of the facility's Medication Monitoring Preventing Adverse Consequences and Med Errors policy original/revised date of 10/1/2019 reflected, Policy:The facility employs a system to assure that medication usage is evaluated on an ongoing basis.6. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary to protect the resident's safety and welfare. Significant is defined as: .B. Requiring hospitalization.The Administrator was notified on 5/29/26 at 7:39 p.m. that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation on 3/12/26. The facility had corrected the noncompliance before investigation began.The facility had implemented the following interventions:1.Resident #1 was sent out to hospital after having seizure on 4/8/26.2.Residents with seizures were reviewed and baseline levels were obtained. Record review of audit documentation provided by the DON reflected she reviewed residents on anti-seizure medications and obtained current labs to ensure appropriate lab value levels. 3.Performance Improvement Plan (PIP) was initiated on 4/9/26 by the Administrator where they identified concerns, Performance Improvement Goals, Corrective Actions which included staff education, medication administration process review, monitoring and auditing, communication improvements, Timeline, Expected Outcomes and Follow-up and Evaluation. Progress will be reviewed through medication administration audits, staff competency evaluations, QAPI committee review. PIP was reviewed on 5/29/26 and reflected as completed on 4/9/26. 4.Medication Competency Assessment completed on nurses on 4/9/26. Record review of Medication Competency Assessment on 5/29/26 showed completed and signed on 4/9/26. 5.Nursing staff were in-serviced on Seizures Symptoms and Causes of seizures, Medication Administration, Notification of changes, and Medication competency on 4/9/26. Record review on 5/29/26 of in-services reflected in-services on Seizure Symptoms and Causes of Seizures, Medication Administration, Notification of Changes, and Medication Competencies were completed on 4/9/26. Staff interviews on 5/29/26 between 10:40 am to 3:45 pm reflected staff were in-serviced and knowledgeable of seizure symptoms, causes of symptoms, procedure to input hospital DC orders and that they had received competency training/skills check offs.During interviews of nursing staff from all shifts on 5/29/26 between 10:40 am to 3:45 pm, LVN B, RN C, RN D, LVN E, LVN F, LVN G, and ADON revealed they were knowledgeable of the facility training provided above including seizure symptoms, causes of symptoms, procedure to input hospital DC orders and that they had received competency training/skills check offs.

Based on interviews and record review, the facility failed to have physician orders for the resident's immediate care at time of admission, for 1 (Resident #1) of 3 residents reviewed for physician admission orders. The facility failed to have physician orders in place for Resident #1's enhanced barrier precautions. This failure could place residents at risk of developing infections. Findings included: Record review of Resident #1's face sheet, dated 03/02/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: cerebral infarction (stroke), metabolic encephalopathy (brain dysfunction caused by chemical imbalances), dysphagia (trouble swallowing), cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions), muscle wasting and atrophy (loss of muscle mass and strength), and gastrostomy status (surgically created opening into the stomach, typically with a feeding tube in place for nutrition, hydration, or medication delivery). Resident #1 was discharged to the hospital on [DATE]. Record review of Resident #1's MDS assessment, dated 02/15/26, reflected Resident #1 had a BIMS score of 4, indicating severe cognitive impairment. Resident #1's MDS reflected the use of a feeding tube noted on admission. Record review of Resident #1's baseline care plan, dated 02/12/26, reflected [Resident #1] required tube feeding and was dependent with tube feeding and water flushes. See orders for current feeding orders. Record review of Resident #1's order summary report, on 03/02/26 at 1:20 PM, reflected Resident #1 had an active order for, Enteral Feed Order every shift, Glucerna 1.5 at 55ml/hr via feeding tube stationary pump with a start date of 02/12/26. Record review of Resident #1's physician's orders, on 03/02/26 at 3:30 PM, reflected there were no orders for EBP for the resident's admission from 02/12/26-02/15/26. During an interview with the DON on 03/02/26 at 11:00 AM, she said Resident #1 required EBP since admission because he had a feeding tube which was considered an indwelling device. The DON said she reviewed the physician's orders for Resident #1 and he did not have an order for EBP. The DON said the team reviewed new admissions during the meetings and ensured all orders were in place. The DON said although the order was not in place for Resident #1's EBP, the staff were aware that Resident #1 required EBP and followed the precautions. The DON said there was no negative outcome for Resident #1, however, it was important to have an order for EBP to ensure staff followed the precautions to prevent infection. During an interview with the ADON on 03/02/26 at 12:00 PM, she said she did not remember who Resident #1 was. The ADON said a resident with a feeding tube required EBP because the feeding tube was an invasive device. The ADON said the team reviewed the physician's orders during the meetings and ensured everything was accurate. During an interview with the ADM on 03/03/26 at 2:00 PM, she said the team reviewed the physician's orders for new admissions and ensured all orders were in place as needed. The ADM said for the residents with feeding tubes, they needed to be on EBP which required an order. The ADM said there was no negative outcome for Resident #1, however, it was important to have the order to ensure Resident #1 received the appropriate care. Record review of the facility's Enhanced Barrier Precautions policy, dated 11/24/25, reflected - Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of MDRO. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. b. An order for EBP will be obtained for residents with any of the following: i. Wounds, indwelling medical devices (including feeding tubes), even if the resident is not known to be infected or colonized with a MDRO.

Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #1) of 3 residents reviewed for baseline care plans. The facility failed to ensure Resident #1's baseline care plan reflected enhanced barrier precautions.This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #1's face sheet, dated 03/02/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: cerebral infarction (stroke), metabolic encephalopathy (brain dysfunction caused by chemical imbalances), dysphagia (trouble swallowing), cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions), muscle wasting and atrophy (loss of muscle mass and strength), and gastrostomy status (surgically created opening into the stomach, typically with a feeding tube in place for nutrition, hydration, or medication delivery). Resident #1 was discharged to the hospital on [DATE]. Record review of Resident #1's MDS assessment, dated 02/15/26, reflected Resident #1 had a BIMS score of 4, indicating severe cognitive impairment. Resident #1's MDS reflected the use of a feeding tube noted on admission. Record review of Resident #1's baseline care plan, dated 02/12/26, reflected [Resident #1] required tube feeding and was dependent with tube feeding and water flushes. See orders for current feeding orders. Resident #1's baseline care plan did not reflect the EBP. Record review of Resident #1's order summary report, on 03/02/26 at 1:20 PM, reflected Resident #1 had an active order for, Enteral Feed Order every shift, Glucerna 1.5 at 55ml/hr via feeding tube stationary pump with a start date of 02/12/26. During an interview with the DON on 03/02/26 at 11:00 AM, she said Resident #1 required EBP since admission because he had a feeding tube which was considered an indwelling device. The DON said a baseline care plan was developed within 48 hours of admission and the comprehensive care plan was developed with more time. The DON said Resident #1 was only at the facility for about three days, so he had the baseline care plan completed. The DON said she reviewed the baseline care plan and signed off on it. The DON said the baseline care plan did not reflect the EBP because the question that asked if the resident required any special precautions was marked no. The DON said although the baseline care plan did not reflect the EBP, the staff were aware that Resident #1 required EBP and followed the precautions. The DON said there was no negative outcome to Resident #1, however, it was important to have the EBP in the baseline care plan to ensure staff followed the precautions to prevent infection. During an interview with the ADON on 03/02/26 at 12:00 PM, she said she did not remember who Resident #1 was. The ADON said a resident with a feeding tube required EBP because the feeding tube was an invasive device. The ADON said the baseline care plan was done within 48 hours of admission and the comprehensive care plan was developed with more time. The ADON said if the resident was admitted with the feeding tube, then the EBP should have been noted on the baseline care plan. During an interview with the ADM on 03/03/26 at 2:00 PM, she said the team reviewed new admissions and ensured everything was in place as needed for their care. The ADM said for the residents with feeding tubes, they needed to be on EBP. The ADM said the baseline care plan was done within 48 hours of admission and they had a longer timeframe to complete the comprehensive care plan, but the EBP would at least be noted in the baseline care plan. The ADM said there was no negative outcome for Resident #1, however, it was important to have the EBP in the baseline care plan to ensure Resident #1 received the appropriate care. Record review of the facility's Baseline Care Plans policy, dated 06/06/25, reflected - Policy: 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. 1. The baseline care plan will: A. Be developed within 48 hours of a resident's admission. B. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control.1. The facility failed to inform all staff that Resident #1 was on droplet precautions.2. The facility failed to ensure that Resident #1 had a droplet precaution sign at the door.This deficient practice could place residents at-risk for cross contamination and the spread of infection.Findings included: Record review of Resident #1's face sheet, dated 01/3/2026, revealed the resident was a [AGE] year-old male, admitted [DATE], readmitted [DATE] with diagnoses that included: transient cerebral ischemic attack (mini-stroke/temporary blockage of blood flow to the brain, causing stroke-like symptoms), hypertension (high blood pressure), dementia (significant decline in mental abilities such as memory, thinking, and reasoning, severe enough to disrupt daily life), and dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS assessment, dated 11/19/2025, revealed a BIMS score of 03, indicating severe cognitive impairment and was dependent on staff for all self-care needs. Record review of Resident #1's undated comprehensive care plan revealed Resident #1 was on Enhanced Barrier Precautions and interventions included: Place on Enhanced Barrier Precautions, ensure a sign was placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and might participate in communal activities. Use a mask, goggles/eye shield as indicated. Date Initiated: 11/14/2024 Provide the resident and family member with education on and the reason and for EBP.Date Initiated: 11/14/2024 Use non-shared resident medical equipment if possible. Disinfect shared resident use equipment with the appropriate disinfectant. Date Initiated: 11/14/2024Record review of Nursing - Initial Baseline/Advanced Care Plan for readmission dated 1/12/2026 revealed the resident had a clinical condition that required special precautions of Rhino Virus (a group of viruses that are the primary cause of the human common cold and upper respiratory infections that are highly contagious and spreads easily through droplets, contaminated surfaces, and direct contact) which required droplet transmission-based precautions (precautions, such as placing the patient in a private room, wearing a surgical mask when withing 3-6 feet of the patient, and requiring the patient to wear a mask during transport, that prevent the spread of pathogens (microorganisms or germs) transmitted through close respiratory contact). Record review of Resident #1's daily skilled progress note, dated 1/12/2026, revealed resident was on single room isolation. Record review of Resident #1's nursing progress note, dated 1/13/26 at 12:25 a.m., revealed the NP approved the facility to follow hospital discharge orders for readmission. Record review of Resident #1's Orders Summary report revealed Droplet Precautions (precautions, such as placing the patient in a private room, wearing a surgical mask when withing 3-6 feet of the patient, and requiring the patient to wear a mask during transport, that prevent the spread of pathogens (microorganisms or germs) due to influenza order dated 1/13/2026. Record review of Resident #1's nursing progress, note dated 1/13/25 at 12:36 p.m., revealed the NP discontinued droplet isolation precautions. Observation on 1/13/26 at 8:40 am revealed there was not a sign posted next to Resident #1's door and PPE were not outside the resident's room. LVN G and CNA A were observed placing isolation sign next to door and hanging PPE on the door shortly after. During an interview on 1/13/26 at 10:15 a.m., CNA A revealed she provided care for Resident #1 around 6:30 a.m. to change his brief. She said she was familiar with Resident #1, so she wore a gown and gloves because she recalled Resident #1 had a g-tube and on EBP prior to his hospitalization. She said she was informed around 8:30 a.m. that Resident #1 was on isolation/droplet precautions. She said she helped place the sign up and hang the PPE on the door. She said prior to that, while working the 600 hallway, she was not aware Resident #1 was under any isolation precautions. She said she left the facility yesterday (1/12/2026) at 3:00 p.m. and Resident #1 had not returned from the hospital. She said even if it was late in the evening, signs and PPE should be placed as soon as they learned a resident was on isolation precautions. She said normally staff were good at placing signs and PPE immediately after identifying a resident was on isolation because everyone knew where the items for precautions were located. She said they had an infection control in-service yesterday (1/12/2026) and usually had one monthly. She said they went over hand hygiene and EBP versus other precautions. She said if she knew the resident was on isolation/droplet precautions, she would have also worn a mask and a face shield. She said if appropriate precautions were not in place, proper PPE would not be worn, and they could transfer the infection to other residents or take it home. She said she entered a lot of rooms and assisted with breakfast in the dining room prior to learning Resident #1 was on isolation precautions. During an interview on 1/13/25 at 10:43 a.m., CNA B said she did not work 600 hallway this morning (1/13/2026) but heard the signs were not placed. She said usually upon admission, a resident would be placed on proper precautions and signs, and PPE would be placed immediately on the doors. She said the shift that admitted the resident should have placed PPE and signs up. She said she did not know who worked the night shift. She said if there was a delay in placing the precautions signs on the door, staff could enter a resident's room without applying the appropriate PPE for protection and could spread the infection to everyone. She said they had an infection control in-service yesterday (1/12/2026) and they usually had them monthly. She said they went over hand-hygiene and appropriate length of time to complete it. She said they also went over applying appropriate PPE. She said she had worked with Resident #1 prior to entering the hospital. She said Resident #1 was on EBP for feeding tube, so staff usually wore a gown and gloves when provided him care. She said the difference with Resident #1's current isolation/droplet precautions was that they needed to add the face mask and shield. During an interview on 1/13/26 at 11:35 a.m., CNA C said Resident #1 was on air/droplet precautions, so she applied the mask, shield, gloves and gowns when she entered his room. She said she completed hand hygiene prior to and after. She said PPE was usually always located on the linen carts, so she grabbed what she needed to use from there. She said she disposed of the PPE in a bag and sealed it before taking it out of the room. She said a CNA from the prior shift gave her the information since she arrived later than 10:00 p.m She said she believed that if they told her, the other CNAs were informed as well Resident #1 was on droplet precautions. She said she was assigned to the 600 hallway, so she was the only CNA going in and out of Resident #1's room last night. She said if a resident was admitted and they knew the resident was on some type of isolation precautions, they usually posted signs and PPE and informed the staff right away. She said usually the nurse applied the precaution signs and PPE. She said when she used to work mornings, housekeeping did that or sometimes they told the CNAs to do it. She said while she worked the 600 hallway last night (1/12/2026), there was no PPE or isolation precaution signs in front of Resident #1's room. She said if the proper sign and PPE were not posted, staff that were unaware could provide care without appropriate PPE worn and transfer the infection to another resident. She said if a resident was on isolation/contact precautions, she did not notify someone that the signs and PPE were not there, Because the nurses are supposed to know right? CNA C knew what the precautions were and what PPE she needed to use. She said usually those items were in a locked room, so if they need her to place the precautions, they asked and provided the items. She said they had infection control in-services frequently and were annually trained. She said training included the different types of precautions, how to complete proper hand hygiene, the different types of PPE and proper disposal of PPE. During an interview on 1/13/26 at 12:07 p.m., LVN D said she was working when Resident #1 was admitted . She said she stayed late to assist the floor nurse with his admission. She said she entered Resident #1's room to complete his skin evaluation. She said she received report from the hospital DC nurse, so she was aware he was on droplet precautions. She said she placed a mask, gown, hat, goggles, and gloves on before entering his room. She said she completed hand hygiene before and after. She said she disposed of the PPE in the room, since it had not been set up yet. She said she tied the bag, removed it from the room, and placed new bag. She said she did not place the signs or PPE but did not recall if they were already there. She said she got her PPE from the building, and she had a pack of gowns at the nurse's station. She said it was all the staff's responsibility to place signs and PPE when a resident was on precautions. She said that usually the admitting nurses ensured it got done. She said the signs and PPE were usually always up as soon as they were made aware the resident was on isolation precautions. She said if she was the admitting nurse who received the information that the resident was on droplet precautions, they would had prepared the room, placed all the appropriate precautions, monitored and used appropriate precautions. She said they would also notify the staff. She said she was not the admitting nurse. She said she knew they notified the CNAs for Resident #1. She said she heard the nurses give the report to the CNAs. She said the signs were always located in the nurse's station and not locked up. She said if precaution signs and PPE were not placed it could place staff and others at risk for spreading the droplets. She said the facility had annual infection control training and frequent in-services on infection control. She said they go over hand hygiene, the purpose of wearing PPE, where to get PPE, how to prevent the spread of infection, and the different types of isolation. During an interview on 1/13/25 at 3:50 p.m., RN H said he came in at 5 am this morning. He said LVN E, the night nurse, provided him with report. She said Resident #1 was on isolation precautions because of a virus but we know now it was not a virus. He said he received the results of an x-ray today and the results said it was pneumonia. He said it was actually him that told them there was no precautions up at the resident's room, so they were just getting it on. He said the person responsible for placing all precautions was the admitting nurse. He said if the resident was already in the facility, then the nurse who receives the order should be responsible. He said the signs were located at the nurse's station in a drawer. He said the door was not locked. He said they had them everywhere. He said he was a new employee and he knew where they were located. RN H said he should had been the one to inform the CNAs Resident #1 was on isolation precautions. He said usually the the signs and PPE are already in place upon admission. He said if he was working upon the resident admission, he would have had it all ready before the resident came in because they get report prior to a resident being admitted . He said even though they knew he did not have flu now, Resident #1 should had been placed on droplet precautions as soon as they got report from the hospital because as far as they were concerned, he had the flu. He said they had in-services and reminders on infection control daily. RN H said the facility informed him of any missed in-services. He said the last infection control in-service was yesterday. He said they went over hand washing greater than 21 seconds, wearing masks, gowns, and gloves. Different types of precautions, such as EBP for dialysis, g-tube and wounds. He said EBP versus droplet precautions includes addition of a mask and shield. He said he wore appropriate PPE when he entered Resident #1's room. During an interview on 1/13/26 at 5:56 p.m., LVN E said she was not the admitting the nurse for Resident #1's admission on [DATE]. She said there was a note that Resident #1 was on droplet precautions, so she was aware she needed to wear the appropriate PPE, such as face mask, face shield, gown and gloves and wore them every time she provided care. She said she performed hand hygiene before she went into the room and before she left. She said she disposed of the PPE in the biohazard bag. She said they did not have the boxes yet, so she placed them in the biohazard bags until the boxes were placed. She said the sign and PPE were not placed by his door at the time. She said they were under lock and key. She said they had gowns, gloves, and facemasks in the carts and biohazard bags were always available. She said she verbally told the CNAs Resident #1 was on droplet precautions and even told the laboratory technician so she could apply PPE before drawing labs. She said upon admission, whoever had the knowledge the resident had precautions must tell housekeeping so they could set up the appropriate precautions in the room. She said at night they didn't have any access to it because they did not have housekeeping. She said she reported the information to her CNA, the incoming nurse, RN H and the incoming CNA, CNA A. She said an outbreak could happen if the precaution signs were not placed on the doors and the staff were not aware of the precautions, which was why they should have access to everything. She said the night shift staff had a little more time to place the precautions up, so there would be no confusion. She said even though she knew now Resident #1 might not have the flu, they still should have had the precautions up, because as far as they knew, he had the flu, and they did not have access to the precautions. She said the facility had infection control in-services once a month and more during flu season. She said they had an in-service this week. She said they went over appropriate PPE to wear, where to locate the PPE, how to disinfect, how to apply and remove PPE so staff did not break infection control, who to report precautions to, and hand hygieneDuring an interview on 1/14/26 at 8:53 a.m., LVN F said she was a floating nurse and helped with Resident #1's admission, but she was not the admitting nurse. She said the admitting nurse was LVN D. She said she did not enter Resident #1's room at all. She said she was made aware Resident #1 was admitted on droplet precautions by LVN D, who received the discharge paperwork prior to admission. She said the information regarding Resident #1's precautions was also on the hospital paperwork the hospital provided in-hand with Resident #1. LVN F said that was when she noticed the isolation precautions for Resident #1. LVN F said she informed CNA C who worked with Resident #1 at the time. She said the normal protocol was prior to admission, the nurse who received the report that the resident was coming with isolation, prepared the room, but it was everyone's responsibility. She said sometimes they did not have access to the bins or certain PPE. She said they did not have any face shields. For some reason they were under lock and key, and they didn't have that key. So usually, they waited until someone showed up with a key. She said they did have access to the signs they must post, gowns, masks, biohazard bags and gloves. She said the night nurse was responsible for informing the morning nurse and she did inform LVN E. She said the night shift CNAs were good about passing information to the next shift CNAs and the morning nurse should notify the CNAs as well, when they received report. She said a bad outcome of not having appropriate isolation precautions, was it could cause cross-contamination and get everyone else sick. LVN F said she was informed today (1/14/2026) that Resident #1 did not need to be isolated. She said that she felt the precautions still should had been followed because at the time they did not know Resident #1 did not have the flu. She said because if he was positive at the hospital, she felt the precautions should had remained and that was her opinion. She said they had a lot of in-services for infection and believed they had one within the week but could not recall the date. She said they went over hand washing, applying proper PPE before entering rooms, cross contamination and different types of PPE for different precautions. During an interview on 1/14/26 at 3:22 p.m., the DON said they were not expecting Resident #1 until the following day, but the hospital called right before 10:00 p.m. on 1/12/26 he was discharged from the hospital. The DON said LVN D received the report Resident #1 had rhino virus (a group of viruses that are the primary cause of the human common cold and upper respiratory infections that are highly contagious and spreads easily through droplets, contaminated surfaces, and direct contact.)not the flu. LVN D reported to LVN E during shift change Resident #1 was under isolated but was not very clear what it was. They placed Resident #1 in a room alone. She said they had the PPE they needed. The nurses told the staff to wear the mask, gown, and gloves before going in. When the DON got into the facility the next morning, they tried to clarify if Resident #1 had rhino virus or the flu. She said they were told that everything was negative. She said she requested the rest of the laboratory results from the hospital. She said so they were not sure if it was a true isolation. She said the nurses called the NP and she returned the call around noon to discontinue the isolation. The DON said it was less than 12 hours. She said she started an in-service for the nurses. She said she was the IP and they did infection control in-services at least monthly and last one was recent due to flu surge in the state. The DON said she tells staff if they are sick do not come into work. She emphasized hand hygiene, differences with precautions and recently educated staff on droplet precautions. She said they currently did not have any residents on isolation or contact precautions, only EBP. She said if a resident was being admitted on precautions they would now prior to admissions and should start those precautions once they were told. She said she was not sure if Resident #1 was on droplet precautions, she just knew he was on isolation precautions. She said LVN D received report from the hospital nurse and was told Resident #1 had the flu. He was isolated in his with his own room, staff were notified. She said isolation supplies were in a storage room next to RM [ROOM NUMBER] and it was not locked. She said now they had bins with PPE down each hallway. She said signs were at the nurse's station and they were not locked. She said they were on open shelves. She said the bins for sheets and the doff (remove) and don (applying) boxes were usually kept with housekeeping, but for the meantime they used the bins in the rooms until housekeeping arrives. She said she was newer than night staff and she knows where they were located. She said staff usually ask when they need anything. She said the nurses should have clarified the isolation. She said if there were no signs posted at the room, the staff would not know what isolation precautions to follow. She said they could spread it if they went into the room without the appropriate PPE and took care of other residents. She said it was the night shift nurse's responsibility to report the precautions to the next shift. She said she felt they did not receive good enough report from the hospital to make a good determination of what isolation precautions. Because upon further review Resident #1 was negative for everything but pneumonia. She said that it is not a perfect world and if she didn't have the appropriate information and only had information that he had flu/rhino virus to go by, she would still place all the isolation/droplet precautions in place which included the signs and the appropriate PPE.During an interview on 1/14/26 at 4:27 p.m., the Administrator said the day before Resident #1 was admitted , they received information from the hospital that the facility was going to receive a new admission possibly on isolation. She asked the RN on 1/13/25, and thought she heard Resident #1 had the flu, but later the RN said it was something else. She said the if a resident was on droplets precautions, they needed the appropriate PPE and the proper signage for the type of isolation. Her understanding was that Resident #1 needed to be on droplet precautions. She said the nurses should ask for clarification. She said they had 24 hours to review the hospital discharge paperwork and if they see the isolation was not needed after review, they would take off the isolation. She said until then appropriate signage, PPE, and isolation precautions should be in place. She said nurses give report to each other. Morning shift would give report to all of us in morning around 8:15 a.m Nurses were also responsible to inform the CNAs. She said if there were no signs and no PPE in place for a resident who was on droplet precautions, they could risk exposure to themselves. She said, but in this case, Resident #1 didn't have the flu, so they did not risk exposure. She said if after her review of the records Resident #1 was positive for flu, they would have risked exposure without proper PPE and signs. Record review of the facility policy, titled Infection Prevention and Control Program, dated 05/13/2023, revealed: PolicyThis 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:1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infection diseases resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: .c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.5. 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.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 10 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to document Resident #1's physician ordered 1 to 1 constant observation every hour on 12/08/25 from 3:00pm - 9:00pm. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #1's face sheet, dated 12/17/25, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: vascular dementia (decline in thinking skills from conditions damaging brain blood vessels, reducing oxygen and causing issues with memory, planning, focus and mood ), moderate, with other behavioral disturbance, and unspecified psychosis (disconnect from reality, may involve hallucinations or delusion) not due to a substance or known physiological condition Record review of Resident #1's quarterly MDS assessment, dated 11/27/25, revealed Resident #1 had a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #1's care plan with an initiation date of 01/13/25 reflected a focus of the resident was physically aggressive r/t Dementia and thinking that other people steal from her with intervention of, Resident was placed on a 1 to 1 for 72 hours both with an initiation date of 12/06/25. Record review of Resident #1's physician's orders revealed orders to, Place resident on 1:1 constant observation every hour. Including during all activities, toileting, and sleeping x72 hours, with a frequency of every hour for aggressive behaviors with an end date of 12/10/25. Record review of Resident #1's December 2025 MAR reflected her order to Place resident on 1:1 constant observation every hour. Including during all activities, toileting, and sleeping x72 hours, with a frequency of every hour for aggressive behaviors was not signed hourly on 12/08/25 from 3:00pm - 9:00pm. During an interview with LVN A on 12/18/25 at 4:11pm she stated on 12/08/25 staff including herself completed a 1 to 1 with Resident #1 and made sure they knew where she was at all times. LVN A stated she was the staff member monitoring Resident #1 during the unsigned times on the MAR from 3:00pm-9:00pm on 12/08/25 and stated she was responsible for documenting it as well. LVN A stated she had reviewed Residents #1's December 2025 MAR and did see that she had not signed it. LVN A stated when you see a blank on the MAR it meant it had not been signed and could mean that it was not done. LVN A clarified that in this situation the monitoring was completed by her and Resident #1 did not have any aggressive behaviors during those times. LVN A stated she thought the floor nurse at the time, LVN B was going to sign off on the MAR but stated the person who is completing the monitoring should be the one signing off and stated in this situation it was her. LVN A stated it was important to sign off on the MAR to ensure they are documenting any behaviors and to show they were compliant with the physician's orders. LVN A stated the DON or ADON C would review the MAR for any omissions but did not know how often or how they did that. LVN C stated she had been trained over documentation on the MAR by the DON within the previous 30 days but did not recall an exact date. LVN A stated the facility policy regarding documentation stated the moment the order was completed they needed to sign it. LVN A stated she did not follow the policy because she did not sign the MAR. LVN A stated not signing off on behavior monitoring on the MAR could negatively impact residents because if they were not documenting behaviors the following nurses would not know what to look for and when the physician reviewed the behaviors would not be documented. During an interview and record review with the DON on 12/18/25 at 6:27pm she stated LVN B was technically responsible for signing the MAR between 3:00pm and 9:00pm on 12/08/25 for Resident #1 because he was the hall nurse but stated herself and LVN A had volunteered to sit with Resident #1 and LVN A was the one sitting there with Resident #1 at that time. The DON reviewed Resident #1's December 2025 MAR and confirmed Resident #1's order for her 1 on 1 for behavior monitoring was not signed from 3:00pm-9:00pm on 12/08/25. The DON stated an unsigned section on the MAR indicated that the order was not completed, but stated during those times the monitoring was completed, and Resident #1 did not have any aggressive behaviors at those times. The DON stated she did not know why it had not been signed but stated it was important to do so to make sure there were no aggressive behaviors because it was for the safety of the patient and the residents. The DON stated the facility policy regarding documentation stated documentation needed to be completed at time of service. The DON stated the facility staff did not follow the policy in this situation. The DON stated both LVN A and B had been trained over documentation recently by herself. The DON stated that LVN A, ADON C and herself monitored the MAR for omissions daily except over the weekends they would do it on Monday mornings. The DON stated in this situation she did not feel there was any negative impact on any residents due to not signing off on the MAR because the monitoring was done and staff were in place, however they did not give themselves credit for it by signing on the MAR. Record review of facility in-service training report dated 12/05/25 with a topic of Documentation reflected LVN A had received the training provided by the DON. LVN B was not identified on the in-service sign in sheet. Record review of facility policy titled, Documentation in Medical Record with an implemented date on 10/24/22 stated, 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. And b. documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care. C. Documentation shall be timely and in chronological order.

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 61 of 61 residents. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review on 05/20/25 at 10:30 a.m. of the facility's Administrative and other licensed professional staff Licensure audit revealed the current Activity Director was not certified. In an interview on 05/20/25 at 12:00 p.m., the HR Coordinator said the facility's Activity Director was not certified. In An interview on 05/20/25 at 12:38 p.m., the AD, said she had been hired as the Activity Director on 01/15/25. She said when she was hired, she was advised by the facility's Administrator she needed to enroll in an AD program within 6 months of being hired. She said she had no previous experience in being an AD. She said she had recently (not sure of date) submitted the required paperwork and fee to enroll in an online AD program. She said as of 05/20/25, she had not been officially enrolled. She said the program consisted of 180 hours to be completed at her own pace. In an interview on 05/20/25 at 1:30 a.m., the Administrator said the qualifications to be an Activity Director were to have their AD certificate or be an occupational therapist. She said the current AD started working at the facility on 01/15/25 and did not have the required qualifications. She said she, the current AD, had signed an agreement that stated she would enroll in and begin an AD program within 6 months of her hire date. She said it was her responsibility to ensure the AD had enrolled in an AD program within 6 months. The Administrator said during the morning meeting she had made it a point to ask the current AD on the status of her enrollment in an AD program. The Administrator said the facility did not have a policy on the requirements for an AD, only a job description. The Administrator said the current AD did not have any of the following state requirements: licensed or registered, eligible for certification as a therapeutic recreation specialist, or an activities professional by a recognized accrediting body on or after October 1, 1990, had 2 years of experience in a social or recreational program with the last 5 years, one of which was full-time in a therapeutic activities program; or was a qualified occupational therapist or occupational therapy assistant; or Had completed a training course approved by the state Record review of the written agreement signed on 01/20/25 by the Administrator and the current AD reflected: This agreement is made on [DATE]th, 2025, between facility and AD. AD is required to enroll in and begin an AD program within 6 months of this agreement. The deadline for enrollment is June 20th, 2025. Record review of the facility's job description for the job title of AD reflected: Education/Training Requirements: Bachelor's Degree in therapeutic recreation or equivalent training experience if preferred. Licensing Requirements: Certified Therapeutic Recreation Specialist (CTRS). Experience Requirements: Two years of experience in a social or recreational program.

Based on interviews and record review the facility failed to 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 for 1 (Resident #216) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #216's use of insulin and anticoagulant medications in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #216's Admission Record dated 05/20/2025 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Heart Failure, Peripheral Arterial Disease (an accumulation of plaque (fats and cholesterol) in the arteries in your legs or arms), Hyperlipidemia (high cholesterol), Muscle Wasting and Atrophy (decrease in muscle size and wasting of muscle tissue), and Dysphagia (difficulty swallowing). Record review of Resident #216's 5-day MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #216's Baseline Care Plan initiated 05/11/2025 revealed medications insulin and anticoagulant were not included. Record review of Resident #216 ' s Physician Orders dated 5/11/2025 revealed, Tresiba Flex Touch Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Degludec) inject 32 units subcutaneously in the morning for DM #2 hold if BS less than 100 and Eliquis Oral Tablet 2.5mg (Apixaban) Give 1 tablet by mouth two times a day for PAD. Record review of Resident #216's electronic Medication Administration Record for May 2025 revealed Eliquis oral tablet 2.5mg 1 tablet by mouth was administered twice a day, started 05/12/2025 and Tresiba Flex Touch Subcutaneous solution Pen injector 100 unit/ml (Insulin Degludec) 32 units injected subcutaneously in the morning, started 05/12/2025. During an interview with MDS nurse on 05/19/25 at 3:05 p.m., stated that the baseline care plan was to be completed within 48 hours. She stated that the admitting floor nurses were responsible for completing the baseline care plan upon admission and the registered nurses sign it off. The MDS nurse stated the essential information that should be included in the baseline care plan should be the resident ' s cognition status, ADLs, respiratory, and medications. The MDS stated that it was important to have that information in the baseline care plan because the resident could fall, elope or have a reaction to a medication. During an interview with LVN A on 05/19/25 3:15 p.m., she stated the baseline care plan was completed between 24-48 hours. He stated the baseline care plan should include information such as medications like insulin, anticoagulants, antidepressants, and code status. LVN A stated insulin should be in baseline care plan to manage the resident ' s diabetes, so they won ' t go into hypoglycemia or hyperglycemia. To make sure we were not giving too much insulin. He stated that the anticoagulants were important to be on the baseline care plan, so they won ' t bleed out. This information was important for better patient care. The admitting nurse was responsible for completing the baseline care plan. During an interview with the DON on 05/19/25 at 3:18 p.m., the DON stated that the nurses were responsible for completing the baseline care plan. She stated that she overlooks the baseline care plans and signs them off. The DON stated the baseline care plans were to be completed within 72hours, but she signs them off before 24hours. She stated that by signing them she acknowledges that it was complete. She stated that the baseline care plan should include the advance directive, allergies, and medications. The DON looked at Residents #216 baseline care plan and under medications, she confirmed that the insulin and anticoagulants were not checked off. She stated that if the resident was currently taking them then the medications needed to be on the baseline care plan. The DON stated the negative outcome was that it would not be care planned and the resident would not have a proper plan of care. Record review of the facility policy titled Baseline Care Plan reviewed 10/05/2023 revealed, Policy: 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: The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician Orders .

Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 ([DATE]) of 90 days reviewed for RN hours, for the months [DATE], through [DATE] The facility failed to have RN coverage for 1 day on Saturday, [DATE]. This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Record review of the facility's RN timesheets, no date, reflected the on Saturday [DATE]; the facility only had RN coverage for 3.91 hours. During an interview on [DATE] at 1:39 p.m., the DON said it was her responsibility to ensure the facility had RN coverage for 8 consecutive hours every day. She said if the scheduled RN were to call in then it would be her and the ADONs responsibility to look for another RN or one of them would have to cover the shift. The DON said she could not remember what happened on [DATE] that the scheduled RN only worked 3.91 hours. The DON said either she or the ADON might have covered the remainder of the shift on [DATE] but since they were salary, they were not required to clock in to document that day. The DON said the negative outcome of not having an RN in the facility for 8 consecutive hours could be that the certain tasks only an RN could do,(i.e., signing off on baseline care plans, removing midline/picc catheters, and/or pronouncing a resident deceased ) could not be performed. In an interview on [DATE] at 1:46 p.m., the Administrator said it was the DON's responsibility to ensure she scheduled an RN for 8 consecutive hours every day but ultimately it was her responsibility the Administrator. The Administrator said the negative outcome of not having an RN work 8 consecutive hours every day could be that the tasks that only an RN could perform like administering certain medications and treatments would not be done. The Administrator said the facility had sufficient RNs to cover their 8 consecutive hours shift every day. Record review of the facility's Nursing Services-Registered Nurse (RN) policy dated [DATE] reflected: Policy: It is the intent of the facility to comply with Registered Nurse requirements as per Social Security Act 1919 and 1819. Policy Explanation and Compliance Guidelines: 1.the facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiple RNs.) The hours worked by the DON would be considered applicable towards the requirement. Record review of the facility's policy Nursing Services and Sufficient Staff dated [DATE] reflected: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and obtain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

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 (Resident #10) of 5 residents whose care plans were reviewed for accurate records. Resident #10 was diagnosed with schizoaffective disorder but parts of her medical record inaccurately indicated she had schizophrenia. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admitted [DATE]. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected her BIMS score was blank, which indicated the resident had severe cognitive impairment. She was always incontinent of bladder and bowel. Record Review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: I have schizophrenia, I receive Risperdal to help control my symptoms (mood changes, yelling) Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: I will receive my ordered medications and be free of psychotropic drug related complications through review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: Black Box Warning: Risperdal Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 02/25/2024 LN Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 02/25/2024 LN SS Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/25/2024 LN Pharmacy consultant to review medications per facility policy Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN. FOCUS: I has a mood problem r/t Disease Process (SCHIZOPHRENIA) Date Initiated: 01/25/2025 Revision on: 01/25/2025 GOALS: I will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Date Initiated: 01/25/2025 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/25/2025 LN RN Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood. Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 01/25/2025 CNA LN RN. Record review of PCP 's diagnosis on 08/22/24 reflected, Schizoaffective Disorder. Record review of Nursing - Psychoactive Medication Quarterly Evaluation dated 08/23/24, reflected Medical Diagnosis warranting use F25.1 Schizoaffective Disorder, Depressive Type. Record review of physician ' s orders dated 08/23/24 reflected, risperDAL Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth at bedtime for schizophrenia. In an interview on 05/20/25 at 03:53 PM, the DON notified surveyor that schizophrenia was in the medical diagnosis. Surveyor checked and schizophrenia was added on 05/20/25 under medical diagnosis. DON stated the NP's notes on 10/05/24, 01/27/25, and 05/01/25 have schizophrenia in the note for a diagnosis. In an interview on 05/20/25 at 04:07 PM, NP stated she signed the Antipsychotic Consent for Risperdal for Resident #10 for schizoaffective disorder. NP stated Resident's PCP diagnosed Resident with schizoaffective disorder on 08/22/24. NP stated three of her notes on 10/05/24, 01/27/25, and 05/01/25 had the diagnosis of schizophrenia. The original diagnosis of schizoaffective disorder was given by PCP and not NP. NP was notified schizophrenia was not on the medical diagnosis on any other paperwork except hers and the order the nurse put in PCC. NP stated the diagnosis should be schizoaffective.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #10) of five residents reviewed for supervision. The facility failed to ensure Resident #10, who required assistance of 2 staff for bed baths, was not given a bed bath by 1 staff. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admitted [DATE]. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected, - BIMS score was blank which indicated the resident had severe cognitive impairment. - Always incontinent of bladder and bowel. - She took antipsychotic and antidepressant medications. - Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: I require assistance with all my ADLS due to impaired mobility and cognitive impairment. Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: I will have self-care needs met and have few, if any, complications through the review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: FUNCTIONAL PERFORMANCE: BATHING: Shower/ bathe self: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Tub/ shower transfer: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN CNA. Observation on 05/20/25 at 09:15 AM, revealed Resident #10 was getting a bed bath with CNA B in attendance. Resident #10 was uncovered, brief tabs detached and pulled down. The bath water was murky with soap bubbles. In an interview on 05/20/25 at 09:45 AM, CNA B stated Resident #10 was a 2-person assist for bed bath. CNA B stated she was the only one in Resident #10's room giving a bed bath when the surveyor came in to the room. CNA B stated CNA C went in to help her with Resident #10 's bed bath a few seconds after the surveyor left the room. CNA B stated she already knew if a resident was a 1- or 2-person assist, but if a resident was new, she would ask the nurse if the new resident was a 1- or 2- person assist. CNA B stated if 1 person went in to assist Resident #10, if you closed the curtain and Resident #10 could not see her tv, she would hit the CNA. CNA B stated she did not know if they had any in-servicing on 1- or 2- person assists. In an interview on 05/20/25 at 09:45 AM, CNA D stated if a resident required a mechanical lift, they were a 2-person assist. She said with Resident #10, it depended on how she was behaving whether she was a 1- or 2-person assist. CNA D stated therapy was asked if a new resident were a 1- or 2- person assist. She said sometimes the nurse would tell them if a resident were a 1- or 2-person assist. CNA D stated sometimes she would check the POC when a resident was new. She said if a resident who required a 2-person assist was helped by only 1 person, the resident could fall. In an interview on 05/20/25 at 09:50 AM, RN E stated Resident #10 was a 2-person assist. RN E stated the resident's Care Plan tells whether a resident was a 1- or 2-person assist. RN E stated the charge nurse was responsible for monitoring the CNA for 1- or 2-person assist. RN E stated, I have seen a couple of in-services going around for 1- or 2-person assist, but I do not know when. When RN E was asked what could happen if a resident was a 2-person assist and only one person was assisting, RN stated, That sounds like hypothetical, and I do not want to answer. RN E then stated, 1- or 2-person assists are geared to safety reasons. In an interview on 05/20/25 at 01:27 PM, CNA C stated she assisted CNA B with bed bath for Resident #10 that morning (05/20/25). CNA C stated she was outside the door when the surveyor was in asking questions. CNA C stated Resident #10 was a 2-person assist because she kicked and hit. CNA C stated they had an in-service on 1- or 2-person assist about a month ago. CNA C stated she would check the Kardex (a concise, quick -reference system for resident information) when she had questions about a patient and when there was a new patient. In an interview on 05/20/25 at 02:55 PM, LVN A stated the nurses or CNAs can check the care plan or Kardex to see if a resident is a 1- or 2-person assist. He said the 24-hour report can also be checked for changes in assist. LVN A stated it was the nurse ' s responsibility to notify the CNAs of any changes. He said it was the nurse ' s responsibility to monitor the CNAs to make sure they were following the care plan. LVN A stated injury to either the resident or CNA can occur if a 2-person assist is only done by one CNA. In an interview on 05/20/25 at 03:05 PM, the DON stated the charge nurse, and all licensed nurses are responsible to supervise CNAs. She said the CNAs are in-serviced at least monthly on 1- or 2-person assists. The DON stated the Kardex should be checked when providing care. She stated that the nurses are notified of changes in resident's condition and the nurses notify the CNAs. She said if a resident who was a 2-person assist had only a 1-person assist, the resident could fall or get injured. In an interview on 05/20/25 at 03:35 PM, the Administrator and ADON F stated they had a policy on ADLs, but not on supervision, Kardex or CNAs responsibility on whether a resident was a 1- or 2-person assist.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for one (Resident #10) of five resident reviewed for medications. The facility failed to have an adequate indication for the use of the medication risperdal (Risperdone - an antipsychotic) for Resident #10. This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed an [AGE] year-old female with an original admitted [DATE]. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected her BIMS score was blank, which indicated the resident had severe cognitive impairment. She was always incontinent of bladder and bowel. Section I reflected Resident #10 had an active diagnosis of schizophrenia (e.g., schizoaffective disorder and schizophreniform disorders). She took antipsychotic and antidepressant medications. Record review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: I have schizophrenia, I receive Risperdal to help control my symptoms (mood changes, yelling) Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: I will receive my ordered medications and be free of psychotropic drug related complications through review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: Black Box Warning: Risperdal Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 02/25/2024 LN Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 02/25/2024 LN SS Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/25/2024 LN Pharmacy consultant to review medications per facility policy Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN. FOCUS: I have a mood problem r/t Disease Process (SCHIZOPHRENIA) Date Initiated: 01/25/2025 Revision on: 01/25/2025 GOALS: I will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Date Initiated: 01/25/2025 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/25/2025 LN RN Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood. Date Initiated: 01/25/2025 LN RN Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 01/25/2025 CNA LN RN. Record review of physician ' s diagnosis on 08/22/24 reflected, Schizoaffective Disorder. Record review of Nursing - Psychoactive Medication Quarterly Evaluation dated 08/23/24, reflected Medical Diagnosis warranting use F25.1 Schizoaffective Disorder, Depressive Type. Record review of physician ' s order dated 08/23/24 reflected, risperDAL Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth at bedtime for schizophrenia. Attempted interview on 05/20/25 at 01:40 PM, with PCP for Resident #10 who diagnosed Resident #10 with schizoaffective disorder on 08/22/24. Answering service to pass on message to doctor to call surveyor. Attempted interview on 05/20/25 at 02:00 PM, with NP who signed consent for Risperdal 1 mg at bedtime for Resident #10 on 08/23/24. Receptionist will pass a message along for NP to call surveyor. Attempted interview on 05/20/25 at 02:28 PM, with Medical Director of the facility whose name was on the order for Resident #10's Risperdal 1 mg at bedtime. No answer. Voicemail left. In an interview on 05/20/25 at 02:55 PM, LVN A stated that the nurse who took the physician ' s order was the one who put it in PCC (residents' charts system). LVN A stated the orders are double checked by two nurses and the ADONs and DON. In an interview on 05/20/25 at 03:05 PM, the DON stated the nurse who gets the order was the one who put it in PCC. The DON stated all orders were double checked. She said if the wrong diagnosis was put on the order, it would be an inappropriate regimen. She said if the wrong diagnosis was care planned, the interventions may be inappropriate. In an interview on 05/20/25 at 03:53 PM, the DON notified surveyor that schizophrenia was in the medical diagnosis. Surveyor checked and schizophrenia was added on 05/20/25 under medical diagnosis. DON stated the NP's notes on 10/05/24, 01/27/25, and 05/01/25 had schizophrenia in the note for a diagnosis. In an interview on 05/20/25 at 04:07 PM, NP stated she signed the Antipsychotic Consent for Risperdal for Resident #10 for schizoaffective disorder. NP stated Resident's PCP diagnosed Resident with schizoaffective disorder on 08/22/24. NP stated three of her notes on 10/05/24, 01/27/25, and 05/01/25 had the diagnosis of schizophrenia. The original diagnosis of schizoaffective disorder was given by PCP and not NP. NP stated schizophrenia was not on the medical diagnosis on any other paperwork except hers and the order the nurse put in PCC. NP stated the diagnosis should be schizoaffective.

Based on interview and record review the facility failed 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 5 residents (Resident #1) reviewed for medications. The facility failed to ensure nursing staff filled Resident #1's prescribed Acetaminophen-Codeine Tablet 300-30 MG. This failure could place residents at risk of not being adequately treated for pain and for receiving less than therapeutic benefits of their medication. Findings include: Record review of Resident #1's face sheet, dated 4/24/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acquired absence of left leg below knee (a condition where an individual has had a surgical or traumatic removal, amputation, of part of the left leg below the knee joint), peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain, primarily the arteries and veins, causing reduced blood flow to the limbs), type 2 diabetes mellitus with hyperglycemia (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels) and cellulitis of right lower limb (a bacterial skin infection that can cause redness, swelling, pain, and tenderness in the affected area.) Record review of Resident #1 care plan, dated 1/16/2025, revealed Resident #1 had risk for pain related to left below Knee Amputation. Resident #1 BIMS was 14. Record review of Resident #1's Medication Administration Record for February 2025, revealed Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours for pain, and Resident #1 missed 3 doses (1 dose on 2/8/25 at 6:00 p.m. and 2 doses 2/9/25 at 12: a.m. and 6:00 a.m. During an interview on 4/23/2025 at 9:40 a.m., Resident #1 said he had in pain to his right lower extremity, he said he asked for his pain pill and LVN A went to give him a pill that did not looked like his pain medication.Resident #1 said that he got an oval shape pill and said his Tylenol #3 was a round shape pill. Resident #1 said he took the medication because he was in pain. Resident #1 said he asked LVN A three times if that pill was the Tylenol #3 he usually took, the resident said LVN A said yes the three times he asked her. Resident #1 said on 2/10/25 he filed a grievance and spoke the administrator. During a phone interview on 4/24/2025 at 2:54 p.m., LVN A revealed Resident #1 did not have a filled prescription for Acetaminophen-Codeine Tablet 300-30 MG. She also stated the resident had an active order for this medication as of 1/18/2025 and she was unsure why it had not been filled. LVN A said that the morning nurse had called the physician assistant asking for a refill. LVN A said she got a Tylenol 500mg and gave it to Resident #1. LVN said she went back to reassess Resident #1 and he was sleeping. LVN A said she signed off on the medication record the Acetaminophen-Codeine Tablet 300-30 MG by mistake. LVN A said she forgot to add the order for Tylenol 500mg to Resident #1's electronic medical record. LVN A explained she was very familiar with the resident. LVN A said she had a standing order from the physician for Tylenol 500mg but forgot to add it and signed off on the electronic medication administration chart of Resident #1. LVN A said she did not had access to the cubex (emergency medication supply system) and she did not inform anyone that Resident #1 was out of the Acetaminophen-Codeine Tablet 300-30 MG. LVN A said that she was supposed to call the DON or ADON. During an interview on 4/24/25 at 3:40 p.m., the physician assistant said he was familiar with Resident #1's chronic pain. The Physician assistant first stated Resident #1's pain was 9 out of 10 on the scale of 1 to 10, would not have subsided with one acetaminophen 500 milligram tablet, after further discussion he said he was not sure if it would have been enough because Resident #1 regularly complained of pain without signs of distress. During a phone interview on 4/24/25 at 4:00 p.m., the pharmacist stated the facility received a new Tylenol #3 blister pack for Resident #1 on 2/9/25 at 12:00 p.m. The Pharmacist said he received a call from the Physician Assistant for a refill on Acetaminophen-Codeine Tablet 300-30 MG. The Pharmacist said the blister pack was delivered on 2/9/25. During an interview on 4/28/25 at 9:50 a.m., RN B said he worked on 2/8/25 in the morning shift. RN B said the resident was not in pain and he gave the last pill of the Acetaminophen-Codeine Tablet 300-30 MG at 12:00 p.m. RN C said he contacted the Physician Assistant to ask him for a refill. RN B said on 2/5/25 he called the physician assistant and told him Resident #1 was running low on the Acetaminophen-Codeine Tablet 300-30 MG. RN B said all nurses knew there was medication available on the cubex for an emergency. RN B said the blister packs had a blue line and when the medication was low to that blue line, that meant it was time to reorder the medication from the pharmacy. During an interview on 4/28/2025 at 11:30 a.m., the DON said she was not aware about this incident with Resident #1 until 2/10/25 when Resident #1 filed a grievance. The DON said an investigation was initiated. The DON said nurses were trained on how to access the medications from the cubex and nurses knew to contact her or the ADON if the medication was not available on the cubex. The DON said the Physician assistant or the doctor had to call the pharmacy for the refill because this medication was a controlled medication, and the pharmacy needed a prescription for it. The DON said nurses did not know when the doctor was going to call the pharmacy, but she knew RN B called the physician assistant to informed him the resident was running low on the medication. The DON said the Acetaminophen-Codeine Tablet 300-30 MG was received at the facility on 2/9/25. The DON stated it was the facility's responsibility to ensure the resident had all of her ordered medications at the facility once the resident was transferred to long term care. The DON said when she spoke to the resident he was very upset because he felt LVN A lied about the medication he received. During an interview on 4/28/2025 at 12:00 p.m., the Administrator said Resident #1 spoke to her to file a grievance on 2/10/25. The Administrator said she started an investigation and spoke to LVN A and asked her what had happened, the Administrator said LVN A said to her she gave Resident #1 a Tylenol 500mg instead of Acetaminophen-Codeine Tablet 300-30 MG, because LVN A did not want for Resident #1 to get upset because it was not available. The Administrator said LVN A got a write up and was trained on how to access the cubex, medication administration and call supervisors when any medication was not available. Record review on 4/24/25 of Employee counseling report, dated 2/14/25, revealed LVN A statement documented I did tell patient it was a pain pill because i did not want to trigger an episode of patient getting upset and making a big issue of not having the narcotic available. I did not specify Tylenol just said pain pill. Record review of the facility's policy titled Controlled Substances Prescriptions, stated under section, Policy - before a controlled drug can be dispensed, the pharmacy must be in a receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribed. A char order is not equivalent to a prescription for controlled drugs. Therefore the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long-term care facility residents. Record review of the facility's policy titled Pain Management stated under section, Policy: The facility must ensure that pain management is provided to residents who require such services,, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained for each resident that was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for medication administration. The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented. This deficient practice could place residents at risk for less than therapeutic benefits and/or not receiving ordered medications. Findings include: Record review of Resident #1's face sheet, dated 4/24/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included acquired absence of left leg below knee (a condition where an individual has had a surgical or traumatic removal, amputation, of part of the left leg below the knee joint), peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain, primarily the arteries and veins, causing reduced blood flow to the limbs), type 2 diabetes mellitus with hyperglycemia (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels), cellulitis of right lower limb (a bacterial skin infection that can cause redness, swelling, pain, and tenderness in the affected area.) Record review of Resident #1's Physician Orders, dated 4/24/25, revealed an order for Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #1's Medication Administration Record for February 2025, revealed Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours for pain. Resident #1 missed 3 doses (1 dose on 2/8/25 at 6:00 p.m. and 2 doses 2/9/25 at 12: a.m. and 6:00 a.m. Record review of Resident #1 care plan, dated 1/16/2025, revealed Resident #1 had risk for pain related to left Below Knee Amputation. During an interview on 4/23/2025 at 9:40 a.m., Resident #1 said he had pain to his right lower extremity, he said he asked for his pain pill, and LVN A went to give him a pill that did not looked like his pain medication. Resident #1 said he took the medication because he was in pain. Resident #1 said he asked LVN A three times if that pill was the Tylenol #3 he usually took. The resident said LVN A said yes the three times he asked her. Resident #1 said on 2/10/25 he filed a grievance and spoke the administrator. Resident #1 said that the Tylenol 500 milligram that he took helped from a 9 on a scale from 1 to 10 to a 8. During a phone interview on 4/24/2025 at 2:54 p.m., LVN A revealed Resident #1 did not have a filled prescription for Acetaminophen-Codeine Tablet 300-30 MG. She also stated the resident had an active order for this medication as of 1/18/2025 and said she was unsure why it had not been filled. LVN A said that she got a Tylenol 500mg and gave it to Resident #1 LVN said that she went back to reassess Resident #1 and he was sleeping. LVN A said that she signed off on the medication record the Acetaminophen-Codeine Tablet 300-30 MG by mistake. LVN A said she forgot to add the order for Tylenol 500mg to Resident #1's electronic medical record. LVN A explained she was very familiar with the resident. LVN A said that she had a standing order from the physician for Tylenol 500mg but forgot to add it and signed off on the electronic medication administration chart of Resident #1. LVN A said that she did not had access to the cubex (emergency medication supply system) and that she did not inform anyone that Resident #1 was out of the Acetaminophen-Codeine Tablet 300-30 MG. During an interview on 4/24/25 at 3:40 pm, the physician assistant said that he was familiar with Resident #1 chronic pain. Physician assistant first stated Resident #1's pain 9 out of 10 on the scale 1 to 10 would not have subsided with one acetaminophen 500 milligram tablet, after further discussion he said that he was not sure if would have been enough because Resident #1 regularly complain of pain without signs of distress. During a phone interview on 4/24/25 at 4:00 pm the pharmacist verified that the facility received a new Tylenol #3 blister pack for Resident #1 on 2/9/25 at 12:00 pm. Pharmacist said that he received a call from Physician Assistant for a refill on Acetaminophen-Codeine Tablet 300-30 MG. pharmacist said the blister pack was delivered on 2/9/25. During an interview on 4/28/2025 at 11:30 a.m., the DON said she was not aware about this incident with Resident #1 until 2/10/25 when Resident #1 filed a grievance. DON said that an investigation was initiated. DON said that nurses were trained on how to access the medications from the cubex and nurses knew to contact her or the ADON if the medication was not available on the cubex. DON said that the Physician assistant or the doctor had to call the pharmacy for the refill because this medication was a controlled medication, and the pharmacy needed a prescription for it. DON said that nurses did not know when the doctor was going to call the pharmacy, but she knew RN B called the physician assistant to informed him resident was running low on the medication. DON said that the Acetaminophen-Codeine Tablet 300-30 MG was received at the facility on 2/9/25. The DON agreed that it was the facility's responsibility to ensure the resident had all of her ordered medications at the facility once the resident was transferred to long term care. DON said that when she spoke to resident he was very upset because he felt LVN A lied about the medication he got. The DON said LVN A should have documented giving the Tylenol 500mg on the electronic medication record. LVN A said that she forgot to input the order on Resident#1's medical administration record. During an interview on 4/28/2025 at 12:00 p.m. with the Administrator said that Resident #1 spoke to her to file a grievance on 2/10/25. The administrator said that she started an investigation and spoke to LVN A and asked her what had happened, the administrator said that LVN A said to her that she gave Resident #1 a Tylenol 500mg instead of Acetaminophen-Codeine Tablet 300-30 MG because LVN A did not wanted for Resident #1 to get upset because was not available. The administrator said that LVN A got a write up and was trained on how to access the cubex, medication administration and call supervisors when any medication was not available. Record review on 4/24/25 of Employee counseling report dated 2/14/25 revealed LVN A statement I did tell patient it was a pain pill because i did not want to trigger an episode of patient getting upset and making a big issue of not having the narcotic available. I did not specify Tylenol just said pain pill. Record review of the facility's policy titled Medication Administration, revealed: Medications are administered by a licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination of infection. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services. 1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. Findings included: 1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admitted [DATE]. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). Record Review of Resident #38's physician orders indicated: 1.) Olanzapine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for bipolar disorder. Dated:1/26/2024 2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth at bedtime for depression. Dated: 1/26/2024 21:00 Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety. Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. 2.Record review of Resident #36's Admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #36's Care Plan dated 01/22/24, revealed FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024 INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24 INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24. FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24 INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24. Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders: -Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). -Start date: 02/06/24 Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety). Start date: 03/14/24 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). Start date: 03/14/24 Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism). Start date: 03/14/24 Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid). Start date: 03/14/24 Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease). Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone. No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Consent for Risperdal was signed by resident and not RP. Consent was not dated. Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed: Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24. Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. 3.Record review of Resident #7's Admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #7's Care Plan dated 03/22/24, revealed, FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder. INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23. FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23. INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23. FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23. FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders: -Start date: 03/26/23 Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety). -Start date: 09/26/23 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). -Start date: 10/06/23 Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication) -Start date: 11/28/23 Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.) -Start date: 12/14/23 Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative) -Start date: 03/25/24 Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia. Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed: -Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. -Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24. - Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. - Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. -Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet. In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

Resident #47 FTag Initiation 41761 Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 4 residents (Resident #36, Resident #7, and Resident #38) reviewed for resident rights, in that: 1.Resident #36 did not have a signed (by RP), dated consent for psychotropic medications (Risperdal, clonazepam, buspirone, fluvoxamine, or Wellbutrin XL ER) he received. 2.Resident #7 did not have signed (by RP), dated consents for psychotropic medications (clonazepam, buspirone, Seroquel, Paxil, and Trazadone) she received. 3.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication for Resident #38. This failure could place residents who received psychoactive medications without informed consents and placed 33 additional residents who received psychoactive medications at risk of receiving treatments without informed consent. Findings include: 1.Record review of Resident #36's Admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #36's Care Plan dated 01/22/24, revealed FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024 INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24 INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24. FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24 INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24. Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders: -Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). -Start date: 02/06/24 Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety). Start date: 03/14/24 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). Start date: 03/14/24 Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism). Start date: 03/14/24 Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid). Start date: 03/14/24 Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease). Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone. No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Consent for Risperdal was signed by resident and not RP. Consent was not dated. Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed: Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24. Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. 2.Record review of Resident #7's Admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #7's Care Plan dated 03/22/24, revealed, FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder. INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23. FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23. INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23. FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23. FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders: -Start date: 03/26/23 Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety). -Start date: 09/26/23 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). -Start date: 10/06/23 Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication) -Start date: 11/28/23 Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.) -Start date: 12/14/23 Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative) -Start date: 03/25/24 Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia. Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed: -Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. -Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24. - Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. - Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. -Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet. 3.) Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admitted [DATE]. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities). Record Review of Resident #38's physician orders indicated: 1.) Olanzapine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for bipolar disorder. Dated:1/26/2024 2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth at bedtime for depression. Dated: 1/26/2024 21:00 Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety. Record review of Resident #38's MDS dated [DATE] indicated a BIM score of 00 (severe cognitive impairment) and the use of antipsychotic and antidepressant medications. No behaviors were indicated. Record review of Resident #38's clinical record revealed there was no consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. In an interview on 03/28/24 at 12:00 p.m., the DON stated there was a binder at the nurse's station with the consents. The DON stated they were not on PCC (electronic charting system) under miscellaneous. Observation on 03/28/24 at 01:30 p.m., revealed 35 residents consents undated and some were not signed by the RP. Resident #36 and Resident #7 signed their consent even though they had an RP and were not their own RP. Resident #7 did not have a consent for Clonazepam. Resident #36 did not have a consent for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Resident #38 did not have a consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. In a phone interview on 03/28/24 at 02:35 p.m., Resident #38's RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. In an interview on 03/29/24 at 02:05 p.m., LVN B stated the nurse who gets the order for psychotropics or antipsychotics, was the person who would get the consent (signed and dated), notified the RP and would get their approval (consent) for the medication. LVN B stated RPs gave consent or they do not. LVN B stated the consent form was always dated. LVN B stated she made a progress note concerning getting approval for the medication and then she would put the consent in the tray at the nurse's station for MDS to scan into PCC under miscellaneous. In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft for Resident #38, but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

Based on observations, interviews, and record review, the facility failed to ensure each resident recieved adequate supervision for one resident (Resident#44) of 2 residents whose records were reviewed for elopements. Resident #44 eloped from the facility undetected on 05/05/23. Resident #44 was able to remove her wanderguard bracelet and exit the facility on 06/24/23. Resident #44 eloped from the facility undetected after removing wanderguard bracelet for a second time 06/26/23. The non-compliance was identified at PNC (Past non-compliance). The Immediate Jeopardy (IJ) situation began on 06/26/23 and ended 06/27/23 The facility had corrected the noncompliance before the survey began. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included : Record review of Resident #44's admission record dated 03/08/24 documented a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses of Primary Osteoarthritis (common form of arthritis; wear and tear arthritis), other Specified Site, Difficulty in Walking, Not elsewhere Noted, Other Abnormalities of Gait, Unspecified Dementia, unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance (group of serious illnesses that affect the mind), Mood Disturbance, and Anxiety. Record review of Resident #44's MDS annual assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Record review of the Provider Investigation Report revealed Resident #44 eloped on 05/05/23 at approximately 1:32 pm from the facility. Dietary Aide B witnessed Resident #44 walking on the sidewalk outside the facility and notified LVN G. LVN G redirected resident back to facility and assessed Resident #44. Record Review of Progress Note dated 06/27/23 revealed Resident #44 was discharged home with family. In an interview on 03/07/24 at 11:55 am LVN G said from what she could recall, on the day of[ Resident #44's] first elopement, Dietary Aide B notified her that Resident #44 was outside the facility. LVN G said she went outside and found Resident #44 walking in the parking lot. LVN G said R#44 was redirected into the facility with no incident. LVN G said that Resident #44 said that wanted to go outside and walk around. LVN G said Resident #44 was placed on 1:1 for 72 hours after this elopement. LVN G added that Resident #44 also had a wander guard placed on her wrist. LVN G said the wander guard was being checked to make sure it was in place and functioning properly every shift. She said it was documented in PCC daily. LVN G said staff was in-serviced on elopement prevention and what to do in case of an elopement. In an interview on 03/07/24 at 2:00 pm the DON said Resident #44 did not have a history of wandering or elopement prior to the incident on 05/05/23. She said wandering evaluations were done upon admission and quarterly to find out if a resident poses an elopement risk. The DON said Resident #44 had a wandering evaluation done upon admission and was not noted to be a risk. The DON said after the incident, she was reassessed again as an elopement risk, and received doctor's orders to have a wander guard placed on Resident #44. The DON said other interventions were to engage Resident #44 in activities throughout the day as well as having her by the nurse's station for supervision. The DON said an in-service on elopement was conducted with staff after the incident. Record Review of care plan updated on 05/05/23 revealed the following interventions were put in place: -1:1 sitter x 72 hours -Provide structured activities -Offer opportunities for outside recreating in safe areas -Complete wandering evaluation tool -Wander guard in place. Monitoring and checking device per facility policy, staff education regarding elopement policies and interventions Record Review of Resident #44 Skilled Administration Record dated 03/12/24 revealed; Wander guard use, check placement each shift to left wrist was checked off day, evening, and night shifts starting on 05/05/23 to 06/26/23. Record review of the facility Provider Investigation Report revealed on 06/26/23 at approximately 5:45 pm Resident #44 eloped from the facility undetected. Resident #44 was located approximately 0.2 miles away from the facility by a busy intersection by the facility SW . SW notified LVN R who was able to redirect Resident #44 back to the facility. Further record review of Resident #44's Progress notes revealed an entry dated 06/24/23 which indicated Resident #44 was found outside of building in front patio. As per progress note the nurse assessed the resident and noted that the resident was not wearing the wander guard bracelet. As per progress note Resident #44 stated she had removed and placed the wanderguard bracelet in a drawer. A new wander guard was placed on Resident #44's left wrist . In an interview on 03/07/24 at 12:25 pm LVN R said he had not worked at the facility for about 5 or 6 months and did not recall the incident on 06/26/23 with Resident #44 and did not wish to speak to the state surveyor. In an interview on 03/07/24 at 2:10 PM the ADON said Resident #44 had been found by the facility SW walking towards the local store about an 8th of a mile from the facility. She said Resident #44 was brought back by LVN R. The ADON said that the investigation found Resident #44 had removed her wander guard. The staff was unable to determine how she did it. After the incident Resident #44 was placed on 1:1 for 72 hours and staff was in-serviced on elopement and wandering . DON said the facility keeps a binder with the names of the residents that have a high risk for elopement. In an interview on 03/07/24 at 3:31 pm the DON said she asked Resident #44 how she had removed her wander guard bracelet and she said Resident #44 did not tell her how. The DON said Resident #44 showed her where she had placed it in her dresser drawer in her room. The DON said Resident #44 was assessed after the incident and was found to have no injuries, no skin tears. The DON said a care plan was conducted with Resident #44's family and the facility was recommending placement at a facility with a locked unit. The DON said family decided to take Resident #44. Resident #44 was discharged by family on 06/27/23 the day after the incident . In an interview on 03/12/24 at 3:00 pm LVN G said she did not recall the incident that happened on 06/24/23 with Resident #44. LVN G was able to read her progress note documented in PCC and said that the resident was outside sitting in the patio area and LVN G said Resident #44 did not have the wander guard on. She said she believed she asked her where it was or how did she remove it, but Resident #44 did not answer . DON said had in-serviced all the staff on elopement prevention. In an interview on 03/12/24 at 3:58 pm the DON said on 6/24/23 Resident #44 was seen sitting outside the facility in the patio area. She said LVN G assessed her and noted that the wander guard was missing. The DON said she asked Resident #44 how she took it off and the resident did not respond. The DON said another wander guard was placed on Resident #44's wrist and the family was notified as well as the nurse practitioner with no new orders given. The DON said staff continued to monitor Resident #44 and continued with activities for her. Record Review of facility in-services revealed the following In-services conducted with staff after each incident: Topic: 05/05/23 Elopement - Supervise residents at all times, head count of all residents, initiate a code yellow Topic: 06/27/23 Elopement - Staff be vigilant in responding to alarms, supervise residents for accidents/elopement and the use and monitor of wander guards. There were 4 LNVs, one RN, and 5 CNAs on all three shifts interviewed on facility policy and procedure related to identifying and monitoring residents with exit seeking tendencies, redirecting, and ensuring residents at risk remained engaged . Facility Policy titled Elopements and Wandering Residents dated 11/21/22 states; Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

Based on observation, interview, and record review, the facility failed to provide the necessary care to prevent the development of six avoidable pressure ulcers for one Resident (R#4) of four residents reviewed with pressure ulcers. R#4 had one pressure ulcer and developed six additional "facility identified" pressure ulcers: Stage 2 to the top of the left foot, size 0.5 x 0.4 x 0.1 cm. Stage 2 to the top of the right foot, size 0.24 x 0.2 x 0.1 cm Stage 2 to the top of the left foot, size 0.1 x 0.1 x 0.1 cm Stage 2 to the top of the left foot, size 0.24 x 0.2 x 0.1 cm Stage 2 to the right outer foot, size 0.64 x 0.5 x 0.1 cm Stage 1 to the right outer foot, size 0.54 x 0.5 x 0.0 cm The facility did not: -comprehensively assess R#4's clinical condition and risk factors for developing pressure ulcers on the feet, -ensure sheet friction did not occur when spontaneously moving the lower extremities against a tightly tucked sheet, and, -provide appropriate skin breakdown preventive measures to the lower extremities. Failure to conduct comprehensive assessment of a resident's clinical condition and the risk factors for developing avoidable pressure ulcers and failure to provide appropriate skin breakdown preventive measures likely caused R#4 to develop six avoidable pressure ulcers to his feet. These failures could affect all 13 residents with pressure ulcers. The findings were: R#4's Face Sheet revealed R#4 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. R#4's physician's orders [REDACTED]." The initial order was given on 02/10/12. Nursing Admission assessment dated [DATE] at 2:01 p.m. revealed, "Pt. (patient) [MEDICAL CONDITION]([MEDICAL CONDITION] - surgical opening through the neck, into the windpipe) and PEG tube (tube inserted through the abdomen and into the stomach for provision of fluids, medications, and nutrition). Pt. has scab to left ankle, scab to 2nd digit left foot, scab to 4th digit right toe, stage 3 (Stage 3 pressure ulcer - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to right elbow, and dry skin to left side of upper back." Review of the Braden Scale for Predicting Pressure Sore Risk dated 02/10/12 revealed R#4 had a score of 10. A total score of 12 or less represented high risk for pressure ulcers. R#4's MDS (Minimum Data Set) created for a Significant Change in Status Assessment with an ARD (assessment reference date) of 02/17/12 revealed R#4 had been re-admitted on [DATE] and his [DIAGNOSES REDACTED]. MDS indicated R#4: - had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar (necrotic - black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges) that measured 3.3 X 2.0 X 2.0 cm (centimeters) Stage 3, - was in a persistent vegetative state, - was totally dependent on staff for bed mobility, transfers, locomotion, dressing, and personal hygiene, and, - had limitations in range of motion on both sides of upper and lower extremities. A review of R#4's Care Plan - Pressure Ulcers dated 03/01/12 and reviewed 05/10/12 and 08/02/12 revealed the Problem to be an "Actual" Pressure ulcer (no site of pressure ulcer identified). The Goal, "ulcer will show signs of healing process as evident by decrease in depth, width and length by at least ___ (left blank) cm and free of further breakdown through next review. R#4 will have intact skin without signs of skin breakdown through next review: 06/01/12, 08/10/12, and 11/01/12." The Approaches included: "air mattress, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each bowel movement, measure and stage wound weekly using the pressure ulcer healing assessment form, monitor lab values as ordered, IDT (Interdisciplinary Team) referrals, Registered Dietitian, Pressure ulcer treatment as ordered..." Review of the Braden Scale for Predicting Pressure Sore Risk dated 07/27/12, 08/03/12, 08/10/12, 08/17/12, 08/21/12, 08/31/12, 09/07/12, and 09/14/12 revealed R#4 had a score of 9. A total score of 12 or less represented high risk for pressure ulcers. A review of the, "Weekly Pressure Ulcer QA & A Log" for 08/03/12 revealed the following right elbow ulcer measurements for R#4: 2.0 X 1.0 X 0.1cm, treatment was [MEDICATION NAME] (antibiotic) ointment. The "Weekly Pressure Ulcer QA & A Log" for 08/10/12 revealed the following right elbow ulcer measurements: 2.0 X 1.0 X 0.1cm, treatment was [MEDICATION NAME] ointment. The "Weekly Pressure Ulcer QA & A Log " for 08/17/12 revealed the following right elbow ulcer measurements: 2.0 X 1.0 X 0.1cm, treatment was [MEDICATION NAME] ointment. The measurements and treatment remained the same. A review of the, "Wound Care Progress Note" for 08/30/12 revealed R#4 was being seen by a Wound Care Specialist for the right elbow ulcer. A note was made about the right 5th toe with dry eschar and the left foot 2nd toe with no [MEDICATION NAME] or necrosis noted. Head to Toe Skin Checks sheet for R#4 dated 09/04/12 documented a pressure ulcer to the right elbow. There was no skin breakdown documented to any other areas of R#4's body. Head to Toe Skin Checks sheet for R#4 dated 09/11/12 documented a pressure ulcer to the right elbow. There was no skin breakdown documented to any other areas of R#4's body. On 09/17/12 at 10:00 a.m., surveyor entered the shower room between 500 and 600 Halls. Certified Nurse Aides (CNA) "K" and "L" were in the shower room. Surveyor observed R#4 to be fully undressed. Surveyor observed R#4's lower extremities to be frozen (stiff, unable to be moved) and the toes to be contracted with a severe foot drop (Paralysis or weakness of the dorsiflexor muscles of the foot and ankle). The joints of the toes were protruding from the joints and were gnarled and contracted. Surveyor observed skin avulsion (body structure is forcibly detached)/pressure ulcers from the bony structures of the toes on both feet and the outside of the right foot and tarsus (seven bones of the foot not including the toes). The toe joints were displaced and angulated causing the bones to be sticking up. On 09/17/12 at 10:03 a.m. surveyor asked CNAs "K" and "L" how long R#4 had the pressure ulcers to the feet. CNA "K" said she had not noticed the skin sores before. CNA "L" made no comment. CNA "K" and CNA "L" returned R#4 to his room. On 09/17/12 at 10:10 a.m. surveyor observed R#4 in bed. R#4's was tight across the tops of his feet and tucked under the mattress at the foot of the bed. Surveyor observed R#4 coughing. Whenever R#4 coughed, his legs lifted off the mattress, rubbing the tops of his feet against the tucked in sheet. On 09/18/12 at 10:10 a.m. surveyor observed Licensed Vocational Nurse (LVN) "H" deliver [MEDICAL CONDITION] care and suctioning for R#4. After the procedure, surveyor asked LVN "H" if she had noticed R#4's feet. LVN "H" said she had not and proceeded to pull the sheet, which was tucked under the mattress, off R#4's feet to expose them. LVN "H" stated, "He has Stage 2 sores on his feet! (Stage 2 pressure ulcer - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.)" LVN "H" said she had not noticed and had not been told of the condition of R#4's feet. LVN "H" said R#4 had pressure reducing interventions and staff ensured that he was repositioned every two hours and off-loading of R#4's right elbow was maintained to keep pressure off the elbow. LVN "H" said a skin assessment was done on every resident every week. LVN "H" attributed R#4's feet ulcers to the tight sheet that was tucked under the mattress at the foot of the bed. When R#4 coughed, he would jerk his feet up off the bed. R#4 had his lower extremities frozen and had contractures preventing any bending of his lower and upper extremities. Surveyor inquired if R#4 received total body assessments. LVN "H" said "Yes" but she had not considered looking at R#4's feet because normally the pressure ulcers developed on the trunk of the body and not the top of the toes. LVN "H" said she had not noticed that the CNAs were tucking the sheet under the mattress. A review of the Weekly Pressure Ulcer Record completed on 09/18/12 by LVN "H" revealed the following assessment of R#4: Left foot top, Stage 2, size 0.5 x 0.4 x0.1 cm. Right foot top, Stage 2, size 0.24 x 0.2 x 0.1 cm Left foot top, Stage 2, size 0.1 x 0.1 x 0.1cm Left foot top, Stage 2, size 0.24 x 0.2 x 0.1 cm Right outer foot, Stage 2, size 0.64 x 0.5 x 0.1 cm Right outer foot, Stage 1, size 0.54 x 0.5 x 0.0 cm The Weekly Pressure Ulcer Record sheet indicated, "Awaiting call from Physician for treatment order. No signs or symptoms of infection to wound." On 09/19/12 at 9:50 a.m. surveyor interviewed Assistant Director of Nurses (ADON) "J" about R#4's feet. ADON "J" said LVN "H" had informed her of R#4's condition. ADON "J" inquired about who had told LVN "H" about the pressure ulcers. ADON "J" said the CNAs should have informed LVN "H" about the condition of R#4's feet after they had bathed him. ADON "J" said the family was involved in the Care Plan and were aware that R#4 had a pressure ulcer on his right elbow which was in the process of healing. Interview with CNA "K" on 09/19/12 at 2:05 p.m. revealed she was not the one that tucked the sheet under R#4's mattress. She said she would cover R#4 with a sheet, but not tuck it in. CNA "K" said the nurse told her about the condition of R#4's feet and the sheet. CNA "K" said if she had seen R#4's feet she would have reported it. CNA "K" said she completed one report on skin condition since she started working in May 2012. Surveyor asked what report. CNA "K" said there was a sheet that had to be completed by the CNAs when a new skin injury was identified by them. Interview with CNA "V" on 09/19/12 at 2:20 p.m. revealed she had been working at the facility one year. CNA "V" stated if she saw a bruise or other change in a resident's condition she would write it down in a booklet, but now they used the "Interact II form." CNA "V" said, "I draw a picture on the back and identify the location of the bruise and I tell the nurses, then I write the name of the nurse on the form and I follow up with the Director of Nurses." The Interact II Early Warning Tool form indicated, "If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift." One of the options to be circled was, "Change in skin color or condition." Interview with LVN "U"/MDS Assessment Nurse on 09/19/12 at 2:50 p.m. revealed the documentation on the MDS was based on documentation found in the clinical record. R#4 was admitted with a pressure ulcer on the right elbow. LVN "U" said to date no other pressure ulcers had been documented or reported. LVN "U" said she would look at the wounds if possible, would read the History and Physical or Progress Notes from the Physician and would ensure the dietitian was made aware of any new pressure ulcers. LVN "U" said the Corporation had a, "Skin System" that was used to monitor pressure ulcers. Interview with the Director of Nurses (DON) on 09/19/12 at 2:31 p.m. revealed he was familiar with some skin reports CNAs could use to report skin conditions, but was not familiar with what was used at this facility. At this time ADON "J" entered the room and she explained the, "Weekly Pressure Ulcer Log." R#4's September 2012 Treatment Administration Record (TAR) documented physician's orders [REDACTED]. A review of the Skin Management Systems revised 08/12 revealed the Practice Guidelines which included the following: "Assess for skin integrity and complete a head to toe physical assessment of the skin, include the Braden Scale, appropriate interventions to be implemented to promote healing, Weekly Pressure Ulcer Record, Low Extremity Ulcer: Non-Pressure Skin Condition Record to be completed, tracking of wounds developed in-house or admitted with, Licensed Nurse documentation daily monitoring of all pressure ulcers on the TAR, skin assessments, completing A Change of Condition Form and new physician's orders [REDACTED]." During the pre-exit conference on 09/19/12 at 4:00 p.m. the Administrator and the DON were given the opportunity to present any additional information regarding pressure ulcers. No additional information was provided. The facility's CMS (Centers for Medicare & Medicaid) form 672 revealed 13 residents with pressure ulcers.