Every finding on record at Wylie Oaks Healthcare and Rehabilitation

Based on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records and failed to ensure each resident had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and resident groups for three of twelve residents (Residents #26, #58, and #73) reviewed for privacy and confidentiality. 1.The facility failed to ensure RN B pulled the privacy curtain while checking Resident #26's blood sugar on 08/12/2026. 2.The facility failed to ensure RN B pulled the privacy curtain while checking Resident #58's blood sugar and administering her insulin on 08/12/2026. 3.The facility failed to ensure RN H closed, locked, or minimized her computer monitor before leaving it, thus exposing Resident #73's medical information, on 08/13/2026. These failures could place residents at risk of not having their personal privacy maintained while treatments were provided, which could result in the residents feeling uncomfortable during care, and having their personal and medical record exposed to unauthorized individuals.Findings included: 1.Record review of Resident #26's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #26's Comprehensive MDS Assessment, dated 07/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #26's Comprehensive Care Plan, dated 07/08/2026, reflected the resident had diabetes mellitus and the interventions included to check the blood sugar and administer diabetes medication as ordered. Record review of Resident #26's Physician Order, dated 02/24/2026, reflected NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 70 - 200 = 0; 201 - 250 = 2; 251 - 300 = 4; 301 - 350 = 6; 351 - 400 = 8; 401 - 450 = call MD, subcutaneously (administer under the skin) two times a day for Diabetes. Record review of Resident #26's Physician Order, dated 05/14/2026, reflected Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 5 units subcutaneously twotimes a day for Diabetes. During an observation on 08/12/2026 at 6:58 a.m., RN B was about to check Resident #26's blood sugar. She put on a pair of gloves and prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside the resident's room and checked the resident's blood sugar. The resident's roommate was inside the room. She did not pull the privacy curtain while checking the resident's blood sugar. 2.Record review of Resident #58's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #58's Comprehensive MDS Assessment, dated 06/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #58's Comprehensive Care Plan, dated 04/07/2026, reflected the resident had diabetes mellitus and the interventions included administering diabetes medication as ordered. Record review of Resident #58's Physician Order, dated 06/03/2026, reflected Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 20 units subcutaneously one time a day for Diabetes. Record review of Resident #58's Physician Order, dated 02/01/2026, reflected NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 60 = 0 call MD; 61 - 149 = 0; 150 - 200 = 0; 201 - 250 = 1; 251 - 300 = 2; 301 - 350 = 3; 351 - 400 = 4; 401 - 999 = 5 And call MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease (a long-term damage to the kidney due to diabetes). During an observation on 08/12/2026 at 6:50 a.m., RN B prepared to check Resident #58's blood sugar. She put on a pair of gloves and prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside the resident's room and checked the resident's blood sugar. The resident's roommate was inside the room. She did not pull the privacy curtain while checking the resident's blood sugar. She then went back to her cart and prepared the resident's insulin. She went again inside the resident's room and asked the resident where she wanted her insulin. The resident said to administer her insulin in her abdomen. RN B lifted the resident's hospital gown and administered her insulin. She did not pull the privacy curtain while administering the resident's insulin. During an interview on 08/12/2026 at 8:24 a.m., RN B said she forgot to pull the privacy curtain when she checked Resident #26 and Resident #58's blood sugars and when she administered resident #58's insulin. She said the privacy curtain should have been pulled to provide privacy during treatment or care. She said the resident might get embarrassed that other people could see what their treatments were. She said it did not matter if the resident minded it or not, but the staff had the responsibility to provide privacy. 3.Record review of Resident #73's Face Sheet, dated 08/13/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with C-diff (Clostridioides difficile: infection of the colon characterized by diarrhea). Record review of Resident #73's Comprehensive Care Plan, dated 08/12/2026, reflected the resident had an infection and one of the interventions was to administer antibiotics as ordered. Record review of Resident #73's Physician Order, dated 08/12/2026, reflected Vancomycin HCl Oral Capsule 125 MG (Vancomycin HCl), Give 1 capsule by mouth four times a day for C. Diff for 10 Days. Record review of Resident #73's Vital Signs, dated 08/12/2026, reflected Weight: 140.4 lbs., Blood Pressure: 98/64 mmHg, Temperature: 98 Fahrenheit, Pulse: 70 bpm, Respiration: 18 breaths/min, O2 sats: 98%, and Pain: 0. Record review of Resident #73's Progress Notes, dated 08/12/2026, reflected New resident this evening, on ABT Vancomycin HCl Oral Capsule 125 MG four times daily for 10 days related to C-Diff. Initial dose given PO, tolerated well, no allergic reactions noted, call light in reach, will continue to monitor. During an observation on 08/13/2026 at 7:24 a.m., RN H was sitting in front of a computer in a common area. She then stood up and went to the nurses' station and left the monitor of the computer open and unattended. The computer displayed Resident 73's name, his birthday, allergies, and his vital signs for 08/12/2026. The computer showed the resident was a new admit and was diagnosed with C-diff. The computer also revealed the name of the resident's antibiotic, its dose and frequency and for how long the medication was to be taken. It was observed there were other residents and non-clinical staff passing by the computer. During an interview on 08/13/2026 at 7:26 a.m., RN H said she was looking for something that was why she left her computer. She said she should have locked the computer first before leaving it because Resident #73's medical information was confidential and could be a HIPAA (law protecting health information aimed to ensure confidentiality) violation when exposed to other individuals who did not have anything to do with the resident's treatment. During an interview on 08/13/2026 at 7:56 a.m., the DON said the privacy curtain should have been pulled during any treatment being done for the residents to give privacy and prevent improper exposure of any body part. He said Resident #73's medical information, like his vital signs, diagnosis, medications, and allergies, should be confidential and if left exposed to unauthorized individuals, was a HIPAA violation. He said he would start an in-service about privacy and confidentiality right after the interview to re-educate the staff. During an interview on 08/13/2026 at 9:01 a.m., the ED said the expectation was for the staff to make sure the residents were provided privacy during treatment so the residents would be comfortable and would not be embarrassed during treatment. He said another expectation was for the staff to secure confidential medical records protected by HIPAA. He said they would in-service the staff to re-educate them about privacy and confidentiality. Record review of the facility's Federal Resident Rights admission Agreement revised February 24, 2022, reflected As a resident of this nursing facility, you have the right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy, including medical treatment . secure and confidential personal and medical records.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of eighteen residents (Residents #31 and #47) and two of two medications aides (MA D and MA F) reviewed for medication storage. 1.The facility failed to ensure Resident #31 did not have a container of biotin and a container of topical analgesic ointment in her shelf and a bottle of wound cleanser on top of her side table on 08/11/2026. 2.The facility failed to ensure MA D did not leave a container of liquid protein on top of her cart, unattended, after preparing Resident #31's medications on 08/11/2026. 3.The facility failed to ensure Resident #47 did not have a sachet of zinc oxide on top of her side table on 08/11/2026. 4.The facility failed to ensure MA E did not put a container of probiotics with an instruction to Refrigerate after opening inside her cart on 08/12/2026. 5.The facility failed to ensure MA E did not put the disinfectant wipes in the same drawer as the narcotics on 08/12/2026. 6.The facility failed to ensure MA F did not put the disinfecting wipes in the same drawer as the narcotics on 08/12/2026. These failures could place residents at risk of misuse of medications and possible adverse reactions.Findings included: 1.Record review of Resident #31's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with pain, dementia, and protein-calorie deficiency. Record review of Resident #31's Comprehensive MDS Assessment, dated 07/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had pain, dementia, and protein-calorie deficiency. Record review of Resident #31's Comprehensive Care Plan, dated 07/22/2026, reflected the resident was at risk for impaired cognitive function related to dementia, had potentials for pain related to osteoarthritis, and was at risk for malnutrition r/t to altered nutritional status. The interventions were to provide the necessary cues, to perform pain assessment every shift, and provide diet as ordered, respectively. Record review on 08/11/2026 of Resident #31's eMAR reflected the resident did not have an order for biotin. Record review of Resident #31's Physician Order, dated 08/04/2026, reflected Cleanse the skin tear to left forehead NS, pat dry, apply skin prep daily every day shift. Record review on 08/11/2026 of Resident #31's Clinical Assessment List, reflected the resident had no assessment for self-administration of medications, an assessment that the resident was competent to take her medications unassisted, an assessment that the resident could safely store medications inside her room, or an assessment that the resident could perform her wound care. During an observation and interview on 08/11/2026 at 9:50 a.m., Resident #31 was in her wheelchair, awake. It was observed that a container of biotin (vitamin H) and a container of topical analgesia (medication that diminishes pain) was on top of her shelf. A container of wound cleanser was observed on top of the resident's side table. The resident said the containers of medications were hers and had always been on her shelf. She said she had on her forehead that the staff were cleaning. She said she did not know who left the container of wound cleanser on her side table. During an interview on 08/11/2026 at 2:36 p.m., LVN C said she was not aware Resident #31 had biotin and topical analgesic inside her room. She said the biotin and the topical analgesic should not be inside the resident's room because the resident might use them inappropriately. She said the topical analgesic had menthol that could cause irritation of the eyes. She said the staff, if the resident was taking the biotin by herself, would not be able to know how many pills she was taking and how often she was taking the biotin which could result in overdosing. She said she did not know who left the wound cleaner in the resident's room. She said the wound cleanser could have ingredients that could be harmful when consumed. She said she would talk to the resident and would explain to her why she needed to get the medications mentioned. She said she would also get the wound cleanser, clean it, and put it the treatment cart. During an interview on 08/12/2026 at 8:34 a.m., the Treatment Nurse said he did not know who left the wound cleanser inside Resident #31's room. He said the wound cleanser might have ingredients that might cause irritation to the eyes. He said they would cleanser should be inside the treatment cart when not in use. 2.Record review of Resident #31's Physician Order, dated 07/10/2026, reflected LIQUID PROTEIN one time a day for At Risk of Malnutrition give 30 ml. During an observation on 08/11/2026 at 9:56 a.m., MA E was in the hallway preparing medications. She went inside Resident #31's room to administer the resident's medication. She left a container of liquid protein on top of the cart, unattended. During an observation and interview on 08/11/2026 at 9:59 a.m., MA E said the liquid protein was for Resident #31. She said she should have locked it in her cart before leaving her cart because residents who were allergic to protein might be able to get hold of it and consume it causing adverse reactions. She took the container of liquid protein and placed it in one of the drawers of her cart. 3.Record review of Resident #47's Face Sheet, dated 08/11/2026, reflected an-85year-old female admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (stroke) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #47's Comprehensive MDS Assessment, dated 05/27/2026, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #47's Comprehensive Care Plan, dated 06/03/2026, reflected the resident was at risk for bowel/bladder incontinence r/t dementia and one of the interventions was to monitor possible causes of incontinence. Record review on 08/11/2026 of Resident #47's Clinical Assessment List, reflected the resident had no assessment for self-administration of medications, an assessment that the resident was competent to apply the barrier cream, or an assessment that the resident could store medications inside her room. During an observation and interview on 08/11/2026 at 9:25 a.m., Resident #47 was in her wheelchair, awake. A tube of zinc oxide (medicated cream used to prevent skin irritation) was on top of the resident's side table and was in plain view. The resident said the staff would use it when they changed her brief. The resident said the barrier cream had always been in her bedside. During an interview on 08/12/2026 at 12:13 p.m., RN A said she did not notice Resident #47 had a tube of zinc oxide when she checked on the resident. She said zinc oxide should not be inside the residents' room because confused residents might accidentally consume it, thinking that the cream was something edible. She said most of the residents already had poor eyesight and might mistakenly use the cream as toothpaste. She said she did not know who left the zinc oxide inside the room of the resident. She said she would ask the CNAs about the zinc oxide to remind them about the risk of leaving zinc oxides inside the room of the residents. 4.During observation on 08/12/2026 at 6:09 a.m., a container of probiotics was observed inside the cart that MA D was using. During an observation and interview on 08/12/2026 at 8:47 a.m., the container of probiotics was still inside MA D's medication cart. She said she took the probiotics from the refrigerator before she started administering medications. She read the back portion of the container that said, Keep refrigerated after opening. She said, she guessed, the probiotic should be kept in a cool place. She touched the container of probiotics and said the container did not feel cold anymore. She said she was not sure what would be the outcome if the probiotics were not cold anymore. During an interview on 08/12/2026 at 10:58 a.m., MA E said she never put a container of probiotics inside her cart because it would lose its effectiveness. She said she would get it from the refrigerator inside the medication room every time she needed to administer the probiotics. 5.During an observation and interview on 08/12/2026 at 10:47 a.m., a container of disinfecting wipes (pre-moistened fabrics containing chemical agents that kill bacteria and viruses) was observed inside the drawer for narcotics. MA D said nobody told her she could store the disinfecting wipes along with the narcotics. She said the only instruction she got was not to leave the container of disinfecting wipes on top of the cart. She said she did not know what the effect would be when disinfecting wipes were with the narcotics. She said, she guessed, it could affect the integrity of narcotics. She said she would ask about it for clarification. 6.During an observation and interview on 08/12/2026 at 10:58 a.m., a container of disinfecting wipes was observed inside the drawer for narcotics. MA E said nobody told her she could put the container of disinfecting wipes could not be in the same drawer as the controlled substances. She said the only reason she could think of was that the disinfecting wipes could have chemicals that could contaminate the controlled substances. During an interview on 08/13/2026 at 7:56 a.m., the DON said the zinc oxide and medications should not be inside the resident's room because residents might use them inappropriately and could result in adverse reactions. He said zinc oxide and topical analgesia were applied to the skin and could be harmful when ingested or when rubbed to the eyes. He said the resident might be taking the biotin beyond to recommended dosage that could lead to overdosing. He said the probiotics should not be stored inside the cart if the instruction was to refrigerate it after opening. He said the probiotics could lose its effectiveness if placed inside the cart. He said if the container of cold probiotics was placed beside the other containers of medications, it might affect the integrity of the other medications that did not require refrigeration. He said the liquid protein should have been secured before leaving the cart because residents allergic to protein might be able to consume it resulting to adverse effects. He said the disinfecting wipes should not be in the same drawer with the medications because the wipes could affect the integrity of the controlled substances. He said he would start an in-service about medication storage to re-educate the staff at the risk of medications inside the rooms of the residents and if left on top of the carts, as well as making sure the medications administered were kept effective. During an interview on 08/13/2026 at 9:01 a.m., the ED said he was not a clinician and would let the DON take the lead regarding the medication storage issue.Record review of the facility's policy Medication Access and Storage Policy / Procedure - Nursing Clinical revised May 2007 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . PROCEDURES . 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications . 6. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area . 8. Potentially harmful substances (e.g., urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in a locked area separately from medications . 11. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

Based on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure all food items in the kitchen were dated and discarded prior to their use-by date and were properly sealed.This failure could place residents at risk for food contamination and food-borne illness.Findings Included: An observation on 08/11/2026 between 9:15 AM and 9:35 AM in the facility's kitchen revealed: Dry storage:One gallon bag containing elbow pasta noodles with no visible open date, no visible expiration date. One 10lbs. bag containing elbow pasta noodles with no open date and no visible expiration date. One gallon bag containing vanilla wafers with an open date of 07/21/26, with a use by date of 07/30/26, not properly sealed and exposed to air contaminants.One gallon bag containing potato chips with no visible open date, and no visible expiration date, not properly sealed and exposed to air contaminants. Freezer #1 One 9lbs. box containing Turkey sausage patties not properly sealed and exposed to air contaminants.One box containing Ground beef patties not properly sealed and exposed to air contaminants. One 12lb. box containing Pork sausage links, not properly sealed and exposed to air contaminants.[PH35.1][DW35.2]During an interview on 08/14/2026 at 1:26 PM, the DM stated she had been employed with the facility since June of 2026. DM stated her expectation was that everything was labeled and dated. DM stated that the issues could cause food contamination. During an interview on 08/13/2026 at 9:20 AM, ADMIN stated he had spoken with the DM and was informed of the findings. ADMIN stated he expected the kitchen to meet guidelines to avoid infection and food contamination. ADMIN stated if items were expired, they should not serve them to residents. ADMIN stated the issues could cause food contamination. ADMIN stated she would expect the DM to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. ADMIN stated the risk to residents if policy was not followed, was they could get sick from food borne illnesses.Record review of Facility's policy on Infection Control Policy Food Service / Procedure Revised 10/2023. POLICY: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. PROCEDURES:1. DIRECTOR OF FOOD SERVICE RESPONSIBILITIESA. Provide safe food services for residents and employeesF. Provide for the proper receipt and storage of all food supplies.5. FOOD STORAGE A. Upon arrival, all food will be inspected for damage, rodent or insect infestation and spoilage.G. Old stock is rotated and used first.Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of fifteen residents (Residents #9, #11, #26, #47, #57, and #58) reviewed for infection control. 1.The facility failed to ensure RN B performed hand hygiene during Residents #9, #26, #47, #57, and #58's blood sugar checks and insulin administration on 08/12/2026. 2.The facility failed to ensure the Treatment Nurse wore a gown when he disconnected Resident #11's IV, who also had a PICC line, a colostomy, a suprapubic catheter, and was on EBP, on 08/12/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1.Resident #9 Record review of Resident #9's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #9's Comprehensive MDS Assessment, dated 07/13/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #9's Comprehensive Care Plan, dated 07/22/2026, reflected the resident was diabetic and one of the interventions was to administer diabetic medication as ordered. Record review of Resident #9's Physician Order, dated 07/06/2026, reflected Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 999 = 12 Call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Resident #26 Record review of Resident #26's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #26's Comprehensive MDS Assessment, dated 07/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #26's Comprehensive Care Plan, dated 07/08/2026, reflected the resident had diabetes mellitus and the interventions included to check the blood sugar and administer diabetes medication as ordered. Record review of Resident #26's Physician Order, dated 02/24/2026, reflected NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 70 - 200 = 0; 201 - 250 = 2; 251 - 300 = 4; 301 - 350 = 6; 351 - 400 = 8; 401 - 450 = call MD, subcutaneously two times a day for Diabetes. Record review of Resident #26's Physician Order, dated 05/14/2026, reflected Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 5 unit subcutaneously twotimes a day for Diabetes. Resident #47 Record review of Resident #47's Face Sheet, dated 08/11/2026, reflected an-85year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #47's Comprehensive MDS Assessment, dated 05/27/2026, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #47's Comprehensive Care Plan, dated 06/03/2026, reflected the resident was at risk for bowel/bladder incontinence r/t dementia and one of the interventions was to monitor possible causes of incontinence. Record review of Resident #47's Physician Order, dated 05/21/2026, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351+ = CALL MD, subcutaneously two times a day for diabetes Resident #57 Record review of Resident 57's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #57's Comprehensive MDS Assessment, dated 06/10/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #57's Comprehensive Care Plan, dated 06/09/2026, reflected the resident was diabetic and one of the interventions was to administer diabetic medication as ordered. Record review of Resident #57's Physician Order, dated 02/01/2026, reflected Humulin R Injection Solution 100 UNIT/ML (Insulin Regular (Human) Inject as per sliding scale: if 150 - 200 = 2 units give 2 units; 201 - 250 = 4 units give 4 units; 251 - 300 = 6 units give 6 units; 301 - 350 = 8 units give 8 units; 351 - 400 = 10 units give 10 units; 401 - 999 = call md call MD , subcutaneously two times a day for dx: diabetes mellites without complications if blood sugar less than 70, call md, check blood sugar BID before meals. Resident #58 Record review of Resident #58's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #58's Comprehensive MDS Assessment, dated 06/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #58's Comprehensive Care Plan, dated 04/07/2026, reflected the resident had diabetes mellitus and the interventions included administering diabetes medication as ordered. Record review of Resident #58's Physician Order, dated 06/03/2026, reflected Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day for Diabetes. Record review of Resident #58's Physician Order, dated 02/01/2026, reflected NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 60 = 0 call MD; 61 - 149 = 0; 150 - 200 = 0; 201 - 250 = 1; 251 - 300 = 2; 301 - 350 = 3; 351 - 400 = 4; 401 - 999 = 5 And call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. During an observation on 08/12/2026 starting at 6:44 a.m. to 7:36 a.m., RN B was to check the blood sugars and administer the insulins for Residents #9, #26, #47, #57, and #58's. She went to Resident #9's room, put on a pair of gloves and prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside Resident #9's room and checked the resident's blood sugar. She did not perform hand hygiene before or after checking Resident #9's blood sugar. She then went to Resident #57's room, put on a pair of gloves, prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside resident #57's room and checked the resident's blood sugar and administered his insulin. She did not perform hand hygiene before checking Resident #57's blood sugar and administering his insulin. She then went to Resident #58's room, put on a pair of gloves, prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside resident #58's room and checked the resident's blood sugar and administered his insulin, She did not perform hand hygiene before checking Resident #58's blood sugar and administering his insulin. She then went to Resident #26's room, put on a pair of gloves, prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside resident #58's room and checked the resident's blood sugar and administered his insulin, She did not perform hand hygiene before checking Resident #58's blood sugar and administering his insulin. She then went to Resident #47's room, put on a pair of gloves, prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside resident #47's room and checked the resident's blood sugar and administered his insulin, She did not perform hand hygiene before checking Resident #58's blood sugar and administering his insulin. During an interview on 08/12/2026 at 7:40 a.m., RN B said she should do hand hygiene before putting on a pair of gloves to prevent cross contamination. She said hand hygiene should be done before and after doing treatment, and after every resident to prevent spread of infection. 2.Record review of Resident #11's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sepsis (body's response to severe infection), colostomy status ( a surgical procedure that created an opening to the abdomen to allow feces to exit), and neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #11's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a catheter (flexible tube inserted into the bladder to remove the urine), a colostomy (a surgical procedure that created an opening to the abdomen to allow feces to exit), and was receiving antibiotics. Record review of Resident #11's Comprehensive Care Plan, dated 06/26/2026, reflected the resident had sepsis, a colostomy, and a suprapubic catheter (device inserted into the stomach to the bladder to drain urine). The interventions were to administer antibiotic, to change the colostomy bag (plastic pouch that collects fecal matter from the digestive tract) as needed, and to change the catheter bag (collects urine from the urinary bladder) and tubing as ordered, respectively. Record review of Resident #11's Physician Order, dated 08/06/2026, reflected Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8hours for UTI for 14 Days. Record review of Resident #11's Physician Order, dated 06/23/2026, reflected CHANGE COLOSTOMY BAG . AS NEEDED FOR LEAKAGE, DIFFICULTY TO SEAL, ACCIDENTAL REMOVAL every 12 hours as needed. Record review of Resident #11's Physician Order, dated 07/31/2026, reflected CHANGE SUPRAPUBIC CATHETER EVERY 3 WEEKS every night shift every 3 weeks on Sat related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED. During an observation on 08/12/2026 at 7:37 a.m., the Treatment Nurse was about to disconnect Resident #11's IV. He washed his hands and put on a pair of gloves. After putting on a pair of gloves, he closed the door and proceeded to disconnect the resident's IV. He did not wear a gown while disconnecting the resident's IV. It was observed that the resident had a PICC line, a catheter, and a colostomy. It was also observed that there were a PPE cart and an EBP signage outside the resident's room. The signage indicated that to wear gloves and gown for device use . central vascular line (long and flexible catheter inserted to the large vein to deliver medications). During an interview on 08/12/2026 at 7:47 a.m., the Treatment Nurse said he forgot to wear a gown when he was disconnecting Resident #11's IV. He said the resident required EBP because he had an IV, a catheter, and a colostomy. He said a gown was required to prevent contamination of the clothing of the staff from fluid or blood that could possibly be acquired from the resident. He said the gown was to prevent the spread of infection to other residents. He said the facility just had an in-service about infection control, but he could not practice it. During an interview on 08/13/2026 at 6:54 a.m., Resident #11 said he had an IV because of a UTI. He said some staff would wear gowns, but some would not. During an interview on 08/13/2026 at 7:56 a.m., the DON said hand hygiene was the most effective way to prevent cross contamination and spread of infection. He said staff should do hand hygiene before and after any treatment, and gowns should be worn when a resident was on EBP. He said if there was an EBP sign outside the residents' rooms, then staff were required to wear a gown in addition to gloves to protect the residents from cross contamination and probable infection. He said the expectation was for the staff to adhere to the policy of infection control. She said she would start an in-service about hand hygiene and infection control. He said he would start an in-service and checkoffs about infection control to re-educate the staff. During an interview on 08/13/2026 at 9:01 a.m., the ED said the expectation was for the staff to practice infection control to prevent its spread. He said he would coordinate with the DON regarding the issues discussed. Record review of the facility's policy IPCP Standard and Transmission-Based Precautions Policy & Procedure revised April 2025 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident . a. PPE: The use of gown and gloves . is indicated . Indwelling medical devices . peripherally inserted central catheter (PICC) lines . c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include . vii. Device care or use: central vascular line. Record review of the facility's policy Hand Hygiene Policy & Procedure revised April 2025 reflected Policy: It is the policy of this facility to provide . oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards . Procedure . 2. Use an alcohol-based hand rub . b. Before and after direct contact with residents . c. Before preparing or handling medications . i. After contact with a resident's intact skin . k. After handling . contaminated equipment . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . m. After removing gloves.

Based on observation, interview 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 and was developed within 48 hours of a resident's admission for one of ten residents (Residents #75) reviewed for baseline care plans. The facility failed to ensure Resident #75 had a baseline care plan for her colostomy after admission to the facility on [DATE]. This failure could place residents at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening conditions.Findings included: Record review of Resident #75's Face Sheet, dated 08/11/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of colostomy status (a surgical procedure that created an opening to the abdomen to allow feces to exit). Record review of Resident #75's Comprehensive MDS Assessment, dated 08/11/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had an ostomy (an artificial opening in the body). Record review of Resident #75's Baseline Care Plan, dated 08/11/2026, reflected the resident did not have a care plan for her colostomy. Record review of Resident #75's Physician Order, dated 08/07/2026, reflected Empty colostomy bag Q shift and when half full and as needed every shift and as needed. Record review of Resident #75's Progress Note, dated 08/07/2026, reflected . has colostomy on right side of abdomen. During an observation and interview on 08/11/2026 at 9:30 a.m., Resident #75 said she was admitted to the facility the week before. She said she had a colostomy when she was admitted to the facility. During an observation and interview on 08/12/2026 at 6:58 a.m., the MDS Coordinator said the baseline care plan should be done within 48 days of a resident's admission. She looked at Resident #75's profile and saw the resident was admitted [DATE]. She then checked the resident's baseline care plan and said the resident did not have a care plan for her colostomy, and it had been beyond 48 hours. She then started to make a care plan for the resident's colostomy. She said the nursing department was responsible for making baseline care plans for the newly admitted residents. She said she was responsible for making the comprehensive care plan, and she had 14 days to do the comprehensive. She said the resident might not have the care needed for her colostomy upon admission. During an interview on 08/13/2026 at 7:39 a.m., RN I said the RNs were supposed to do the baseline care plans of the residents when they were admitted in the facility to enable the staff to render care to the immediate needs of the residents in terms of their admitting diagnosis. During an interview on 08/13/2026 at 7:56 a.m., the DON said the baseline care plan was important because it would give the providers the minimum healthcare information about the resident that needed to be addressed immediately or upon admission. He said without the baseline care plan, the immediate needs of the resident would not be met. He said the admitting nurses were responsible in making the base line care plan. He said she would coordinate with the MDS Coordinator about the issue. He would also re-educate the nurses regarding doing a base line care plan upon admission. During an interview on 08/13/2026 at 9:01 a.m., the ED said residents must have baseline care so the staff would know how to take care of the residents as soon as they were admitted to the facility. He said the expectation was for the staff to initiate the baseline care plan immediately after admission. He said he would collaborate with the DON and the MDS Coordinator regarding the issue. Record review of the facility's policy Comprehensive Person-Centered Care Planning Policy & Procedure, revised April 2025, reflected Policy . The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care . Procedure . 1 . Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.

Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for one of eight residents (Residents #22) reviewed for accuracy of assessments.The facility failed to ensure Resident #22's Comprehensive MDS Assessment, dated 06/09/2026, accurately reflected the resident was admitted to hospice. This failure could place residents at risk of not receiving care and services needed to meet their needs, diminished function of health, and regression in their overall health.Findings included: Record review of Resident #22's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's primary payer was hospice. Record review of Resident #22's Comprehensive MDS Assessment, dated 06/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was not coded for his hospice care. Record review of Resident #22's Comprehensive Care Plan, dated 08/02/2026, reflected the resident was admitted to hospice on 01/09/2026 and one of the interventions was to work cooperatively with hospice to ensure needs were met. Record review of Resident #22's Physician Order, dated 02/13/2026, reflected Hospice services: admit to . hospice services. Dx: Amyotrophic Lateral Sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). Hospice . Effective Date: 01/09/2026. Record review of Resident #22's Progress Note, dated 02/01/2026, reflected Male on hospice care. Record review of Resident #22's Progress Note, dated 05/18/2026, reflected Hospice notified. During an interview on 08/12/2026 at 12:13 p.m., RN A said Resident #22 was receiving hospice services. During an observation and interview on 08/12/2026 at 6:58 a.m., the MDS Coordinator said Resident #22 should have been coded for hospice care. She opened Resident #22's profile and saw the resident was not coded for hospice. She said she did not know how she missed it, and it was an oversight on her part. She started to click on the resident's MDS and modified it to reflect the resident was on hospice care. She said the residents should be assessed properly to accurately answer every section in the MDS. She said the MDS should reflect the whole picture of the resident to provide the best care possible. During an interview on 08/13/2026 at 7:56 a.m., the DON said the MDS should reflect the conditions of the residents and could be the basis for what would be included in the resident's care plan. He said he would coordinate with the MDS Coordinators to audit the MDS of the residents. He said the resident might not get the hospice services needed if the resident was not coded for hospice. During an interview on 08/13/2026 at 9:01 a.m., the ED said he was not familiar with the MDS. He said the MDS Coordinator already told him about a resident not coded for hospice. He said he would coordinate with the DON and the MDS Coordinator to audit the MDS of the residents and edit them appropriately if issues were identified. Record review of the facility's policy Resident Assessment and Associated Processes Policy & Procedure, revised December 2023, reflected Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record . comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on observation, interview and record review the facility failed to ensure that the resident's environment remained as free from accident hazard as possible and each resident received adequate supervision and assistance devices to prevent accidents for one of twelve residents (Residents #68) reviewed for accident hazards. The facility failed to ensure Resident #68 did not have a screw on top of her side table on 08/11/2026. This failure could place residents at risk for misuse of sharp objects that could result in accidents, skin issues, and a decline in health.Findings included: Record review of Resident #68's Face Sheet, dated 08/11/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), anxiety (intense or excessive fear or worry), depression, and muscle weakness. Record review of Resident #68's Comprehensive MDS Assessment, dated 06/10/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had diagnoses which included Alzheimer's disease, anxiety, depression, and muscle weakness. Record review of Resident #68's Comprehensive Care Plan, dated 07/22/2026, reflected the resident had impaired safety awareness and one of the interventions was to intervene as appropriate. During an observation on 08/11/2026 at 9:42 a.m., Resident #68 was in her bed with her eyes closed. There was a screw on top of the resident's side table. During an observation and interview on 08/11/2026 at 9:43 a.m., the ADON went inside Resident #68's room and saw the screw on top of the resident's side table. He said he would check with the Maintenance Supervisor if he did any repair inside the resident's room. He said the resident might use it to harm herself, or other residents might be able to get it and do the same. The ADON took the screw and said he would give it to the Maintenance Supervisor. He said he would also try to find out who put it on top of the resident's side table. He said staff were going in and out of the resident's room since 6:00 a.m. and nobody noticed the screw. During an interview on 08/11/2026 at 1:30 p.m., the Maintenance Supervisor said he did not do any repair inside Resident #68's room. He said the resident might use the screw to scratch herself. During an interview on 08/13/2026 at 7:56 a.m., the DON said there should be no screw or any sharp objects inside the rooms of the residents because the resident might use them to hurt themselves like poke their eyes or the eyes of the other residents. He said he did not know how the screw ended up on the resident's side table. He said the expectation was for the staff to get the screw or anything sharp if seen inside the rooms of the residents. He said he would start an in-service about keeping the residents safe. During an interview on 08/13/2026 at 9:01 a.m., the ED said the expectation was that no residents should have a screw or anything sharp in their rooms to ensure the safety of all the residents in the facility. He stated they would make rounds to ensure any hazardous items were not in any of the residents' rooms. Record review of the facility's Federal Resident Rights admission Agreement, revised February 24, 2022, reflected As a resident of this nursing facility, you have the right to a dignified existence . Safe Environment . You have a right to a safe . environment, including but not limited to . supports for daily living safely.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #9 and Resident #12) reviewed for respiratory care. 1.The facility failed to ensure Resident #9 had an order for her PRN oxygen and that her nasal cannula, at the back of her wheelchair, was properly stored when not in use on 08/11/2026. 2.The facility failed to ensure Resident #12's breathing mask was properly stored when not in use on 08/11/2026. These failures could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1.Record review of Resident #9's Face Sheet, dated 08/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #9's Comprehensive MDS Assessment, dated 07/13/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was on oxygen therapy. Record review of Resident #9's Comprehensive Care Plan, dated 07/22/2026, reflected the resident had oxygen therapy one of the interventions was oxygen per MD order.Record review on 08/11/2026 of Resident #9's Physician Orders reflected the resident did not have an order for the PRN oxygen.Record review on 08/11/2026 of Resident #9's eMAR reflected the order was to connect the oxygen with the resident's BiPAP mask every night. The resident did not have a PRN order when the resident was using it during the day. During an observation on 08/11/2026 at 9:05 a.m., a wheelchair with portable oxygen at the back tank was parked in the hallway. A nasal cannula was attached to the oxygen tank and tubing of the nasal cannula was coiled around a metal rail at the back of the wheelchair. The nasal cannula was not bagged and almost touched the wheel of the wheelchair.During an observation and interview on 08/11/2026 at 9:54 a.m., CNA F said the wheelchair belonged to Resident #9. He said the resident could ambulate but would use the wheelchair when going out of her room. He said the resident would use oxygen sometimes when she was out of her room. He saw that the nasal cannula was not bagged. He said he would tell a nurse that the nasal cannula was not bagged. During an interview on 08/12/2026 at 6:11 a.m., Resident #9 said she would use her oxygen at night with her BiPAP. She said she would sometimes use her oxygen when she was out of her room. She said nobody told her about putting her nasal cannula inside a bag. 2.Record review of Resident #12's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) and shortness of breath. Record review of Resident #12's Comprehensive MDS Assessment, dated 06/10/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had respiratory failure and shortness of breath. Record review of Resident #12's Comprehensive Care Plan, dated 08/07/2026, reflected the resident had heart failure and one of the interventions was to monitor crackles and wheezes. The plan indicated the resident was at risk for shortness of breath, and the intervention was to provide nebulizer treatment. Record review of Resident #12's Physician Order, dated 07/22/2026, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally via nebulizer every 6 hours as needed for SOB or Wheezing via nebulizer. During an observation and interview on 08/11/2026 at 9:30 a.m., Resident #12 was in her bed, awake. A nebulizer machine with a breathing mask was in the resident's drawer. The breathing mask was not bagged. She said she was using the nebulizer only when she needed it. During an interview on 08/11/2026 at 11:45 a.m., RN A said she did not notice that Resident #9's nasal cannula was hanging at the back of the resident's wheelchair. She said she would go check on it so she could disconnect it. She said Resident #12 used to receive breathing treatments every day, but the order was already changed to PRN. She said she did not know that the resident's breathing mask was not bagged, and she did not know when the last time the breathing mask was used. She said she would also go to Resident #12 to disconnect the breathing mask. She said the nasal cannula and the breathing mask should be inside the plastic bag to keep them clean in case the residents needed to use them. During an interview on 08/13/2026 at 7:56 a.m., the DON said the nasal cannula and the breathing mask should be inside a plastic bag to prevent respiratory infection. He said bagging the nasal cannula and breathing was important to prevent cross contamination. He said he would start an in-service about bagging the nasal cannula and the breathing mask right after the interview to re-educate the staff about the importance of keeping them clean. He said he would also check Resident #9's eMAR if the resident already had an order for her as needed oxygen and would request one if there was none. During an interview on 08/13/2026 at 9:01 a.m., the ED said the expectation was for the staff to bag the nasal cannula and the breathing mask properly when not in use to prevent any respiratory infection. He said they would in-service the staff about respiratory care to re-educate them. Record review of the facility's policy, Policy and Procedure: Bagging Oxygen Tubing undated, reflected Purpose: To establish a standardized process for safely storing oxygen tubing when oxygen therapy is temporarily discontinued or not in use . Policy: The facility shall ensure oxygen tubing is handled, stored, and maintained in a clean manner that minimizes the risk of contamination and promotes resident safety. Oxygen tubing shall be bagged when not in active use but expected to be reused.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of eight residents (Resident #22) reviewed for pharmaceutical services. 1.The facility failed to ensure RN B properly disposed of Resident #22's excess medication on 08/12/2026.2.The facility failed to ensure RN B would not crush Resident #22's medications using only one pill crusher pouch on 08/12/2026. This failure placed residents at risk of receiving contaminated medication and chemical interactions.Findings included: 1.Record review of Resident #22's Face Sheet, dated 08/11/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #22's Comprehensive MDS Assessment, dated 06/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #22's Comprehensive Care Plan, dated 08/02/2026, reflected the resident required tube feedings and one of the interventions was to administer medications via g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). Record review of Resident #22's Physician Order, dated 04/15/2026, reflected Omeprazole Suspension 4mg/mL Give 5 ml via G-Tube one time a day for GERD flush g-tube with 20 ml water after administration. During an observation on 08/12/2026 at 7:00 a.m., RN B was about to administer Resident #22's medication via g-tube. One of the medications she prepared was a liquid omeprazole. She poured the liquid omeprazole into a small cup and then checked if she had poured the required dose. She then realized that she poured more than what was ordered. She took the original container and poured the excess medication back to the original container. During an interview on 08/12/2026 at 8:24 a.m., RN B said she did not know why she returned the excess medication to its original container. She said her actions contaminated the whole bottle of medication. She said she would look for a new bottle of medication.2.Record review of Resident #22's Physician Order, dated 03/20/2026, reflected Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet via G-Tube two times a day related to pain.Record review of Resident #22's Physician Order, dated 03/30/2026, reflected Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet via G-Tube three times a day related to Amyotrophic Lateral Sclerosis.Record review of Resident #22's Physician Order, dated 03/30/2026, reflected Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet via G-Tube two times a day related to Amyotrophic Lateral Sclerosis.Record review of Resident #22's Physician Order, dated 02/02/2026, reflected Zyrtec Oral Tablet Chewable 10 MG (Cetirizine HCl) Give 0.5 tablet via G-Tube one time a day related to Disturbances of Salivary Secretion (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities).Record review on 08/12/2026 of Resident #22's eMAR reflected the resident did not have an order that the medications could be mixed.During an observation on 08/11/2026 at 7:39 a.m., RN B was about to administer Resident #22's medication via g-tube. She prepared the medications needed, placed them in cups separately, and began to crush the tablets. She crushed the first medication using a pill crusher pouch. After crushing the first medication, she returned the crushed medication to its respective cup. She took the second medication, put it in the pill crusher pouch that she used to crush the first medication, and returned it to its respective cup. After crushing the second medication, she returned the medication to its respective cup. She then took the third medication, put in the pill crusher pouch she used to crush the first and second medications. After crushing the third medication, she returned it to its respective cup. She did the same for the fourth and fifth medications.During an interview on 08/12/2026 at 8:24 a.m., RN B said she usually used one pill crusher pouch for each medication. She said she did not know why she only used one pouch to crush all the medications that needed to be crushed. She said the medications were crushed separately to prevent medication interaction that could result in how the medications work. She said because she only used one pouch, some particles of the medications were left inside the pouch rendering the particles left to mix to the succeeding medications. She said she did not know why she prepared the resident's medications using only one pill crusher pouch. During an interview on 08/13/2026 at 7:56 a.m., the DON said excess medication, whether liquid or tablets, should not be returned to its original container because it could contaminate the rest of the medications. He said excess medication should have been discarded properly because of the risk of contamination. He said the cup might have been exposed to other substances that could compromise the medication's safety and effectiveness. The DON said the medications for g-tube should be crushed using one pouch for each medication. He said the medications were not administered at the same time to prevent chemical interactions, and the g-tube was flushed after each medication for the same reason. He said using only one pouch to crush the medications, even though the medications were crushed one at a time, still caused fractions of the medications to mix inside the pouch, when poured back to the cup, and when administered. He said he would start an in-service and checkoffs regarding proper disposal of excess medications and medication preparation. During an interview on 08/13/2026 at 9:01 a.m., the ED said he was not a clinician and would let the DON take the lead regarding disposal of excess medications and on how the medications should be crushed. Record review of the facility's policy Administering Medications Policy / Procedure - Nursing Clinical revised October 2024 reflected POLICY: It is the policy of this facility to use these guidelines for a proper med pass . Procedures . V. Measuring liquid meds . F. Excess liquids should NOT be poured back into the original bottle but properly disposed of.Policy for medication administration via gtube, procedure in terms of crushing, or not re-using the pill crusher pouch requested on 08/13/2026 at 10:33 a.m. requested via email to the Administrator but was not provided prior to exit.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of eighteen residents (Residents #57 and Resident #62) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Residents #57's room was in a position that was accessible to the resident on 08/11/2026. 2. The facility failed to ensure the call light system in Resident #62's room was in a position that was accessible to the resident on 08/13/2026. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident 57's face sheet, dated 08/11/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) affecting the left side and muscle weakness. Record review of Resident #57's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 06/10/2026, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS (screening tool used to assess cognitive status) score of 12. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, bed mobility, toileting, hygiene, shower and dressing. Record review of Resident #57's Comprehensive Care Plan, dated 06/09/2026, reflected the resident was at risk for alteration in musculoskeletal (pertaining to the bones and muscles of the body) status related to hemiplegia and was at risk for communication problem related to cognitive impairment (problems with thinking, learning, remembering, and making decisions). The intervention for both was to ensure the call light was within reach. During an observation and interview on 08/11/2026 at 9:26 a.m., revealed Resident #57 was in his bed, awake. The resident's call light was on the floor, and the resident shrugged his shoulders when asked where his call light was. During an observation and interview on 08/11/2026 at 9:54 a.m., CNA F said he would always make sure the residents' call lights were within their reach so they could call the staff if they needed anything. He said he did not notice Resident #57's call light was on the floor. He went inside the resident's room, saw the call light on the floor, picked it up, and placed it on the left upper corner of the bed. The resident told CNA F to clip the call light beside his right arm and the CNA repositioned the call light. CNA F said the call lights should be secured or clipped so it would not fall every time the resident repositioned himself. During an interview on 08/12/2026 at 12:13 p.m., RN A said call lights should be within the reach of the residents because some residents might fall trying to do things by themselves, because they could not call the staff. She said she did not notice Resident #57's call light was on the floor. 2. Record review of Resident #62's face sheet, dated 08/13/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #62's Comprehensive MDS Assessment, dated 06/09/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, bed mobility, toileting, hygiene, shower and dressing. Record review of Resident #62's Comprehensive Care Plan, dated 05/10/2026, reflected the resident was at risk for fall related to deconditioning and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 08/13/2026 at 6:53 a.m., Resident #62 was in his bed, awake. His call light was on the floor. CNA G was inside the resident's room and was attending to Resident #62's roommate. She did not notice Resident #62's call light was on the floor. The resident shook his head when asked where his call light was. During an interview on 08/13/2026 at 9:56 a.m., CNA G said she did not notice Resident #62's call light was on the floor when she was attending to the resident's call light. She said she would go back and would check if somebody had already placed the call light within reach of Resident #62. She said the resident might need something and would not be able to call the staff because he did not have his call light. During an interview on 08/13/2026 at 7:56 a.m., the DON said call lights were for all the residents, and all the staff were responsible in making sure the call lights were within reach of all the residents. He said if the call lights were not within reach, their needs might not be met. He said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensured the call lights were within reach of the residents before they left the rooms. He said he would start an in-service about call light placement right after the interview to re-educate the staff about the importance of call lights for the residents. During an interview on 08/13/2026 at 9:01 a.m., the ED said the expectation was for the staff to secure the call lights before leaving the residents' room and to put the call lights within reach of the residents if they saw them on the floor. He said they would in-service the staff and would continue to remind them about call light placement.Record review of the facility's policy Call Light Policy/Procedure - Nursing Clinical, revised May 2023, reflected POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff . PROCEDURES . 4. Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive assessment for residents, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical and psychological needs that were identified in the comprehensive for 1 (Resident #46) of 8 residents reviewed for care plans. The facility failed to ensure Resident #46 had a care plan for his anti-anxiety medication, ordered on 08/10/2026.These failures could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #46's Face Sheet, dated 08/13/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's Disease (a disorder that primarily affects memory and a brain disorder that slowly destroys memory and thinking skills) and COVID-19 (infectious disease caused by a virus) with onset date 08/07/2026. Record review of Resident #46's Comprehensive MDS Assessment, dated 05/27/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had Alzheimer's Disease. Record review of Resident #46's Comprehensive Care Plan, dated 08/11/2026, reflected the resident was on droplet isolation related to COVID-19 positive and one of the interventions was to monitor resident's psychological and mental well-being. Record review on 08/13/2026 of Resident #46's care plan reflected the resident did not have a care plan for his anxiety (intense or excessive fear or worry).Record review of Resident #46's Physician Order, dated 08/10/2026 reflected Alprazolam Tablet 0.5 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety.During an observation on 08/11/2026 at 9:08 a.m., Resident #46 could be heard cursing because he wanted to go out of his room. It was observed that a sign was outside his door which indicated the resident was on droplet precautions. During an interview on 08/11/2026 at 10:37 a.m., RN A said Resident #46 was uneasy because he was not allowed to go out of his room due to COVID-19. She said he had an order for anti-anxiety. In an interview on 08/13/2026 at 12:01 p.m. the MDS nurse stated there should be a care plan to address the use of an anti-anxiety medication. She stated she would update the care plan if it occurred during the look back period of a quarterly or annual MDS, but if it was an acute care plan, the ADON was responsible to add it to the care plan. In an interview on 08/13/2026 at 12:15 p.m. the DON stated it was the responsibility of the ADON to update the acute care plans and the use of anti-anxiety medication should have been added to the care plan. He stated the risk to the resident was staff would need to know about the medication and how to care for the residents. Record review of the facility's policy labeled Comprehensive Resident Centered Care Plan, revised 04/2025 reflected, The interdisciplinary team shall develop a comprehensive person centered care plan that includes measurable objectives and time frames to a meet a residents medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #1) reviewed for ADLs. The facility failed to ensure staff provided consistent showers/baths for Resident #1. The facility failed to ensure Resident#1 fingernails were cleaned and trimmed. These failures could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, infection, a loss of dignity and self-worth. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 12/15/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 07, which indicated her cognition was severely impaired. Her diagnoses included cancer (a group of diseases characterized by uncontrolled, abnormal cell growth that can invade nearby tissues or spread [metastasize] to distant parts of the body), Non-Alzheimer's Dementia (forms of cognitive decline not caused by Alzheimer's disease), Depression, and pain disorder with related psychological factors. Functional ability-Personal hygiene: Partial/moderate assistance, and Shower/bathe self: Substantial/maximal assistance. Resident required assistance with ADLs. Record review of Resident #1's care plan, initiated on 12/24/25, reflected, Problem-Category: ADLs Functional Status/Rehabilitation Potential Resident experiences differences in ability to perform ADL. Goal: Resident will complete ADL during morning or evening with use of limit assistive thru the Next review date. Approach: Provide assistance for ADL as eating -supervision x1 , toileting extensive x1, bathing dependent x1, dressing extensive assist, transfer x1 . Resident requires hospice R/T disease process.Record review on 12/30/25 of Doctor order summary dated 04/23/24 revealed admitted to Founders Plaza with hospice. Record review of Resident #1's encounter notes by the hospice agency staff member dated 12/22/25, 12/23/25, 12/24/25,12/29/25 and 12/30/25 revealed no documentation for Resident#1 ADLs. Review of the hospice agency and the facility communication file for Resident#1 revealed no indication of Resident#1 receiving or refusing shower/bed bath. Review of Resident#1' nurses progress notes revealed no indication of resident refusing shower/bed bath, and nail care. In an interview and observation with Resident #1 on 12/30/25 at 09:49 a.m., The resident was observed lying in bed, covered with a blanket. Her hair was uncombed; had an unpleasant body odor. Resident#1 had approximately a 1/5 inch of facial hair on her chin, her fingernails on both hands were long approximately 1/4 inches in length, with brown matter underneath. Resident#1 stated she was not getting her showers. She stated she could not remember the last time she had her shower and stated it had been weeks since she had one. When asked if she was getting a bed bath, she replied no. Resident#1 stated she did not care about the facial hair, but would like to get shower, have her fingernails cleaned and trimmed. In observation and interview on 12/30/25 at 10:45 a.m., CNA A looked at Resident#1 fingernails and stated they were long and needed to be cleaned. CNA A stated Resident#1 was on hospice services and the hospice aides came in daily to visit Resident#1 ADLs Mondays through Fridays. CNA A stated the hospice aides were supposed to do Resident#1 ADLs including showers and fingernails care. CNA A stated she saw HA B visiting Resident#1 this morning but did not know which kind of care was given to the Resident. CNA A asked Resident#1 if she had a shower or bed bath by HA B on 12/30/25; 12/29/25, 12/26/25 and 12/25/25 and the Resident replied no. CNA A asked Resident#1 when was the last time she received shower/bed bath and Resident#1 stated it had been weeks. CNA A stated it was the responsibility of the CNAs to make sure Resident#1 received proper care, and report to the nurses in charge if the residents refused the care. CNA A stated risk to residents loss of dignity, skin break down, scratching self, and development of infection. In a telephone interview on 12/30/25 at 12:53 p.m., CNA C stated she worked weekends, and she offered Resident#1 shower on Saturday 12/27/25, but Resident#1 refused, and she washed her waist down in the bathroom while helping her with incontinent care, and changed her clothes. She stated for residents on hospice services the CNAs only offer them shower/bed bath, because they are supposed to have shower during the hospice Aides visits on the weekdays (Monday through Friday). She stated she did not notify the charge nurse about the refusal of shower for Resident #1. In an interview over the phone on 12/30/25 at 02:12 p.m., HA B stated her last visit with Resident#1 last week was on 12/24/25 and there was another hospice Aide that visit the resident on 12/25/25, 12/26/25. HA B stated during her visits on 12/29/25 and 12/30 Resident#1 refused shower, and she only washed her down. When asked to be more specific, she repeated the same. She stated she did not notify the charge nurse about Resident#1 refusal of shower. HA B stated she cleaned Resident#1 fingernails during her visit on 12/29/25 but because Resident#1 scratch her skin her fingernails get dirty. HA B stated she logged her visit on the Resident's hospice file and did her document on an app on her phone. In an interview on 12/30/25 at 01:37 p.m., LPN D stated the Nurse in charge were responsible for ensuring the resident's showers and ADLs care were performed. He stated the HA B visit Resident#1 daily Monday through Friday for her ADLs care per hospice services including shower, nails care and changing bed lining. He stated HA B called him today to Resident#1 room to help her transfer the Resident#1 from bed to wheelchair, and he left the room after that. He stated he did not know that HA B did not give Resident#1 shower or bed bath. He stated the CNAs/Hospice Aides were supposed to let them know if a resident refused ADLs care or if they were unable to give the scheduled shower or bath. He stated the risk to residents skin break down, and development of infection. In an interview on 12/30/25 at 01:56 p.m., The DON stated she was unable to locate any refusal documentation of shower/bed bath or nails care for Resident#1. She stated residents on hospice services were supposed to get showers and nail care during the hospice Aides visit on the weekdays Mondays through Fridays. She stated HA B had a good relationship with Resident#1 and had been visiting and providing care for her for the last three years. She stated the CNAs were supposed to offer showers for the residents on hospice. She stated the hospice Aides were supposed to communicate to the charges nurses the care rendered to the residents and if there was any refusal of care. The DON stated it was the responsibility of the CNAs and the Charge nurse to make sure residents were kept cleaned, and well-groomed all the time. She stated they were talking with the hospice agency to implement a new system where any refusal had to be documented by the hospice Aides, Charge nurse, and the resident to see if the resident wished for a shower at a different time. She stated the hospice Aides were documenting the care in a separate system belonging to the hospice agency, and the facility was looking to have the documentation forwarded to the facility. She stated ultimately the Charge nurses need to be ensuring the care is provided. The DON stated the risk to residents not getting their showers and nails care was skin issues, hygiene, development of infection, and loss of dignity. In an interview on 12/30/25 at 2:26 p.m., The ED stated the hospice services were supposed to fulfill their contract and provide the services agreed upon to the residents. He stated the DON and the ADON were in servicing CNAs and charge nurses on better communication with the hospice staff, and to make sure the residents received their care daily. He stated he was in contact with the hospice service for the facility to start getting the documentation of the care provided by the hospice staff. Review of the facility policy titled Nursing Policies and Procedures Subject Hospice Care revised 5/5/2023 revealed .2. The Hospice retains primary responsibility for the provision of hospice care and services, based upon the resident's assessment, including but not limited to the following: .nursing (including assigning a hospice aide as needed to support the resident's on-going care) .8. The facility and hospice will have ongoing collaborative communication. Review of the facility policy titled Nursing Policies and Procedures Subject Activities of Daily Living , Optimal Function revised 5/5/2023 revealed Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system.The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the mouth) was stored in a bag when not in use on 10/30/2025.This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 10/30/2025, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (elevated blood pressure), atrial fibrillation (irregular heart rhythm), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #1's MDS (tool used to measure health status) Quarterly Assessment, dated 09/08/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 10. Section I (Active Diagnoses) reflected Resident #1 was treated for COPD.Record review of Resident #1's Comprehensive Care Plan, dated 08/28/2025, reflected the resident received nebulizer treatments related to COPD. One intervention was to provide breathing treatments as ordered.Record review of Resident #1's Physician's Orders, dated 07/02/2025, reflected to administer Albuterol Sulfate (medication that makes it easier to breathe) inhalation solution 2.5 milligrams/3 milliliters every four hours as needed for COPD.During an observation and interview on 10/30/2025 at 11:49 AM, Resident #1's nebulizer with tubing attached to a face mask was on top of a small refrigerator on the resident's bedside table. The face mask was not stored in a bag. Resident #1 was sitting in a wheelchair next to his bed. Resident #1 replied no when asked if he had a breathing treatment that day. He stated he did not receive a breathing treatment every day.During an interview on 10/30/2025 at 1:51 PM, the ADON stated Resident #1's nebulizer mask should have been in a bag to prevent it from getting dirty. He stated it was unsanitary to leave it uncovered. The ADON stated it was important to prevent infection.During an interview on 10/30/2025 at 2:11 PM, the DON stated Resident #1's nebulizer mask should have been stored in a bag. She stated the facility did not have a policy specifically about storing respiratory items when not in use. The DON stated the facility had already begun in-service training on storing respiratory items. She stated it was an important measure to help prevention infection.During an interview on 10/30/2025 at 1:34 PM, LVN B stated Resident #1's nebulizer mask should have been in a bag. She stated the facility had an in-service the previous Friday about storing respiratory items in a bag when not in use. LVN B stated she had already replaced the nebulizer mask and tubing and bagged the items. She stated it was important to prevent contamination and infection.Record review of the facility's policy Respiratory Policies and Procedures: Small Volume Nebulizer, revised 02/12/2024, did not reflect how to store respiratory items when they were not in use.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #5, #6, #7,#8,#9 and #10, were thoroughly cleaned and sanitized. 2. The facility failed to ensure the trash can in the dining room had a lid on it while residents were dining. These failures deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 06/10/25 at 10:55 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. An observation on 06/10/25 at 10:59 of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. An observation on 06/10/25 at 11:02 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The shower floor in the bathroom had white and brown stains on it. The corners and edges of the room floor had white dust build up. An observation on 06/10/25 at 11:06 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had white dust build up. An observation on 06/10/25 at 11:08 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. An observation on 06/10/25 at 11:15 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. A black personal fan had thick dust on the fan blades and inside of the casing. The bathroom shower floor had large yellow and black stains all over it. the floor. The corners and edges of the room floor had white dust and black dirt build up. An observation on 06/10/25 at 11:20 AM of resident room [ROOM NUMBER] reflected the air condition unit filter had thick dust in them. One of the filters was missing from the air condition unit. The air condition vents had white and [NAME] stains in them. The corners and edges of the room floor had black dirt build up. An observation on 06/10/25 at 11:24 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had black dirt build up. An observation on 06/10/25 at 11:30 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. An observation on 06/10/25 at 11:33 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had yellow and black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. A white personal fan had thick dust on the fan blades and the inside of the casing. An observation on 06/10/25 at 12:33 PM in the facility's only dining room revealed a large trash can located in the dining area near a table where a resident was dining , with the lid removed from it. The trash can had trash in it and it had a vulgar smell coming from it. In an interview on 06/11/25 at 12:50 PM, the Dietary Manager was advised about a trash can being in the dining room without the top placed on it and it had an odor. She stated housekeeping and the nursing staff were responsible for ensuring the lid wasare placed back on the trashcans as food wasis being dumped into it. She stated the concerns of not covering it was that it could smell and not be pleasant for the residents. In an interview on 06/11/25 at 1:50 PM, Housekeeping R stated housekeeping ensured the trash cans had lids on them before the start of meals. He stated the kitchen aide was responsible for ensuring the lids remained on the trash cans during meals because it was a safety hazard if the trash cans did not have the lids on them. He stated housekeeping dumped the trays at the end of the meals and emptied the trash cans at the end of each meals, but sometimes the CNAs dump the trays and do not ensure the lids were placed back on them. In an interview on 06/12/25 at 9:17 AM, Housekeeping R stated he had been at the facility for 2 years. He was shown pictures of the concerns Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for cleaning the air filters in the room and when he works Wednesdays, Thursdays, and Fridays, he cleaned them. He stated he had reported to the Housekeeping Supervisor about his peers not cleaning the room thoroughly. He stated he also reported the concerns of the room floors and the shower floors needing a machine to scrub the built-up dirt. He stated the Housekeeping Supervisor told staff that the personal fans in resident rooms were not to be touched by housekeeping. He stated not cleaning the room thoroughly could result in residents getting an infection. In an interview on 06/12/25 at 9:17 AM, the Housekeeping Supervisor stated she had been at the facility for 3 years and in her role as supervisor for 9 months. She stated staff were responsible for cleaning the entire room, from top to bottom. She stated maintenance was responsible for cleaning the air condition unit filters and the vents of the units but they were responsible for wiping down the outside of the units. She stated housekeeping cleaned the floors in the resident rooms and bathrooms. She stated she deep cleaned the floors at least once a month. She stated they were probably supposed to clean the personal fans in the resident rooms, but her staff had not been cleaning them. She was shown pictures of Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. She stated maintenance was responsible for deep cleaning the shower floors or repainting them and she had let them know. She stated the risk of not cleaning the areas mentioned could impact the resident's living experience. In an interview on 06/12/25 at 9:17 AM, the Director of Maintenance [NAME] stated he had been at the facility for 2 years. He stated housekeeping was responsible for cleaning the air filters and they cleaned the air condition units. He stated housekeeping was responsible for scrubbing the floors. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10, and he stated housekeeping was responsible for cleaning the floors and they were responsible for reporting any maintenance concerns such as the air filter missing in the air condition units so he could replace them. He stated maintenance cleansed the air condition units and he checked them once a month. He stated if the areas were not addressed, it could impact their allergies. In an interview on 06/12/25 at 10:45 AM, the Administrator stated he had spoken with his housekeeping supervisor about the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for ensuring the rooms wereare thoroughly cleaned, including the room and bathroom floors. He stated housekeeping was responsible for cleaning the air filters, but maintenance was responsible for ensuring the air condition unit was cleaned. He stated he would have maintenance include to their schedule to clean the air condition units on a more regular basis. He stated they would try to deep clean the bathroom shower floors to see if they can clean it or repaint it if needed. He stated the trashcans in the dining rooms were maintained by the kitchen staff, but the nursing staff should be monitoring them during the meals to ensure the trashcans had a lid on them throughout the resident's dining experience. He stated the concerns mentioned could impact the resident's homelike experience and it could be a biological hazard for them. Record review of the facility's policy on Environment That Preserves Dignity-Resident Right For 11/01/2017) reflected The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self image.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #15 and Resident #222) of 14 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #15's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/10/2025 and that there was an order to assess the resident before and after the breathing treatment. 2. The facility failed to ensure a sign was placed outside of Resident #222's room to indicate oxygen was in use on 06/10/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #15's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), shortness of breath, and anxiety (intense or excessive fear or worry). Record review of Resident #15's Quarterly MDS Assessment, dated 05/07/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had heart failure, shortness of breath, and anxiety. Record review of Resident #15's Comprehensive Care Plan, dated 05/09/2025, reflected the resident had congestive heart failure and shortness of breath and the approaches were to monitor for shortness of breath and administer medications as ordered. Record review of Resident #15's Physician's Order, dated 06/25/2024, reflected Ipratropium-albuterol solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 mL Shortness of breath 1 VIAL VIA NEBULIZER (a machine that converts liquid medication into fine mist) TWO TIMES A DAY AS NEEDED. There was no order to assess the resident's breath sound, respiratory rate, and oxygen saturation before and after the administration of the breathing treatment. Record review of Resident #15's Progress Notes, dated 05/30/2025 reflected Resident c/o SOB, V/S 118/67, 74, 97.6, 18,92% RA. DuoNeb administered as prn ordered O2 sat 94% RA. Observation and interview on 06/10/2025 at 9:20 AM revealed Resident #15 was sitting at the side of her bed. It was observed that the resident had a nebulization machine on her side table with a breathing mask attached to it. The breathing mask was not bagged and was on top of reading material on a chair beside the side the table. She said she seldom used the breathing mask. She said if she could remember it right, she only used the breathing mask two weeks ago because she experienced shortness of breath. She said the breathing mask had been on the chair since then. Observation and interview on 06/10/2025 at 9:37 AM, LVN B stated Resident #15 had an as needed breathing treatment but only used it once. She said if the resident was not using the breathing mask, it should be inside a clean plastic bag to ensure cleanliness for the next use. She went inside the resident's room and saw the breathing mask on the chair. She disconnected the breathing mask and threw it in the trash can and said she did not notice it when she did her morning round. She said she would get another one and make sure it was inside the plastic bag to prevent any respiratory infection. In an interview on 06/11/2025 at 9:12 AM, Resident #15 stated they replaced her breathing mask and put it in a plastic bag. She said it only made sense that her breathing mask would be clean in case she would need it again. Observation and interview on 06/11/2025 at 11:08 AM, LVN B stated when a resident was administered a breathing treatment, the staff should assess the resident before and after the treatment to see if the treatment was effective. She opened Resident #15's profile and saw that the resident only had a physician's order to administer the breathing treatment and did not have a separate order to assess for breathing sound, respiratory rate, and the oxygen saturation before and after the treatment. She said an order for the assessment could be added or incorporated on the instruction part of the order for the breathing treatment. She said if the staff needed to assess the breathing sound, respiratory rate, and the oxygen saturation, then there should be order for the assessment. Observation and interview on 06/11/2025 at 2:26 PM, RN A stated she did not notice that Resident #15's breathing mask was not bagged when she made her round. She said the resident seldom used it but when she was not using it, it should be inside a plastic bag to prevent it from being dirty. She transcribed the resident's order for the breathing treatment in connection to her anxiety. She said an assessment should be done before and after the treatment to check the effectiveness of the breathing treatment. She said the assessment should be done for routine and as needed breathing treatment. She then opened the resident's profile and added to assess the breath sound, respiratory rate, and oxygen saturation before and after the treatment on the instruction box of order for the treating treatment. In an interview on 06/12/2025 at 6:05 AM, LVN C stated Resident #15 was administered a breathing treatment due to shortness of breath. She said she was the one who assessed for the effectiveness of the treatment. She said she checked the resident after treatment was done. She said according to the shift report on 05/30/2025, the resident was complaining of shortness of breath that was why she was given a breathing treatment. She said there should be an order to evaluate the effectiveness of the breathing treatment before and after the treatment's administration to see if the treatment was effective. She also said that she did not notice that the resident's breathing mask was on the chair and was not inside a bag on 06/10/2025. She said it should be bagged to maintain cleanliness of the mask for future use. In an interview on 06/12/2025 at 6:29 AM, the ADON stated the breathing mask should be stored properly inside a plastic bag if the residents were not using them to prevent cross contamination and respiratory infections. He said the staff were responsible in monitoring if the breathing mask was bagged. He said the resident should be assessed before and after giving the breathing treatment to. He said there should be a separate order for the assessment of the breathing treatment or should be incorporated in the order for the breathing treatment. He said the result of the assessment should be recorded in the resident's vital signs documentation. He said the expectation was for the staff to be mindful and bag the breathing mask and make sure there was an order for the assessment. He said the nurses were responsible for bagging the breathing mask as well as transcribing tie order. he said he was responsible in overseeing that they were compliant. He said they already started an in-service about bagging the breathing mask as well as the need for an order for assessing the resident before and after administering the breathing treatment. In an interview on 06/12/2025 at 7:00 AM, the DON stated Resident #15's breathing mask should be inside a plastic bag even though it was sitting in a chair. She said it was not known when the mask had been sitting in the chair. She said the mask should be inside a bag to maintain its cleanliness as well as its patency. She said it was standard for nurses to assess a resident using a breathing treatment before and after the administration to assess the effectiveness of the treatment. She said even though the nurses knew what to do, there should be an order for the intervention because everything done for the residents needed an order. She the nurses were responsible in transcribing the orders in the resident's profile but she was responsible in checking if the order were complete or if the related orders were also included. She said she already started an in-service about bagging the breathing mask and assessing the resident with breathing treatments before and after for breath sound, respiratory rate, and oxygen saturation. If the treatment was not effective, the staff needed to notify the physician so appropriate interventions could be done. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated they were vigilant in reminding the staff to bag the respiratory paraphernalia that the residents were using. He said the breathing mask should be inside a plastic bag when the resident was not using it or remove it and just put a new one when needed. He said the risk of the breathing mask lying on the chair were transfer of the germs from the chair to the breathing mask that could eventually cause any respiratory issues. He said the expectation was for the staff to be mindful that when they do their rounds, they should also check if the breathing mask was bagged. he said the DON already started an in-service pertaining to bagging the breathing mask. He said, since he was not a clinician, the DON would take the lead with regards to the order before and after the breathing treatment. In an interview on 06/12/2025 at 2:56 PM, LVN F stated she administered Resident #15's breathing treatment on the night of 05/30/2025 because the resident verbalized she was having a hard time breathing. She said, in nursing, one of the principles was to assess the resident before administering the breathing treatment so that there would be a comparison after the treatment. She said she did assess the resident but what she was not sure of was if there was an order for it. She said there should be an order to assess before and after the treatment because everything done for the resident should have an order. she said the breathing mask should also be bagged to prevent cross contamination. She said she did not notice that the breathing mask was not bagged on her last shift in the facility. 2. Record review of Resident #222's Face Sheet, dated 06/12/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #222 had diagnoses which anemia (low blood cell count) and immunodeficiency (disorder that prevents immune system from working correctly). Record review of Resident #222's Comprehensive MDS Assessment, dated 06/05/2025, reflected the resident had intact cognition with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had anemia. Section O (special treatments, procedures, and programs) indicated Resident #222 received continuous oxygen. Record review of Resident #222's Comprehensive Care Plan, dated 11/04/2024, reflected the resident was at risk for shortness of breath related to the disease process. One of the interventions was to administer oxygen as ordered. During an interview and observation on 06/10/2025 at 9:10 AM, revealed Resident #222 was sitting up in bed. Resident #222 stated he had been in the facility for about a week and used oxygen all the time. There was no sign on the door indicating oxygen use in the resident's room. During an interview on 06/11/2025 at 12:45 PM, the ADON stated it was important to have a sign outside the resident's room indicating the use the oxygen in the room. He stated it was dangerous to have anything flammable around oxygen because it risked harm to the resident. During an interview on 06/11/2025 at 2:20 PM, the Administrator stated all residents who used oxygen continuous or PRN should have a sign outside their room reflecting oxygen in use. He stated the nurse who admitted a resident with oxygen was responsible for placing a sign outside the door. The Administrator stated the signs were kept in the room where oxygen tanks were stored. During an interview on 06/12/2025 at 9:02 AM, the DON stated the charge nurse who admitted the resident was responsible for placing a sign outside the resident's room indicating oxygen in use. She stated prior to a resident arriving, the staff knew if a resident was on oxygen. She stated the nurse should have an oxygen concentrator in the resident's room and a sign outside the room indicating oxygen in use. She stated the checklist in the admission packet includes putting a sign on the door if a resident is on oxygen. She stated the ADON and DON look at the admission paperwork also. She stated management should also observe when doing guardian angel rounds. The DON stated everyone was responsible for monitoring and ensuring there were signs outside a room reflecting oxygen in use. Record review of the facility's policy RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 05,2023 revealed POLICY: The Facility ensures the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice . PROCEDURES . Infection control practices including standard and transmission-based precautions are . B. Handling of equipment, including cleaning, storage. Review of the facility's policy, Respiratory Policies and Procedures: Oxygen therapy, revised 02/12/2024, reflected Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for two (Resident #18 and Resident #56) of sixteen residents reviewed for pharmaceutical services. 1. The facility failed to dispose of Resident #8's expired Advair (medication inhaled to treat asthma) dated 05/21/2025. 2. The facility failed to ensure that the amount on Resident #56's Lorazepam (antianxiety medication) container was the same with the amount written on the narcotic sheet on 06/11/2025. These failures could place residents at risk of not receiving the medication's full therapeutic benefits, possible side effects, and not identifying promptly the potential loss of a controlled medication. The findings included: 1. Record review of Resident #8's Face Sheet, dated 06/11/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #8's Comprehensive Care Plan, dated 05/30/2025, reflected the resident had COPD and one of the approaches was to provide medications as ordered. Record review of Resident #8's Physician's Order, dated 10/11/2024, reflected Advair HFA (fluticasone propion-salmeterol) HFA aerosol inhaler 115-21 mcg/actuation 2 puff. Observation and interview on 06/11/2025 at 11:50 AM revealed an expired Advair on the hall 200 cart. The date on the inhaler was 05/21/2025. LVN B said she did not notice that Resident #8's expired inhaler was still inside the cart. She said resident had a new one and that was what she was administering to the resident. She said the expired one should not be inside the cart so that staff administering the medication would not mistakenly use the expired one. She said the effectiveness of the medication already diminished when it was expired or there could be adverse reactions from the expired medication. She said she would audit her cart to make sure there was no expired medications. She took the inhaler from the cart and went inside the medication room to dispose it. 2. Record review of Resident #56's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder. Record review of Resident #56's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated that the resident had anxiety disorder (intense or excessive fear or worry). Record review of Resident #56's Comprehensive Care Plan, dated 05/21/2025, reflected the resident receives antianxiety medication and one of the approaches was to give medications as ordered. Record review of Resident #56's Physician's Order, dated 05/14/2025, reflected Lorazepam concentrate 2 mg/mL 0.25 give 0.25-1ml q 4hrs PRN Generalized anxiety disorder. Observation and record review on 06/11/2025 at 11:57 AM revealed a bottle of Resident #56's Lorazepam was inside the refrigerator in the medication room. It was observed that the amount remaining in the bottle was approximately between 15 ml and 20 ml while the recorded amount on Resident #56's Lorazepam narcotic sheet was 21.5 ml. There was a discrepancy of approximately 4 ml between the written compared to the amount in the bottle. Observation and interview on 06/11/2025 at 12:04 PM revealed the ADON inspected Resident #56's Lorazepam and saw that the amount inside the bottle was not the same when compared to the written amount on Resident #56's Lorazepam narcotic sheet. With the use of a flashlight from his cellphone, he checked again the amount on the bottle and said it was less than 20 ml. He opened the bottle and made sure that the dropper on the bottle was empty but the amount was still less than 20 ml. He said he would notify the DON and the Administrator about the concern and would also start interviewing the staff regarding the discrepancy. In an interview on 06/11/2025 at 12:15 PM, LVN B stated they always counted the narcotics in the lock box as well as the narcotics inside the refrigerator in the medication room. She said it was an oversight on her part because she did not notice that there was an inconsistency between the actual amount of the Lorazepam and the amount written in the narcotic sheet. She said it was important that both amounts were the same because it seemed like there was a missing medication. She said she did not give Resident #56 's Lorazepam because it was scheduled during bedtime but she was responsible in making sure the amount left was right. She said the incident should never happen again. In an interview on 06/11/2025 at 2:26 PM, RN A stated she would administer Resident #56's Lorazepam at bedtime. She said she did not notice that the amount on the bottle was not the same with what was written in the narcotic sheet. She said they always counted the narcotics during shift change and did not have any excuse for not seeing the discrepancy. She said she would be mindful in checking the narcotics so she could report it immediately to the DON. She also said that she did not see the expired inhaler in the cart. She said there should be no expired medication inside the cart for the basic reason that it was already expired and could not be used for the resident. She said there might be no so harmful effect but the potency of the medication was already less. In an interview on 06/12/2025 at 6:05 AM, LVN C stated she would always count the narcotics with the outgoing nurse and the incoming nurse to make sure that the narcotic count was correct. She said it did not occur to her that there was a discrepancy on the amount of Resident #56's Lorazepam. She said she overlooked it and would be careful the next time she would count the narcotics that all narcotics were accounted for. She said she was not aware that there was an expired inhaler inside the hall 200 cart. She said it should have been disposed as soon as it expired so the staff would not accidently use it for the resident. In an interview on 06/12/2025 at 6:29 AM, the ADON stated there should not be expired medication inside the carts. He said the nurses and medication aides were responsible in ensuring there were no expired medication. He said he was also responsible in checking and auditing the carts for expired medications. He said the expectation was the staff would really check the count and amount of the narcotics during shift change, report immediately if discrepancies were found, and make sure there was no expired medication inside the carts. In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware about the inconsistency on the amount of Resident #56's Lorazepam and she immediately started the in-service. She said she did not how it happened and why it was not discovered during shift change. She said she already talked to the nurses handling the narcotic and they could not explain as well how it happened. She said it was important that the remaining amount in the bottle was the same with what was documented to negate the fact that there were missing Lorazepam. She said the discrepancy should have been noticed during narcotic count every shift change. She said the expired inhaler should not be kept inside the cart so it will not be used for the resident. She said the risk she could mention was that the potency of the medication was already less but one would never know because there might be a harmful effect when an expired medication was used. She said she already started an in-service pertaining to making sure the amount of the narcotics would be the same with what was written in the narcotic sheet and said she would start an in-service that no expired medication be inside the cart. she said her expectation was for the staff to make sure that the count were correct and that the expired medications were disposed accordingly. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he was made aware by the DON about the narcotic discrepancy and he already reported it to state and also started the investigation. He said when the staff were administering liquid narcotic, they have to make sure that they were giving the exact amount to prevent any discrepancies in the amount. He said he also checked Resident #56's Lorazepam and saw it was below 20 ml in contrast to the amount written which was 21.5 ml. He said he also suggested the use of a syringe instead of a dropper to get the exact amount. He said expired medications should be disposed as soon as it expired. He said he was not a clinician, but one thing he knew, expired medication cannot be used. He said they already started an in-service regarding the making sure the correct remaining amount of the narcotics were the same with what was written. He said he would coordinate with the DON regarding the expired medication. In an interview on 06/12/2025 at 2:56 PM, LVN F stated they do narcotic counts every shift change but since there a discrepancy, then they were not doing a great job in making sure the correct count or amount of Resident #56's Lorazepam was observed. She said she also did notice the expired inhaler inside the cart. She said if the medication was expired, the resident might not receive the full benefit of the medication. Record review of the facility's policy Controlled Substances Pharmacy Services Policies and Procedures revised 04/17/2024 revealed POLICY . 2. The Facility will conduct routine reconciliations of all Controlled Substances to prevent any potential loss or diversion . PROCEDURE . 4. A scheduled reconciliation (shift change count) of controlled substance inventory should be completed at every nursing shift change and documented . D. The oncoming nurse/authorized staff member visually checks this number against the Inventory Record Sheet . E. The nurse/authorized staff should always use the meniscus level of the liquid to estimate the volume of a liquid-controlled substance . F . Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported to the DON. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . D. Checking for expiration dates and removing any expired products.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #53 and Resident #56) of ten residents reviewed for infection control. 1. The facility failed to ensure HA D wore a gown while dressing Resident #53, who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), and was on enhanced barrier precautions, on 06/10/2025. 2. The facility failed to ensure that LVN H changed his gloves and performed hand hygiene when providing wound care to Resident #56 on 06/11/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #53's Comprehensive Care Plan, dated 04/27/2025, reflected the resident was on enhanced barrier precautions for g-tube and one of the goals was infection control. Record review of Resident #53's Physician Order, dated 04/26/2024, reflected Patient is on ENHANCED BARRIER PRECAUTIONS to help protect the resident from infection every shift. Observation and interview on 06/10/2025 at 9:42 AM, HA D stated she just gave Resident #53 a bath and she was just finishing dressing him. It was observed that the resident had a g-tube and that there was a sign outside the resident's door that enhanced barrier precautions were required when dressing the resident. HA D did not wear a gown while dressing the resident. She said she was not aware that she needed to wear a gown when dressing the resident. In an interview on 06/10/2025 at 9:51 AM, HA D stated she should have worn a gown when he was dressing Resident #53 because he had a g-tube and the gown was used to prevent cross contamination to a resident that was vulnerable. She said she did not know what happened that she forgot to wear a gown. In an interview on 06/10/2025 at 9:54 AM, LVN B stated HA D should wear a gown when dressing Resident #53 because the resident had a g-tube. She said there was sign outside the door to remind the staff that when doing a high contact care like dressing the resident, a gown should be worn to protect the resident from infection. She said the enhanced barrier protection was used to minimize the spread of resistant organisms. She said she would talk to HA D and remind her to wear a gown as ordered. In an interview on 06/12/2025 at 6:29 AM, the ADON stated when a resident had a g-tube, open wound, or catheter, the staff should wear a gown because those residents were on enhanced barrier precautions. He said the purpose of which was to prevent cross contamination and development of infection to resident with indwelling medical devices. He said the expectation was all the staff would wear a gown when performing high contact care to the resident who required enhanced barrier precautions. He said the DON already started an in-service about enhanced barrier precautions as soon as LVN B told them the issue of HA D not wearing a gown when required to. In an interview on 06/12/2025 at 7:00 AM, the DON stated if a resident was on enhanced barrier precautions, the staff should wear a gown when providing care to them. She said residents with feeding tubes required enhanced barrier precautions to decrease their exposure to pathogens that could cause infection. She said the expectation was for the staff wear gowns when caring for residents on enhanced barrier precautions. She said she already started an in-service about enhanced barrier precautions when LVN B made them aware about the issue. She said she would personally monitor the staff's adherence to the policy and procedure of enhanced barrier precautions. She said since HA D was from a hospice agency, she already made a plan on how to check the competency of staff from outside agency. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated that staff must be mindful in preventing spread of germs and development of infection, especially for the vulnerable. He said there was a sign outside the Resident #53's door to remind the staff that they should wear a gown when caring for the resident. He said he was not a clinician and would let the DON take the lead about the issue. He said the DON already started an in-service regarding enhanced barrier precautions. 2. Record Review of Resident #56's Face Sheet, dated 06/12/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #56 had diagnoses which included malignant neoplasm (cancerous tumor) of the liver (essential organ that filters blood and makes substances needed by the body), hypertension (high blood pressure), and a pressure ulcer (damage to skin caused by prolonged pressure) on the right heel. Record review of Resident #56's Quarterly MDS (tool used to assess functional capabilities and health needs) Assessment, dated 05/15/2025, reflected the resident had severely impaired cognition with a BIMS (tool used to assess cognition) score of 04. Section M (skin conditions) reflected the resident received skin treatment for a pressure ulcer. Record review of Resident #56's Comprehensive Care Plan, dated 08/28/2024, reflected the resident had a pressure ulcer on the right heel. One intervention was to provide wound care as ordered. During an observation and interview on 06/11/2025 at 9:20 AM, revealed LVN H was preparing to provide wound care for Resident #56. LVN H washed his hands in the resident's restroom. LVN H used a sanitizing wipe to clean the resident's bedside table. He removed his gloves, used hand sanitizer, and put on clean gloves. LVN H draped wax paper over the bedside table and placed the wound care supplies on it. LVN H removed the gloves and used hand sanitizer. LVN H entered Resident #56's room, explained to the resident what he was going to do, and pulled the curtain to provide privacy. LVN H used hand sanitizer and put on clean gloves. LVN H removed the soiled dressing and used moistened gauze to clean the wound on Resident #56's heel. LVN H removed his gloves and did not use hand sanitizer before putting on clean gloves. LVN H used a cotton swab to remove the medicated ointment from a small medicine cup. He applied it to the wound and placed xeroform (non-adherent wound dressing that promotes healing) on the wound. LVN H changed his gloves, used hand sanitizer, and covered the wound with a dry dressing that was dated and initialed. LVN H removed his gloves and used hand sanitizer. LVN stated he should have used hand sanitizer after removing the soiled dressing and cleaning Resident #56's wound. He stated it was important to wash their hands or use hand sanitizer when changing gloves. LVN H stated it was important to prevent contamination from the wound and soiled dressing. During an interview on 06/11/25 at 12:27 PM, the ADON stated LVN H should have cleaned his hands after removing the soiled gloves. He stated it was important to prevent infection. He stated the failure could prevent the wound from healing like it should. During an interview on 06/11/25 at 12:35 PM, the DON stated precautions were in place to add protection for the resident and caregiver, and to prevent the spread of infection. She stated the facility provided mandatory in-services and always talked to staff about infection control. She stated in-services included return demonstration by staff. The DON stated she would immediately provide an in-service on infection control. Record review of the facility's policy, TRANSMISSION BASED STANDARD PRECAUTIONS, AND ENHANCED BARRIER PRECAUTIONS Infection Prevention and Control Policies and Procedures revised May 15, 2023 revealed PROCEDURES: Enhanced Barrier Precautions . Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high contact resident care activities . A. EBP will be implemented for all residents . 2) Wounds . feeding tube . B. EBP will be implemented during . 1) Dressing . Review of the facility's policy Hand Hygiene/Handwashing, revised 05/15/2023, reflected Hand hygiene/handwashing is done .H. After removal of medical/surgical or utility gloves.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #53) of one resident reviewed for Confidentiality of Records. The facility failed to ensure LVN B secured Resident #53's medical information when she left her cart unattended on [DATE]. This failure could place the residents at risk of their medical information being exposed to unauthorized individuals. Findings included: Record review of Resident #53's Face Sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support), restlessness, agitation, anxiety (intense or excessive fear or worry), depression (persistent feeling of sadness or loss of interest), pain, and amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). The Face Sheet indicated that the resident was on hospice and had a directive of DNR (a legal and medical document that tells the providers the patient does not want to be revived when he stops breathing). Record review of Resident #53's Comprehensive MDS Assessment (tool used to assess functional capabilities and health needs), dated [DATE], reflected the resident was unable to complete the interview to determine the BIMS (tool used to assess cognition) score. The Comprehensive MDS Assessment indicated that the resident was on hospice, had anxiety, depression, amyotrophic lateral sclerosis, with unspecified pain, and with g-tube. Record review of Resident #53's Comprehensive Care Plan, dated [DATE], reflected the resident was care planned for antidepressant, antianxiety, hospice, g-tube, ALS, and pain. Record review of Resident #53's Physician Order, dated [DATE], reflected Every SHIFT (3) Check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale (M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe. Record review of Resident #53's Physician Order, dated [DATE], reflected lorazepam 2 mg/mL 0.5ml Every Day at bedtime Restlessness and agitation. Anxiety Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIANXIETY LORAZEPAM. SIDE EFFECTS: 0. NONE 1. Hypotension 2. Sedation 3. Dizziness 4. Dry Mouth 5. Blurred Vision 6.Urinary Retention 7. Drowsiness, Fatigue 8. Slurred Speech 9. Confusion 10. Nightmares 11. Appetite Changes. Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIDEPRESSANTS TRAZODONE, SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5.Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11.Suicidal ideations; Wishes of death; Attempts to harm self. In an interview and observation on [DATE] at 8:40 AM, LVN B was about to do Resident #53's bolus feeding and at the same time administer his medications. She said she would wash her hands first before she prepares the resident's medications. She parked her nurse's cart beside the resident's door and went inside the resident's bathroom to wash her hands. It was observed that there was a laptop on top of the cart. The laptop was open, facing the hallway, and displayed the resident's name, directive, was on hospice, primary physician, emergency contact, allergies, and that the resident was on NPO and tube feeding. Physician orders to monitor the resident for pain and the side effects of antianxiety and antidepressant were also visible. LVN B went back to her cart after washing her hands and saw that her laptop was open. She closed the laptop and said she forgot to close it before washing her hands. She said she should have locked, minimized, or closed the monitor of her laptop every time she left the cart. She said the purpose was to protect the health or personal information of the residents. She said she should be mindful to close her computer every time she left it. In an interview on [DATE] at 6:29 AM, the ADON stated the staff should make sure that no information about any resident be left on top of the cart before leaving the cart unattended because it was HIPAA violation. He said the resident's information were confidential and should not be seen by unauthorized individuals. He said the expectation was for the staff not to leave any personal or medical information about a resident. He said he would coordinate with the DON to do an in-service about privacy and confidentiality. In an interview on [DATE] at 7:00 AM, the DON stated personal and medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have closed the monitor, minimized the monitor, or parked the cart not facing the hallway before going inside the resident's room. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors will be able to see it. She said all staff were expected to provide full privacy and confidentiality of all the residents' personal and medical information. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on [DATE] at 7:29 AM, the Administrator stated the staff must make sure the residents' information was not exposed because it was a violation of the resident's privacy and confidentiality of the care/treatment they were receiving. He said it was a HIPAA violation when unauthorized individuals saw the medical information. He said the expectation was for all the staff to make sure the personal and medical information of a resident were secured and their laptop were closed to prevent exposure of the said information. He said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality. Record review of the facility's policy, INFORMATION SECURITY Leadership Policies and Procedures revised [DATE] revealed POLICY . 3. Users who logon to a computer system . log off of the system and network or, at minimum, lock the computer or laptop prior to leaving the workstation . Procedures . 2. Proper Treatment . E. Shared workstations . 1) Users log-off when leaving the workstation unattended . F. Dedicated workstations . 1) Users lock the workstation when unattended.

Based on observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #53) of six residents reviewed for labelling of drugs and biologicals. The facility failed to ensure a change of instruction label was placed on Resident #53's Lorazepam after a change to the order. This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety (intense or excessive fear or worry). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had anxiety. Record review of Resident #53's Comprehensive Care Plan, dated 4/21/2025, reflected the resident received antianxiety medication and one of the approaches was to give medication as ordered. Record review of Resident #53's Physician's Order, dated 12/20/2024, reflected Lorazepam concentrate 2 mg/mL 0.5 ml Every Day Restlessness and agitation Antianxiety. Observation and interview on 06/11/2025 at 8:02 AM revealed Resident #53's order for Lorazepam was to give every day routinely. There was no order for as needed. It was observed that the order on the medication bottle was to give as needed. LVN B stated the order for the resident's Lorazepam were both routine and as needed. She checked the resident's profile and did not see an order for PRN. She went inside the medication room and said there was no other bottle for the resident's Lorazepam. She said if the staff were still using the Lorazepam with an order for PRN, there should be a sticker on the container notifying the staff that there was a change in instruction. She said or put a note on the container the order was changed to prevent confusion in administering the medication. Observation and interview on 06/11/2025 at 8:09 AM, the ADON stated when administering medications, the staff giving the medications should make sure they were reading the order in the bottle and comparing it with the order in the system. He said if there was change in order, the container should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff. The ADON added the nurses could place a change in order instruction on the bottle. He checked Resident #53's Lorazepam and saw that the order in the bottle was to give as needed. He checked the order on the system and saw the order was to give routinely. The ADON concluded he would monitor the staff administering the medications, give re-education, audit the medication carts, and make sure the medications correlate with the eMAR and the order in the package. In an interview on 06/12/2025 at 7:00 AM, the DON stated the staff should have placed a change in order instruction on Resident #53's Lorazepam to avoid confusion. The DON said the staff should have been alerted if they saw there was a difference with the order in the bottle and the order in the system. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order. She said she already started an in-service regarding proper labelling. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he would let the clinician answer about the administering medications. The Administrator said whatever the procedure was in giving the medications, it should have been followed to prevent any errors. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . 5. The authorized staff member validates the following information is documented on the MAR . A. Correct physician's order and diagnosis for each medication . B. Medication and label are correct.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #53) reviewed for accident prevention. The facility failed to ensure HA D would not transfer Resident #53 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 06/10/2025. These failures could prevent the residents from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #53's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had amyotrophic lateral sclerosis, used a wheelchair, was dependent on staff for transfer, and required two or more helpers to complete the transfer. Record review of Resident #53's Comprehensive Care Plan, dated 4/11/2025, reflected the resident required the use of Hoyer lift to transfer and one of the approaches was ensure 2 X staff assist transfer. Record review of Resident #53's Physician Order, dated 04/10/2023, reflected TRANSFER with assist X 2 via Hoyer lift. Observation and interview on 06/10/2025 at 9:42 AM revealed HA D was done dressing Resident #53. She said she would transfer the resident to his wheelchair using the Hoyer lift. HA D rolled the resident and fixed the Hoyer sling onto the resident's back. After fixing the Hoyer sling, she went to the resident's wheelchair parked at the base of the resident's roommate bed and lowered the backrest of the wheelchair. She then hooked the loops of the Hoyer sling to the sling attachment points of the Hoyer lift and started to raise the resident by holding the remote control using her right hand. When the Hoyer sling with the resident on it was up, she started to move the Hoyer lift away from the bed and towards the wheelchair located at the base of the resident's roommate. Once the Hoyer lift was near the wheelchair, she spread the legs of the Hoyer lift, and continued to push the Hoyer lift towards the wheelchair. HA D then lowered the resident to the wheelchair with the right hand holding the remote control and with the left hand guiding the Hoyer sling as it descends to the wheelchair. Once the resident was already in the wheelchair, she unhooked the loops of the Hoyer sling from the Hoyer lift, and pulled the Hoyer lift away from the wheelchair. She did not call any staff to help her transfer the resident using a Hoyer lift. In an interview on 06/10/2025 at 9:51 AM, HA D stated she did transfer Resident #53 to his wheelchair after giving him a bath using a Hoyer lift. She said she did not call any staff to help her because she could do it by herself. She said nobody told her that she should call another staff when transferring the resident. In an interview and observation on 06/10/2025 at 9:54 AM, LVN B stated HA D should have called her or another aide when she was ready to transfer Resident #53 from bed to wheelchair to make sure that the transfer was safe and no injuries would happen to the resident. She said the staff always helped HA D when she called them for any assistance like if she was ready to transfer the resident via Hoyer lift. She said she would talk to HA D about the risk of transferring a resident via Hoyer lift by herself. LVN B went inside the resident's room and talked to HA D. In an interview on 06/12/2025 at 6:29 AM, the ADON stated he was made aware by HA D about the issue in transfer. He said two aides were required every time a resident was transferred using a Hoyer lift to ensure safety of the resident during the transfer. He said one staff would operate the lift and the other one would handle the resident. He said the resident might fall out of the sling and the staff would not be able to catch the resident. He said the facility was responsible in making sure all the staff caring for the residents were trained in using the Hoyer lift, even though they were from an outside agency, like Hospice. He said they would also check for the competency of staff from outside agency. He said the DON already called the Hospice agency to report what happened and started an in-service about safe transfer to inhouse staff. He said the expectation was for all the staff would follow the considerations of transferring via Hoyer lift to any safety issues pertaining to transfer. In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware by LVN B regarding HA D transferring Resident #53 using a Hoyer lift by herself. She said it was a no-no to transfer a resident using a Hoyer lift with just one staff. She said the facility's staff said they always assist HA D everytime she called for help with transfer or repositioning Resident #53 so she did not know why HA D did not call anybody when she transferred the resident. She said one-person transfer via Hoyer lift could present safety issue to the resident and to the staff also. She said the resident might fall that could result to injuries. Or the machine could tilt to one side and fell on the staff. She said she already reported HA D to Hospice DON. She said she already made a plan on how to check the competency of the the staff from outside agency. She said she already instructed a head-to-toe assessment for Resident #53. She said the expectation was for all the staff to be knowledgeable on how to transfer the resident and that she already started an in-service about the said issue. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he already knew the incident about the transfer and they already started an in-service about safe transferring. He said even though the staff was from an external agency, the facility was still responsible in ensuring that all the staff caring for the resident were competent and were compliant with the procedure of safe transfer. He said the expectation was residents would be transferred safely, not only using the Hoyer lift but also using the other forms of transfer. Record review of the facility's policy, MECHANICAL LIFTS: GENERAL GUIDELINES Nursing Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility may employee the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents, and staff . PROCEDURE . 3. Prior to initiating use of mechanical lift . C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended.

Based on interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. On [DATE] RN A failed to monitor Resident #1 but documented doing vitals during a timeframe which she had become deceased . On [DATE] RN A insisted to Police Officer C Resident #1 was alive when he checked on her at 6:30 AM. RN A documented the vitals for Resident #1 at 7:04 AM. CMA (Certified Medication Aide) B found Resident #1 unresponsive at 7:00 AM during a routine morning medication pass. Police Officer C stated Resident #1 showed obvious signs that were incompatible with life at 7:44 AM and indicated she had most likely already been deceased prior to when RN A checked on her at 6:30 AM. In an interview with RN A, he later stated he did not check on Resident #1 before CMA B found her unresponsive at 7:00 AM and the vitals he uploaded were a mistake. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of serious injury or death. The findings included: Review of Resident #1's Face Sheet documented Resident #1 was a [AGE] year old female admitted on [DATE]. Resident #1 had a pacemaker. Resident #1 had diagnoses including atrial fibrillation (irregular heart rhythm that begins in the heart's upper chambers), hypertension (high blood pressure, motion sickness (motion caused nausea, vomiting, cold sweat, headache, dizziness, tiredness, loss of appetite, and increased salivation), acute pharyngitis (sore throat inflammation), dementia (decline in cognitive function), depressive disorder (persistent feelings of sadness or loss of interest), abdominal distension (swelling or enlargement of the abdomen), constipation (difficulty passing stools or infrequent bowel movements), muscle weakness (lack of muscle strength), asthma (inflammation of airways), gastro-esophageal reflux diseases (stomach acid flows back into the esophagus), anxiety (feeling of tension or worried thoughts), insomnia (sleep disorder that causes a difficulty in falling asleep or sleeping), dysphagia (difficulty swallowing), and gout (pain and inflammation of the joints). Review of Resident #1's Care Plan dated [DATE] documented Resident #1 had a pacemaker. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed for a Brief Interview for Mental Status (BIMS) and received a score of 14 which indicated that her cognition was intact. Review of Resident #1's vital signs documented by RN A, dated [DATE] at 7:04 AM revealed Resident #1 BP: ,d+[DATE], SPO2: 96%, HR: 68, Resp: 18, and Temp: 97. Review of Resident #1's vital signs documented by RN H, dated [DATE] at 1:35 AM revealed Resident #1 BP: ,d+[DATE], SPO2: 98%, HR: 68, Resp: 18, and Temp: 97. Review of Resident #1's progress notes written by RN A, dated [DATE] at 10:30 AM documented Around 7 am The floor Med tech informed this nurse the patient is unresponsive .This nurse and the other nurses rush to the patient room and patient observed lying on the bed unresponsive and code blue initiated. pulse was not detective CPR started and then pulse detected by the machine reading varies from ,d+[DATE] .The emergency personnel arrived and took over .MD,Family, notified change of condition .The emergency personnel informed this nurse they could not get rhythm and told this nurse to inform the family that she expired . and was pronounced dead by paramedics at 9:33am and they going to call the medical examiner .this nurse notified the family and the MD and the ADON. Review of the Medical Examiner Report notes dated [DATE] documented the synopsis was a facility hospice death. There was no trauma. Resident #1 had diagnoses of A-FIB, pacemaker, obesity, GI, pressure ulcers, bladder issues, asthma, hypertension, heart disease, intestinal obstruction, and failure to thrive. Police Officer C stated a caretaker reported he took vitals on the decedent at 0630 hours. A MedTech found the decedent unresponsive at 0700 hours. CPR was started and FD was contacted. The FD reported the decedent was in full rigor (postmortem stiffening of the muscles that occurs after death, typically starting 2 to 6 hours after death and peaking around 12 hours postmortem) at 0740 hours. Police Officer C confirmed rigor was present in the jaw, neck, and arms. The PD was satisfied there was no foul play or trauma. Case was released to Police Officer C. Record review of a facility statement from RN A documented he was alerted to Resident #1's by CMA B who stated the patient was unresponsive. When RN A arrived, LPN F was already there. He checked the patient's pulse; they did not get a pulse. He stated he started CPR on Resident #1. RN A documented the incident in his progress notes. When Administrator G questioned RN A about the vitals, he stated he did not do vitals on the resident prior and only when he went into the room for CPR. Record review of a facility statement from LVN Q documented she was at the nurse's station when she saw LPN F running down the 300 Hall with the crash cart. She immediately followed to assist. Upon entering Resident #1's room, she checked the patient's pulse but was unable to detect one. She noted the patient appeared stiff and was cool to the touch. CPR was initiated by RN A. EMS arrived shortly after. In an interview on [DATE] at 11:20 AM, CMA B stated she started work at 6:00 AM. She was going room to room passing medicine until she got to Resident #1's room. She stated when she entered, she said Good Morning but there was no response. She stated normally she responds. She stated the door was already open, but the lights were still off. She stated she said Good Morning three times total. She turned on the lights and saw Resident #1 lying on her side on the bed. She stated she knew something was wrong immediately and began to shiver. She rushed to get LPN F. She stated they ran back to the room together and began listening to Resident #1's heart. They put her hand on her head to feel her temperature, supplied oxygen, and started CPR. CNA O was working the hall and was told to go inform RN A of the situation. The paramedics arrived after 6 or 7 minutes of notifying them. RN A arrived at the room and started checking the pulse for Resident #1 and taking her vitals. CMA B stated she never observed RN A checking on Resident #1. She stated she was able to tell something was wrong immediately and if RN A had checked on Resident #1, he should have also been able to tell something was wrong when he entered her room. She stated she did not remember for sure what Resident #1's skin temperature felt like to the touch. She stated the facility performed in-services on the same day. The in-service was about making sure the staff checked on the residents and documented correctly. She stated ADON D was the one who performed the in-service. In an interview on [DATE] at 11:41 AM, LVN P stated they immediately responded when CMA B found Resident #1 unresponsive. They stated RN A, CMA B, and LPN F were all assisting. They stated they heard CMA B and immediately brought the crash cart (emergency medical cart) to the room. LVN P was responsible for checking to see if Resident #1 had an advanced directive or not. Resident #1 was full code (patient wished to receive all available medical interventions). Resident #1 was laying on her right side facing towards the door. RN A delegated LVN P to call 911. It took EMS ,d+[DATE] minutes to arrive. Resident #1 was unresponsive. She was not responding to anything. LVN P stated they could not detect a pulse and Resident #1 was not responding to anything verbal. They stated Resident #1 was a little cold to the touch. Resident #1 was stiff. It took 3 people to roll her over. LVN P, RN A, and LPN F began CPR. Once the paramedics arrived, they took over. The facility performed in-services on the same day. The risk of not checking on a resident would be not being able to give a thorough assessment of the resident at that time that you are supposed to be checking on them. In an interview on [DATE] at 12:00 PM, CNA O stated they were working the hall that morning. The situation with Resident #1 happened at the beginning of her shift. She stated she noticed CMA B going into Resident #1's room and heard her immediately call for help. She stated she ran over towards her and that's when they found Resident #1 unresponsive. She stated she assisted LPN F with repositioning Resident #1 while CMA B went to get help. As soon as the crash cart arrived with LVN P they began giving CPR to Resident #1. RN A had also arrived to assist with checking vitals. CNA O stated they did not remember seeing RN A going into Resident #1's room before the start of the incident. She stated she did not remember seeing him go into anyone else's room either. She stated she did see one call light that was on at 6:30 AM for a different resident so she went into that resident's room. If RN A had gone to check on residents on the hall while CNA O was in that resident's room, then she wouldn't know. She stated the facility performed in-services for abuse/neglect and documentation. In an interview on [DATE] at 12:15 PM, LVN Q stated that there is a risk of missing the required resident check timings if you are not checking on a resident when you are supposed to. If the timings are incorrect then there is a risk that a resident could be crashing. That would not be right for the resident because had they been checked on like they were supposed to be then maybe something could have been noticed to prevent the resident from injury, accident, or worse. In an interview on [DATE] at 2:41 PM, RN H stated she was the overnight nurse that worked the hall before RN A. She stated during her shift there were no condition changes. She stated she performed her resident check rounds in the beginning of her shift. She stated around 1 AM, Resident #1 was asking to have the AC cooled down. She performed vitals for Resident #1 at 1:30 AM and she was stable at that time. She stated at that time Resident #1 was okay. She stated she performed another round at 4 AM. Resident #1 was observed laying down in her bed. She stated she performed a quick round because Resident #1 did not have to take medications overnight. She stated she briefly looked inside the room and asked if Resident #1 was okay but there was no response. She didn't want to disturb Resident #1's sleep because she wasn't saying anything. She was laying on her side with her face towards the window. When asked if she checked to see if Resident #1 was breathing, she stated she only went into the room to perform a quick round because she didn't want to disturb Resident #1. In a telephone interview on [DATE] at 12:30 PM, Physician E stated he was informed of the change in condition and was also told by the facility, RN A had got lazy with his charting. He stated he was told RN A documented he had checked on Resident #1 instead of actually checking on Resident #1 and put vitals that were not accurate but once someone else checked on her they realized she was deceased . He stated the EMS said she most likely passed away prior to any of the checks that were documented. He stated this resident was a high risk for cardiac arrest because she had a pacemaker but it was still a surprise and out of the ordinary. He did not think whether RN A checked on Resident #1 or not would have changed the outcome for Resident #1. He stated the risk of injury was high to all residents if the facility was not checking on residents and falsely documenting. He stated if this occurred to a resident who had been in better health then it definitely could have changed the resident's outcome and been preventable. In a telephone interview on [DATE] at 12:51 PM, RN A stated he came to work around 6:05 AM. He stated when he came to work, he usually did rounds on his halls. He stated he did not remember if he checked on Resident #1 or not during that time. He stated he was alerted of Resident #1 not responding by CMA B and rushed to her room. He stated he checked Resident #1's pulse but could not detect it. He stated she was sleeping with her face towards the door. He stated the nurses called a code blue, and everyone began rushing into the room to assist. He stated it took ,d+[DATE] minutes for EMS services to arrive. He stated he went to check on Resident #1 after taking over from the night shift nurse (RN H) around 7:00 AM. He stated he was told the resident was unresponsive around 7 AM to 7:30 AM. He stated Resident #1 was not stiff but she was a little cold to the touch. He stated he attempted to take her pulse with her finger, and it gave a pulse. He stated his documentation and vital checks were wrong. He stated he thought the pulse was around ,d+[DATE] He stated he did detect a pulse and the resident did have oxygen at that time. He stated the documentation that he put in the vitals could have been for another resident, he wasn't sure. He stated he always checked on his residents every morning but in this scenario he didn't have time to check on her yet. He stated he didn't know what the risk would be of not checking on the resident. He stated she was independent and was someone that would let you know if she needed something. In an interview on [DATE] at 12:35 PM, Assistant Director of Nurses (ADON) D revealed it was the facilities policy to check on the residents at the beginning of their shift and every 2 hours. He stated there was a concern RN A didn't document correctly. He stated the response the facility had upon finding resident was done correctly but it coincided with RN A not checking or documenting correctly. If a nurse were to go into her room in the morning and see her sleeping, then you would assume she was sleeping. She doesn't normally wake up until around 8 AM. This resident was good at using her call light and letting you know if she needed anything. He stated he expected his employees to check on the residents before they take over the shift during shift change. He stated when a nurse takes report you should do your checks. He stated at nighttime this was not a disoriented patient and there was nothing saying you specifically have to take vitals at nighttime for a resident such as this if they were sleeping. He stated for people who didn't talk you should go take their vitals but in this instance she was verbal. He stated he still expected his staff to make sure a resident was breathing and maybe say hi to see if the resident would respond. Otherwise, just let them sleep but make sure they were breathing. This was not a resident we were expecting. This was unexpected. In an interview on [DATE] at 3:16 PM, Police Officer C stated he was responding to a call at the facility at 7:44 AM. He stated once he arrived Resident #1 was not conscious and not breathing. He stated Resident #1 was found to be deceased with obvious signs incompatible with life. He interviewed RN A and RN A insisted Resident #1 was alive when he checked on her and took her vitals at 6:30 AM. He stated RN A later uploaded those vitals into the charting software at 7:04 AM. CMA B was passing medications and found Resident #1 was unresponsive at 7:00 AM. He shared his concern with Administrator G that he believed Resident #1 was in rigor mortis when CMA B found Resident #1 and appeared to have been deceased prior to when RN A claims they checked on her and took her vitals. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on [DATE]. The facility took the following actions to correct the non-compliance on [DATE]: Interview on [DATE] at 11:00 AM with Administrator G revealed he believed RN A falsified the vitals for Resident #1, documenting he had checked on Resident #1 when he had not. Resident #1 was most likely already deceased before CMA B discovered her. Administrator G stated RN A was immediately suspended on the day of the accident [DATE]. He stated the facility has already completed a plan of correction, plan of removal, and were continuing to monitor. Staff have been in-serviced on Abuse and Neglect. Staff have been in-serviced on how to correctly document. Staff have been in-serviced on resident checks. Record review of facility In-services conducted by the ADON dated [DATE] and signed by all staff on the following: a. Nursing Policies and Procedures b. Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Interview on [DATE] at 12:35 PM with Assistant Director of Nursing D stated in-services have been completed for all floor staff and would continue to be conducted until every PRN staff member that has not presented to work has received the in-service at the start of their shift. Record Review of the Audit of Random Vital Signs Form revealed the facility performed random monitoring by observation and supervision thereafter by the DON and the ADON to monitor proper documentation of the residents in the facility. The document revealed the staff needed to correctly document resident vitals and pass an audit of random resident vital signs that were supported by resident testimony. The DON and the ADON would be conducting audits three times a week until every staff member continued to demonstrate proficiency and thereafter. The document included a section for dates and two random resident audits for documentation. Review of the Suspension Form dated [DATE] documented RN A was suspended. Interview on [DATE] at 11:20 AM with CMA B revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 11:41 AM with LVN P revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 12:00 PM with CNA O revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 12:15 PM with LVN Q revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:40 PM with RN I revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:45 PM with CMA J revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:50 PM with CMA K revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 2:55 PM with CMA L revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 3:00 PM with CNA M revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. Interview on [DATE] at 3:05 PM with CNA N revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.

49427 Based on observations, interviews, and record review, the facility failed to ensure that pain management was provided for 2 (Resident#4 and Resident #36) of 8 residents reviewed for pain. 1. The facility failed to provide effective pain management for Resident #36 after she experienced a fall on 05/09/2024 she was observed by staff resulting in signs of pain such as grimancing and screaming with movement. 2. The facility failed to provide effective pain management for Resident #4 when his pain medication was reduced without his knowledge resulting in him experiencing unnecessary pain and suffering and psychosocial harm. On 05/16/2024 at 4:51 PM an immediate jeopardy was identified. While the IJ was removed on 05/17/2024 at 11:21 AM the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and the effectiveness of their Plan of Removal. These failures placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: 1. Review of Resident #36's Quarterly MDS dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (loss of cognition), stroke, depression (low mood), muscles weakness, unspecified lack of coordination, abnormal position, neurocognitive disorder with Lewy bodies (abnormal deposits of protein in brain leading to loss of cognition, balance, alertness), and a BIMS score of 3 (severe cognitive impairment). Review of Resident #36's Care Plan reflected problem start date of 03/30/2022 that the resident had difficulty making self-understood and had unclear speech. Review of care plan reflected problem start date of 03/10/2022 that the resident was at risk of complaints of chronic pain and used narcotic pain medication due to disease process with approaches of: monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors . monitor and record any non-verbal signs of pain, complaints of pain, and evaluate effectiveness of pain management interventions. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by PTA CC 05/06/2024 at 11:08 AM revealed the resident showed no signs of pain, was treated in the gym and showed no signs of pain. The summary of skilled services included gait training, bilateral lower extremity exercises focused on progressive resistive exercise and bike exercises to enhance muscle strength. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by OT BB 05/06/2024 at 6:29 PM revealed Resident #36 showed no signs of pain. Review of Resident #36's resident progress notes dated 05/09/2024 by LVN N revealed the resident had a witnessed fall on 05/09/2024 around 5:45 AM when the resident was observed in the hallway wobbling and then fell sliding into the ground on her right knee. The resident was provided a head-to-toe assessment, neuro checks were started, and the resident could not say why she was out of bed. The only injury noted was to her right knee, it was slightly red and sore. LVN N noted that the resident was put to bed. The resident was noted to have dementia and did not know why she was up. Review of Resident #36's progress notes for 05/09/2024 by LVN N at 1:43 AM revealed the resident continued on neuro checks for fall, no delayed injury noted. Right slightly red no swelling noted and resident was reminded to use walker and with supervision. Review of Resident #36's progress notes for 05/09/2024 by LVN P at 11:19 AM revealed Resident #36 had no delayed injuries due to pain and denied any pain or discomfort. Review of Resident #36's progress notes for 05/09/2024 by RN H at 4:33 PM revealed Resident #36 had no post fall injuries and the resident denied pain. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/09/2024, signed by OT BB 05/09/2024 at 6:15 PM, revealed resident showed signs of pain that included grimacing, protective behaviors to areas of pain, limited resident ability to sit up at the edge of the bed and transfers, pain was relieved by sitting still and exacerbated with prolonged activity, and resident had a fall on the morning of 05/09/2024 and complained of pain to her lower right extremity. Review of Resident #36's progress notes for 05/09/2024 by RN H at 9:39 PM revealed Resident#36 was noted moaning, holding her right leg any time she is given incontinent care. Resident assessed. Right hip to ankle painful to touch, no redness no swelling noted. Tramadol 50mg tab routine admin [sic]. NP notified no new order received. Review of Resident #36's progress notes for 05/10/2024 by LVN N at 5:54 AM revealed there was an incident with Resident #36 and her roommate, and the resident was assessed head to toe, was asleep, had no discoloration or any injuries, denied any pain, and was moved to a different room. Review of Resident #36's progress notes dated 05/10/2024 by MDS LVN between 11:33-11:45 AM revealed a cognitive assessment of Resident #36 was completed and revealed that the resident was able to repeat 2 words, was unable to recall the correct year, month, or day of the week, resident speech was unclear, and resident stated that occasional pain, rarely disturb for sleep, activity, therapy activity, pain scale 7. Will continue to monitor. Review of Resident #36's progress notes dated 05/10/2024 at 12:49 PM by LVN Q revealed resident had no delayed injury, no neuro deficits. Review of Resident #36's progress notes dated 05/10/2024 at 8:46 PM by RN H revealed Resident #36 had continued neuro checks for fall, no post fall injury noted or reported, resident denied pain, and care was given as needed by staff. Review of Resident #36's progress notes dated 05/11/2024 at 2:38 AM by LVN N revealed Resident #36 needed assistance with all activity of daily living, had neuro checks due to fall, and was adjusting to room change. Review of Resident #36's progress notes dated 05/12/2024 at 7:34 PM by LVN R revealed Resident #36 was post fall and noted grimacing in pain during ADL's. Notified NP [Nurse Practitioner DD]. No new orders. Review of Resident #36's progress notes dated 05/12/2024 at 8:40 AM by LVN S revealed the Nurse Practitioner DD for Physician K was notified and a new order was received for an x-ray because Resident #36 was observed in therapy with a nurse aide screaming by holding her right hip. The pain increase [sic] when patient moves her right leg, turn to left side, and during care. Tylenol 500 mg for pain given. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by Physical Therapist GG 05/13/2024 at 3:40 PM revealed resident consistently stated increased pain on the right lower extremity at the start of therapy session and was unable to complete bed mobility exercises due to increased pain and nursing was notified. Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by OT BB 05/13/2024 at 6:24 PM revealed the resident showed signs of pain to her lower right extremity that included reflexive behaviors such as saying ouch, stop, protecting, moaning, holding area of pain, limited resident ability to sit up for meals, and pain was relieved by remaining still and exacerbated with sitting and prolonged activity. OT BB noted that resident complained of severe pain with movement to lower right extremity and that Director of Rehabilitation reported the resident had an x-ray of the knee with negative results and a hip x-ray was recommended to be done. Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/14/2024, signed by PTA CC 05/14/2024 at 11:35 AM revealed the resident had increased pain on both sides of her lower extremities and nurse was aware and arranging for an x-ray series for bilateral hip assessment. Review of Resident #36's orders revealed there was a prescription for pain medication Tramadol 50 mg, one tablet, by mouth, twice a day for unspecified pain with a start date of 11/17/2022 through 05/15/2024 and an order for 500 mg of Tylenol, PRN (as needed) with a start date of 11/17/2022 through 05/15/2024 . Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Tylenol 500mg and was not given any PRN doses after her fall on 05/09/2024 until 05/14/2024 at 8:38 AM by LVN S for pain. Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Ibuprofen 200mg with a start date of 11/17/2022 and was not given any PRN doses after her fall on 05/09/2024. Review of Resident #36's MAR for 05/01/2024 through 05/19/2024 revealed resident was given Tramadol 50 mg, one tablet, by mouth twice a day for unspecified pain at 9:00 AM and 8:00 PM from 05/01/2024 through 05/15/2024. Review of MAR revealed Resident #36 order was changed to Tramadol 50 mg, one tablet, by mouth, 3 times a day starting on 05/15/2024. Review of X-Ray report with date of service of 05/15/2024 for Resident #36 reflected there is a possible nondisplaced intertrochanteric fracture of the right femur of indeterminate age. Review of X-Ray report with date of service of 05/14/2024 for Resident #36 reflected resident had an x-ray of her left and right hip due to unspecified pain with the findings of a nondisplaced right intertrochanteric fracture of indeterminate age with clinical follow up recommended. Observation on 05/14/2024 at 2:16 PM revealed Resident #36 was lying in bed, hair appeared clean, and was wearing a hospital gown and had a blanket. Resident #36 asked to be cleaned and did not appear to know how to use the call button that was within reach. RN H was informed that the resident was in need of assistance and stated she would help the resident immediately. Observation and interview on 05/15/2024 at 3:05 PM revealed X-ray Technician waiting outside of Resident #36's room with a portable x-ray. He stated he was waiting for RN H to assist him because the last time the resident was screaming. Observation on 05/15/2024 at 3:13 PM the resident was heard from outside the room with the door closed saying ow. Interview on 05/15/2024 at 3:30 PM with RN H revealed that Resident #36 recently had a witnessed fall on 05/09/2024 and that she assessed resident the day of the fall and observed some redness to her knee and lower extremity was painful to touch, resident was put in bed and the Nurse Practitioner was notified with no new orders and family was notified. RN H stated that resident did not appear to be in pain when in bed. RN H stated on 05/10/2024, Resident #36 did not appear to be in pain when she was in bed or when asked but there were some signs of pain during activities of daily living care and the Nurse Practitioner was notified with no new orders. RN H stated the x-ray was ordered on 05/15/2024 because the resident was observed screaming and yelling out and grimacing during activity of daily living care. RN H stated it was appropriate to contact the Nurse Practitioner instead of Physician. Interview on 05/16/2024 at 2:04 PM with DON revealed Resident #36 had a fall on 05/09/2024 and staff had told her that resident had some redness to her knee but was not complaining of pain and had good range of motion and thought she was fine, she was walking in the hall. DON stated that it was not uncommon for Resident #36 to complain of generalized pain and was not aware that staff and therapy were documenting that Resident #39 was showing symptoms of right hip pain after 05/09/2024 and that it would have been a change in condition for the resident. DON stated she had not read therapy's notes that noted resident was immobile and she did not have access to those notes. DON stated the Nurse Practitioner was notified of Resident #36's fall on 05/09/2024, were provided no new orders. DON stated that she was aware on 05/15/2024 that resident had hip pain so Dr. K was notified and ordered an x-ray. DON stated that the result of the x-ray was that resident had a hairline fracture and the plan was to not do surgery and to try to keep resident immobile as much as possible and manage pain. DON stated that staff are supposed to notify the physician but physicians direct staff to contact Nurse Practitioner if he was not available. DON stated that she had seen Resident #36 out of bed since her fall on 05/09/2024 and was not told of the symptoms of hip pain by staff. DON stated that Resident #36 was provided Tylenol for breakthrough pain. DON stated that nursing staff were responsible for monitoring, and notifying physician of resident pain if uncontrolled, and to document and provide pain medication given to residents and their pain levels. DON stated that not providing pain management for residents would impact their quality of life if their pain was not managed. DON stated that they always contacted NP EE for changes in condition. Interview on 05/16/2024 at 2:50 PM with Power of Attorney (POA) for Resident #36 revealed she was notified on 05/09/2024 that resident had fallen and did not have any pain. POA stated she was not notified about any symptoms or signs of pain for Resident #36 until 05/15/2024 when she was contacted by facility stating Resident #36 displayed signs of pain and an x-ray had been ordered. Interview on 05/16/2024 at 3:46 PM with Physician K revealed he was an attending physician at the facility and was notified that Resident #36 had a fall and was told she did not have pain. Physician K stated that he was at the facility on 05/14/2024 and a nurse practitioner informed him that the resident had pain, an x-ray was ordered, and resident had a nondisplaced fracture or a hairline fracture of her hip. Physician K stated he ordered a second x-ray to confirm the original findings because it would impact the treatment plan. Physician K stated that he expected if a resident had significant pain they would be sent to the emergency room . Physician K stated it was important for any new or different pain symptoms to be reported to the physician so he was aware of the resident's condition and able to make necessary orders. Physician K stated that staff not reporting resident with pain symptoms could result in a resident experiencing pain for extended periods of time or not receiving proper treatment. Interview on 05/17/2024 at 2:50 PM with Physician L revealed he was a pain management physician at facility and if a resident had a pain management concern physician facility staff might call them if resident was having pain but he was not aware that Resident #36 was experiencing pain after 05/09/2024 until 05/14/2024. Physician L stated that if he knew resident was experiencing pain after her fall on 05/09/2024 he would have ordered an x-ray sooner. Physician L stated he would expect staff to check for resident pain post fall by flexion and adduction and look for visual or verbal indications of pain such as grimacing or crying out. Physician L stated the risk to a resident by not notifying the physician about a change of condition of resident could result in a resident to not be provided care they needed or remain in pain. Observation on 05/19/2024 at 11:30 AM of Resident #36 revealed she was lying in bed sleeping, wearing hospital gown, covered with a blanket with call light within reach and water cup at bedside table. Interview on 05/20/2024 at 1:00 PM with Nurse Practitioner (NP) EE revealed if a resident was already on pain management and they were experiencing pain, the staff would reach out to her. NP EE stated she was not aware that resident was having pain until 05/15/2024 when the nurses told her that the resident was in a lot of pain when she moved. NP EE stated that she doesn't like to give stronger medications than Tylenol 3 or Tramadol and was able to write prescriptions for those medications without asking the Physician AA. NP EE stated Resident #36 was on already on Tramadol 50 mg two times a day for generalized pain and increased frequency to 3 times a day and added Tylenol 650 mg three times a day starting 05/15/2024. NP EE stated she did not know who ordered the x-ray and did not remember asking Physician AA about Resident #36. NP EE stated that the risk to a resident when they do not receive proper pain management was that they could have decreased movement, increase of pain, and decrease in quality of life. 2. Review of Resident #4's Comprehensive MDS dated [DATE] revealed resident was an [AGE] year-old male, admitted on [DATE], with diagnoses of postlaminectomy syndrome (a condition that causes pain or other sensations in the body after spinal surgery), muscle weakness, unspecified abnormalities of gait and mobility, chronic pain syndrome (pain that can be continuous or may come and go and persists for weeks or years), anemia (low iron), hyponatremia (low salt levels), hyperlipidemia (elevated levels of fat in blood), arthritis (inflammation of the joints causing pain and stiffness), stroke (loss of blood flow to the brain), dementia (loss of cognition), depression (persistent low moods), asthma, macular degeneration (eye disease causing vision loss), and a BIMS score of 15 (intact cognition). Review of Comprehensive MDS revealed the care area of pain was triggered for pain. Review of Resident #4's Care Plan with problem start date of 03/25/2024 revealed Resident is at risk complaints of chronic pain, use routine pain meds and Narcotic PRN [as needed] R/T [due to] chronic pain syndrome, disease process. Review of Resident #4's face sheet dated 05/14/2024 revealed Resident #4 had a Resident Representative, and he was his own representative. Observation and interview on 05/14/2024 at 1:46 PM with Resident #4 revealed he was lying in bed with a slightly curled position and with a blanket wrapped over his neck and appeared stiff. He stated he does not get his oxycodone every 4 hours even though the Physician prescribed it. He stated the staff taunt him by saying he has 1 minute until he can have his next dose or 6 minutes and it made him feel really bad and he felt that he was having more breakthrough pain due to the delays. Resident #4 stated he had chronic pain due to previous surgeries, cervical (neck) fusion and lumbar (back) fusion. He stated some of the hardware caused him pain and that he took the same dosage for years with his orthopedic Physician and his pain was usually controlled enough at a level 2 or 4 when he took his medication regularly. Resident #4 stated that he was involved in his care planning and stated that the facility was aware that he had chronic pain syndrome and needed oxycodone every 4 hours. The facility said they can accommodate his need, but the order would have to be PRN. This means when needed, so you would need to ask for it every 4 hours if you needed the pain medication. Resident #4 stated that he understood that to mean he needs to ask every 4 hours, so he did. He stated it seemed like they did not understand his pain, that his pain will flare up if he misses the dose of oxycodone every 4 hours. Review Resident #4 orders revealed following orders: -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours with a start date of 04/29/2024 and end date of 05/01/2024. -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/01/2024 and end date of 05/02/2024. -Oxycodone, Schedule II, 10 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/02/2024 and end date of 05/02/2024. -Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/18/2024. -Buprenorphine Schedule III patch, 10mcg/hour one transdermal film every 7 days for chronic pain with a start date of 04/30/2024 and end date of 05/03/2024 and another start date of 05/03/2024 with end date of 05/17/2024. Review of Resident orders with a start date of 05/18/2024 for Resident #4 for psychology evaluation for possible drug seeking behavior and decreased perception of pain. Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 10 mg for pain on: 05/01/2024: none 05/02/2024 at: -6:18 PM by LVN M 05/03/2024 at: -6:41 PM by LVN M 05/04/2024 at : -12:17 PM by LVN T -4:15 PM by LVN M 05/05/2024 at: -6:52 AM by LVN P -11:23 AM by LVN P -4:07 PM by LVN P -8:17 PM by LVN P 05/06/2024: -7:23 AM by LVN G -11:37 AM by LVN G -3:41 PM by RN I -7:40 PM by RN I 05/07/2024: -5:59 AM by LVN O -10:05 AM LVN G -7:32 PM by RN I 05/08/2024: -5:06 AM by LVN T -9:10 AM by LVN G -4:16 PM by RN I -8:18 by RN I 05/09/2024: -9:13 AM by LVN G -3:15 PM by RN I -7:15 PM by RN I 05/10/2024: -8:47 AM by LVN G -5:02 PM by LVN V 05/11/2024: -1:56 PM by LVN V 05/12/2024: -7:00 AM by LVN P -11:54 AM by LVN V -3:55 PM by LVN P -8:04 PM by LVN P 05/13/2024: -4:30 AM by LVN X -8:37 AM by LVN G -4:38 PM by RN I -9:05 PM by RN I 05/14/2024: -5:05 AM by LVN T -5:06 PM by RN I -9:09 PM by RN I 05/15/2024: -5:02 AM by LVN T -11:55 AM by LVN G -4:20 PM by RN I -8:21 PM by RN I 05/16/2024: -2:50 AM by LVN O -8:04 by LVN G -3:41 PM by RN I -7:50 PM by RN I 05/17/2024: -8:40 AM by LVN G -12:34 PM by LVN G -5:43 PM by LVN V -9:35 PM by LVN V 05/18/2024: -4:39 AM by LVN O -8:46 AM by LVN P Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 15 mg for pain on: 05/18/2024 at 9:09 PM by LVN P 05/19/2024 at 10:11 AM by LVN P Review of Resident #4's nurse's progress notes revealed note dated 04/27/204 by LVN N at 11:56 PM .resident continue on excessive amount of pain med gets it every 4 hours around clock prn [as needed] will contact pain doctor to reevaluate him. Review of Resident #4's nurse's progress notes revealed note dated 04/28/204 by LVN N at 5:50 AM Resident continues on skill charting appears obsessed [sic] with pain med demanding it every 4hr around the clock does not seem to be in pain when checking [sic] on resident always sleeping. Review of Resident #4's nurse's progress notes revealed note dated 04/29/204 at 1:26 AM by LVN N .Appears to be taking to [sic] many pain pills will have day shift get in touch with dr. Review of Resident #4's progress notes revealed note dated 04/29/2024 at 12:20 PM by LVN M As per DON, Oxycodone 15mg changed to schedule Q4hr as Pt continues to request for Pain medication every 4 hrs. Review of Resident #4's progress notes revealed note dated 05/02/2024 at 1:01 AM by LVN N Residents oxycodone 15 changed to 10mg q 4hr prn but was put on pain patch 10mg. Review of Resident #4's progress notes revealed note dated 05/03/2024 at 8:29 AM by LVN M Resident continues on pain mgt with oxycodone 10mg PRN Q4hrs, no discomfort reported at this time, plan of care on-going. Review of Resident #4's progress notes revealed note dated 05/07/2024 at 8:35 AM by LVN G Resident refused to take morning medication when he was offered. Resident wants CMA to wait until later. Medication will be offered in a later time. Review of Resident #4's progress notes revealed note dated 05/08/2024 at 2:16 PM by LVN G Resident refused patches to be placed. Review of Resident #4's progress notes revealed note dated 05/10/2024 at 1:32 PM by LVN G: Resident continues to refuse pain patches. Resident also using Icy Hot cream topically for pain. No order in place. Notified pain NP to obtain order, no order needed for the icy hot, per NP. NP wants resident to be encouraged to use pain patches. NP will be in the facility and will see resident. Review of Resident #4's progress notes revealed note dated 05/15/2024 at 10:43 AM by LVN G: Resident refused pain patches and buprenorphine patch. Resident states I don't want them. I have to talk to my Dr. That is too much chemicals for my heart. This nurse explained to the resident that buprenorphine patch is for pain and he gets it once a week but resident refused stating that he gets oxycodone and does not need that patch. Pain management NP notified. WCTM. Review of Resident #4's progress notes revealed note dated 05/15/2024 at 1:14 PM by LVN G NP called back about resident's refusal of pain patches. Will talk to resident when in facility. Interview on 05/15/2024 at 2:06 PM with Resident #4 revealed he was told by a nurse that he had been prescribed a patch for pain and was concerned about the interactions between that patch and his current pain medication since he had heart problems in the past and bad experiences with patches. Resident #4 stated that he said he told the nurse that he wanted to talk to his Physician about the concern. He stated his previous Physician, he was with for [AGE] years, and felt that he had figured out a pain management schedule that already had been working for him. Resident #4 stated that the staff told him that this was how it was, you talk with the nurse practitioner, he told them he was not going to use the patch, and he did not want any of his pain medications changed. Review of Resident #4's progress notes revealed note dated 05/16/2024 at 6:15 AM by LVN O Resident is alert responsive c/o generalized pain, PRN Oxycodone 10 MG 1 tablet PO administered @ 0255, Rx effective no further c/o pain or discomfort, continue ongoing plan of care . Review of Resident #4's progress notes revealed note dated 05/16/2024 at 9:16 AM by LVN G Resident complain of pain. Resident request for oxycodone. Resident did not state how much pain he is experiencing when asked. States ' All my body is in pain. I'M going through withdrawal'. Pain medication administered at 0810. Review of Resident #4's progress notes revealed note dated 05/16/2024 at 12:24 PM by LVN G Resident continues to refuse pain patches. NP aware. RP notified. Interview on 05/15/2024 at 3:44 PM with RN I revealed that she had worked at the facility for about 6 years and was familiar with Resident #4 and had worked his hall for about a week. RN I stated that he comes up to the nurses station every 4 hours to ask for the oxycodone and was unable to describe to her where exactly the pain was, indicated he feels pain everywhere. RN I stated he had a history of back pain due to surgery. RN I stated that she was aware the resident was refusing pain patches and stated one day LVN G had opened a pain patch and was going to make him take the patch and he refused. RN I stated that Resident #4 commonly ambulates with his walker or was in bed and used Bengay to his lower back every day. Interview on 05/16/2024 at 9:26 AM with Resident Representative for Resident #4 revealed resident was initially a short-term resident but transferred to long term care at the facility. Resident Representative stated Resident #4 had previous surgeries to his neck and spine that left him with chronic pain due to the hardware and he had arthritis. Resident Representative stated that she thought the facility staff needed a lot of education on chronic pain syndrome and Resident #4 experienced withdrawal when he did not take his medication regularly. Resident Representative stated the resident was under the care of a pain physician before long term care for [AGE] years and his pain was managed well with no changes. Resident Representative stated she was a participant during the care plan conference it was explained to staff that he takes oxycodone every 3-4 hours for pain. The facility stated they could not give that medication to the resident on a schedule. They could prescribe it as PRN (as needed) and he would have to ask for it every 4 hours because they can not give it around the clock. Resident Representative stated she did not recall any other discussion or questions around pain management or why the resident has chronic pain. Resident Representative stated Resident #4 had mentioned that he had been in more pain lately and that his pain levels have been about a 7 out of 10. Resident Representative stated that a couple of weeks prior, Resident #4 was prescribed a pain patch, a morphine derivative, by the nurse and he called her because he was concerned about the interactions of the pain patch with his oxycodone. Resident Representative stated she spoke with the pain Physician who told her that the patch should be safe and wanted him to be monitored more frequently to ensure he was not feeling lightheaded or dizzy. Resident Representative stated that Resident #4 did not want to try it and did not want his medications changed. Interview on 05/16/2024 at 9:50 AM of CMA J revealed she was aware the resident took oxycodone and gabapentin for his pain and she provided lidocaine patches for the resident. CMA J stated he sometimes refused the lidocaine patch, but other times would use them. CMA J stated she asked Resident #4 where his pain was, he would motion to his neck but also say he has pain throughout his body. CMA J stated she thought his pain was well managed. Interview on 05/16/2024 at 10:05 AM with Resident #4 revealed he stated, they don't seem to understand my pain needs that he needed the oxycodone every 4 hours, or he would experience withdrawals and that when he goes to the nurse's station to ask for the oxycodone he gets anxious and shaky. Interview on 05/16/2024 at 11:18 AM with LVN G revealed she had worked at facility for about 2 years and regularly worked on Resident #4's hall. LVN G stated that Resident #4 asked for oxycodone every 4 hours and that the lidocaine pain patches were prescribed in March. She stated a controlled pain patch was prescribed on 05/03/2024 for pain by the facility's pain physician. LVN G was asked for the name of the physician and LVN G stated actually, it's the Nurse Practitioner who I talk to when Resident #4 refuses the patch. LVN G stated the nurse practitioner for the facility's pain physician was NP EE. LVN G stated the NP EE was onsite at the facility about once or twice a week or as needed. LVN G stated that Resident #4 came to the nurses station every 4 hours and told them that he needs his Oxycodone 15 mg. LVN G stated she asked Resident #4 what is pain level is and where the pain is and he would become upset. LVN G stated that in the past, he told her that his pain was low and if he waited to take the medicine, he will be in pain. LVN G stated that Resident #4 now he says he is at a pain level of 8 or higher and would become very upset about being asked his pain level. LVN G stated she asked resident where the pain is and he would indicate his neck and say his whole body. LVN G stated that Resident #4 had a diagnosis of dementia, Chronic Pain Syndrome and arthritis but was unsure why resident had chronic pain. LVN G stated that Chronic Pain Syndrome was when he will think he is in pain when he isn't and will ask for pain medication because he thinks he needs it. She stated that residents on strong pain medications were monitored routinely for sedation. Which could indicate that a resident was receiving too much pain medication with symptoms, such as respiratory depression or sleepiness, and would be documented in the eMAR or progress notes. LVN G stated that she never observed any signs of sedation and did not think that Resident #4 was excessively dosed with narcotics. LVN G stated that the controlled pain patc [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury for one (Resident #1) of four residents reviewed for wounds. 1. The facility failed to perform weekly skin assessments for Resident #1. The facility failed to identify early signs of skin breakdown and implement interventions to prevent the re-opening of a Stage 3 Sacral pressure ulcer (PU) {Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present}. The wound deteriorated into a Stage 4 PU {Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer}. 2. Resident #1 did not receive scheduled daily wound care on 04/07/23, 04/10/23, 04/23/23, 04/29/23, 05/07/23, 05/11/23, 05/13/23, & 05/14/23. 3. The facility failed to offer relevant alternatives when Resident #1 declined the specific intervention to remain in bed throughout the day to offload pressure from Stage 3 Sacral PU. Staff did not assist with repositioning to relieve pressure when Resident #1 sat up in wheelchair for more than 4 hours at a time during the day. 4. The facility failed to provide appropriate pressure-relieving device(s), LAL mattress, identified in Resident #1's care plan on 10/13/22 until 04/17/23. 5. The facility failed to provide treatment and services to heal and to prevent infection to Resident #1's sacral PU. Resident #1's sacral wound developed an MRSA infection (a staph (group of bacteria) infection that is difficult to treat because of resistance to some antibiotics) that required IV antibiotic therapy. The resident was admitted to the hospital on 05/15/2023 after RP request. On 05/19/23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 05/22/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: Record review of Resident #1's MDS quarterly review assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions that included HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); DM (chronic condition that affects the way the body processes blood sugar (glucose), the body either doesn't produce enough insulin, or it resists insulin); Non-Alzheimer's Dementia (a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease); Depression; and stiffness of right hand. Resident #1's BIMS score was 11, which suggested moderately impaired cognition. Resident #1 had no behavioral symptoms or exhibited rejection of care behavior during the MDS review period. Resident #1's functional status reflected one-person limited assistance with eating and required one-person extensive assistance for dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bladder and always continent of bowel. The MDS Quarterly review indicated Resident #1 was at risk of pressure ulcer/injury (PU/PI). Resident #1 did not have one or more unhealed PU/PI, venous or arterial ulcers. Skin and Ulcer/Injury treatments included Q2 turn and reposition. A record review of Resident #1's MDS Annual assessment dated [DATE] revealed the following: Section M Skin Conditions. Unhealed PU/PI: The MDS Annual assessment reflected one Stage 3 and one Stage 4 unhealed pressure ulcers/injuries. Skin and Ulcer/Injury treatments included in the MDS Annual assessment: Pressure reducing device for bed, turning/repositioning program, PU/PI care, and applications of ointments/medications. A review of Resident #1's comprehensive care plan, last care conference dated 05/10/23, indicated: Category: Indwelling Catheter [Start: 04/28/23] Problem: Resident requires an indwelling urinary catheter r/t wound Stage 3 and 4 [Edit: 05/04/23] Goal: Resident will have catheter care managed appropriately AEB not exhibiting signs of infection or urethral trauma through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 04/28/23] -Assess drainage. Record the amount, type, color, odor. Observe for leakage -Change catheter per MD order -Provide assistance for catheter care -Provide catheter care as scheduled and as needed -Report s/sx of UTI Category: Baseline Care Plan [Start: 04/28/23] Problem: Resident is prescribed Antibiotic therapy [Edit: 05/04/23] Goal: Resident will take antibiotic as ordered without serious complications through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 04/28/23] -Administer antibiotic as order. Evaluate/record effectiveness. Evaluate/report adverse side effects. -Monitor lab work: as order. Notify MD of results. Category: Baseline Care Plan [Start: 03/28/23] Problem: Resident non-compliant laying bed for release pressure to bottom, likes stay up in w/c all day [Edit: 05/04/23] Goal: Resident will be compliant to laying bed for release pressure to bottom through the next review date. [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 03/28/23] -Assist resident transfer bed after meals -Explain procedure, encourage resident laying bed after meals for release pressure to bottom -Maintain a calm environment and approach to the resident -Observe resident right Category: Continence Status (Bowel/Bladder) [Start: 10/03/21] Problem: [Resident #1] experiences bladder incontinence r/t impaired mobility, weakness. [Edit: 05/04/23] Goal: Will have a decrease in incontinence episodes through review date [Target: 08/04/23; Edit: 05/04/23] Approach: [Start: 10/03/21] -Adapt environment to maximize independence (e.g., path free of obstacles, grab bars, elevated toilet seat, bedside commode, etc.) -Ensure adequate bowel elimination -Keep call light in reach -Obtain therapy consult as needed -Provide incontinence care after each incontinent episode -Report s/sx of UTI Category: Pressure Ulcer/Injury [Start: 07/19/2022] Problem: Resident has a pressure ulcer stage 4 to sacrum AND Stage 3 left heel. [Edit: 05/04/23] Goal: Resident will respond to ulcer treatment AEB improved wound healing with less pain and drainage or positive lab results. [Target: 08/09/22; Created: 07/19/22] Approach: [Start: 07/19/22] -Reposition while in bed [Start: 05/04/23] -Sugar free liquid protein supplement for promoting wound healing [Start: 03/23/23] -LAL mattress as needed [Start 10/13/2022] -Assess condition of surrounding skin. Report emergence of skin excoriation (repetitive picking of skin that leads to skin lesions) -Keep resident and RP aware of wound healing progress and any MD order changes -Observe and report signs of localized infection -Record the amount, type, and odor of drainage from the wound -Record the color, consistency, and location of exudate (fluid that leaks out of blood vessels into nearby tissues) -Use aseptic (to maintain sterility and free of contamination) techniques when performing dressing changes Review of Resident #1's physician orders indicated: - Start Date 09/21/21: Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. 2 PM - 10 PM. - Start Date 08/08/22: Reposition Q2H. Every 2 hours. {Times entered from midnight, 2:00 AM, 4:00 AM, 6:00 AM . to 10:00 PM every two hours on TAR} [D/C Date: 01/19/23] - Start Date 01/17/23: Boots on at night. At bedtime. 7:00 PM [D/C Date 04/19/23] - Start Date 01/19/23: Reposition Q2 hours. Every Shift. First, Second, Third. - Start Date 03/28/23: Other Test: UA with C&S (Urinalysis with Culture and Sensitivity) - Start Date 03/31/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply calcium alginate and dry dressing. Once A Day. [D/C Date: 04/06/23] - Start Date 04/02/23: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily. Once a Day. [D/C Date 04/27/23] - Start Date 04/03/23: Other Test: Arterial doppler study LLE. Once between the 3rd - 5th of the Month. [D/C Date: 04/26/23] - Start Date 04/06/23: Indwelling FC 16 Fr/10 mL d/t sacral wound. Continuous Second, Third. - Start Date 04/06/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Once A Day. [D/C Date 04/14/23] - Start Date 04/14/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing. Once A Day. [D/C Date 04/27/23] - Start Date 04/19/23: Boots on while in bed. At bedtime 7:00 PM - Start Date 04/19/23: Air Loss Mattress. Every Shift. First, Second, Third. - Start Date 04/26/23: Other Test: CBC with differential (measures the number of each type of these white blood cells), CMP (a test that measures chemical balance and metabolism in the blood), TSH (blood test that measures the thyroid stimulating hormone), A1C (a blood test that measures average blood sugar levels over the past 3 months), and prealbumin level (a protein that is made mainly by the liver). - Start Date 04/27/23: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing. Once A Day and PRN. - Start Date 04/27/23: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing. Once A Day. [D/C Date: 05/04/23] - Start Date 05/01/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/06/23] - Start Date 05/11/23: Midline Catheter Intermittent Use: Flush 10 ML NS before and after medication administration. Every Shift. First, Second, Third. - Start Date 05/11/23: Zosyn in dextrose piggyback; 3.375 gram/50 mL Intravenous. Every 8 hours. [D/C Date: 05/11/23] - Start Date 05/12/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/26/23] - Start Date 05/12/23: Ertapenem Solution, Reconstituted (Recon Soln), 1 gram, intravenous once a day [D/C Date 05/12/23] - Start Date 05/15/23: May send to hospital for evaluation of Stage 4 sacral wound per family request. Once A Day. 06:00 (6 AM) - 14:00 (2 PM) [End Date: 05/15/23] Review of Resident #1's April 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in April and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Friday 7th and Monday 10th: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Special Instructions to identify drainage, general appearance, and surrounding skin - Sunday 23rd: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing - Friday 7th, Monday 10th, and Sunday 23rd: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily - Saturday 29th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing - Saturday 29th: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing was blank, did not reflect the initials of a person providing treatment, under the column, that represented the day/date in April. Review of Resident #1's May 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in May and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Friday 7th, Thursday 11th, Saturday 13th, and Sunday 14th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing Review of Resident #1's April 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in April and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR (Electronic Medical Record). The April weekly skin assessments revealed: - 04/04/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/11/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/18/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. - 04/25/23: LVN A initialed the TAR. LVN A completed a Focused Observation Comprehensive Assessment. LVN A answered No to the question Alterations in skin? Review of Resident #1's May 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in May and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR. The weekly skin assessments revealed: - 05/02/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. LVN A completed a Daily Skilled Focused Observation Comprehensive Assessment on 05/03/23. LVN A answered No to the question Alterations in skin? in the skin section - 05/09/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. Resident #1 transferred to the hospital on 05/15/23 per RP request. Review of ADL documentation/flow sheets, the POC (Point of Care) responses in PCC indicated Resident #1 had moisture associated skin damage: - On 03/12/23, charted by CNA C - On 3/14/23, charted by CNA C - On 3/15/23, charted by CNA C Review of a nurse progress note dated 03/16/23 entered by the WCN, stated Resident #1 was seen by the WMD for assessment and evaluation of a reopened stage 3 pressure wound to the sacrum. The nurse also documented Resident #1 was advised to stay up less sitting on the wheelchair, to allow wound to heal. A review of the WMD Wound Evaluation and Management Summary dated 03/16/23 reflected, At the request of the referring provider, [PCP], a thorough wound care assessment and evaluation was performed. [Resident #1] has a stage 3 pressure wound, sacrum, for at least 1 day duration. There is light serous exudate. The wound measured (L x W x D): 0.7 x 0.6 x 0.2 cm. Additional wound detail indicated reopened stage 3 pressure wound. Recommendations: Off-load wound; reposition per facility protocol. A review of the WMD Wound Evaluation and Management Summary dated 03/30/23 reflected, the stage 3 sacrum pressure wound measured (L x W x D): 1.2 x 0.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum improved evidenced by decreased surface area. Additionally, the WMD documentation revealed an Unstageable DTI (Deep Tissue Injury) of the left heel, a blood-filled blister, >1 day. The wound measured (L x W x D) 6.5 x 7.5 x Not Measurable cm. There was no exudate. Recommendations: Off-load wound; Reposition per facility protocol; Float heels in bed; Pressure off-loading boot. The WMD recommended a lower extremity arterial doppler (an ultrasound exam of the arteries in the legs that can help evaluate whether there are blockages) on 03/30/23. A review of the WMD Wound Evaluation and Management Summary dated 04/06/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 2.2 x 1.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum deteriorated. The WMD documentation indicated no change in the Unstageable DTI (Deep Tissue Injury) of the left heel. A review of the April 24-hour reports for Resident #1, dated 04/06/23, 04/11/23, and 04/14/23 in the Day Shift (6A - 2P) column entered by LVN B revealed communication between the health care team and provided information about multiple requests for LAL mattress and heel boots for off-loading wound(s) to sacrum and left heel. A review of the WMD Wound Evaluation and Management Summary dated 04/13/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 4 x 2.5 x 0.2 cm. There was moderate serous exudate, 20% slough, and 80% granulation. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD indicated a generalized decline of Resident #1. The documentation indicated the Unstageable DTI of the left heel deteriorated. The wound measured (L x W x D): 10 x 9 x Not Measurable cm. Additional details reflected the WMD suggested [Resident #1] to see a vascular physician. A review of the WMD Wound Evaluation and Management Summary dated 04/27/23 reflected, the stage 3 sacrum pressure wound deteriorated into a stage 4 pressure wound. The wound measured (L x W x D): 5 x 4 x 2 cm. There was moderate serous exudate, undermining (when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) 2 cm at 9 o'clock, 50% necrotic tissue, and 20% granulation tissue. Other viable tissue: 30% (muscle, fascia). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the Unstageable DTI of the left heel deteriorated into a stage 3 pressure wound. The wound measured (L x W x D): 2 x 1 x 0.3 with improvement. The WMD recommended a WBC lab draw - the WBC collected on 04/27/23 resulted 30.7 CRITICAL HIGH [Range: 3.8 - 10.1]. The WMD Wound Evaluation and Management Summary dated 04/27/23 stated the WMD performed a wound culture on stage 4 pressure wound, sacrum. The WMD discussed the size increase and deterioration of the sacral wound and heel wound improvement with the RP via phone. The WMD put off consulting a vascular physician and recommended focus on the sacral wound. The WMD started oral antibiotic therapy. A review of the WMD Wound Evaluation and Management Summary dated 05/04/23 reflected, the stage 4 sacrum pressure wound measured (L x W x D): 5 x 5 x 2.5 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 20% necrotic tissue, and 50% granulation tissue. Other viable tissue: 30% (muscle, fascia). Additional wound detail indicated the sacral wound had less necrotic tissue and WBC trended down. (The WBC collected on 04/28/23 resulted 23.9 CRITICAL HIGH; and on 05/04/23 resulted 12.0 HIGH). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the stage 3 pressure wound of the left heel was resolved. A review of the WMD Wound Evaluation and Management Summary dated 05/11/23 indicated, the stage 4 sacrum pressure wound measured (L x W x D): 6 x 5 x 3 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 10% slough, and 60% granulation tissue. Other viable tissue: 30% (muscle, fascia). Wound progress indicated improvement. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. Review of Resident #1's wound culture of the stage 4 pressure wound sacrum results presented E. coli (Escherichia coli) and Proteus microorganisms (resistant bacteria methicillin-resistant Staphylococcus aureus) on 05/11/23. Review of a nurse progress note dated 05/10/23 entered by LVN A, stated she was informed by NP of wound to [Resident #1] right 3rd/4th toe. LVN A documented that she cleaned wound with normal saline and patted dry. An interview and observation on 05/18/23 at 9:12 AM at the hospital revealed Resident #1 in an upright position, the HOB elevated between 60 - 90 degrees, bi-lateral offloading boots. Hips offloaded with wedges. Resident #1 appeared groomed and in a clean gown; single lumen midline catheter to right arm. FC draining yellow urine by gravity to drainage bag. NPWT unit (Wound vac) noted at bedside, continuous suction set at 125 mm/hg to sacrum pressure wound site, foam bridged to left hip. Scant dark red drainage noted in tubing and approximately 150 cc dark red solidified drainage in the wound vac canister. Resident #1 was awake, alert and oriented to self and surroundings. Flat affect congruent with mood. Resident #1 spoke in a soft, low-pitched tone and at a slow pace. During the interview, Resident #1 acknowledged understanding of the RN Investigator presence and purpose of visit. Resident #1 denied staff behavior/interaction, infection control, Abuse/Neglect, or quality of care or ADL concerns. Some responses indicated understanding of questions but was unable to describe specific instances about accommodation of needs and care provided at the SNF. A review of the ED to Hospital Admission provider note dated 05/15/23 showed Resident #1 presented to the ED from SNF via EMS c/o wound check. Per EMS, [Resident #1] had a large sacral wound that recently cultured and grew MRSA. [Resident #1] was placed on doxycycline 100 mg BID on 05/12/23. Admit diagnosis: Decubitus ulcer of back. A review of in-patient admission hospital medical records dated 05/15/23 through 05/18/23 indicated Resident #1 had wound healing issues of a non-healing stage 4 sacral ulcer despite antibiotics and wound care. A CT (Computed Tomography - a diagnostic imaging test) of Pelvis with Contrast resulted a large sacral decubitus ulcer measured 10.6 x 5 x 3.8 cm extended directly next to the sacrum and coccyx. Assessment and plan revealed IV antibiotic therapy, resident is not a surgical candidate, no benefit from extended IV course, and recommended palliative care consult. A review of in-patient admission hospital medical records dated 05/15/23 revealed skin assessments and wound images: - Sacrum pressure wound, 6.5 x 3.5 x 1.4 cm, small serous drainage, no odor - Right lateral third toe abrasion, scant serous drainage, no odor. From what appeared to possibly be from 4th toenail - Left lateral fifth metatarsal head with appearance of maroon/purple intact skin consistent with DTPI - Left medial first metatarsal head with appearance of maroon/purple intact skin consistent with DTPI - Left medial knee intact blister - unclear cause - Heels with evidence of old healed wounds, no skin currently open and no appearance of wounds on heels During an interview on 05/17/23 at 10:57 AM, the WCN stated responsibilities were daily wound care, Monday - Friday (the nurses provided wound care on Saturday and Sunday), review shower sheets and followed up on any noted skin issues; followed up labs and notified the MD of lab results. The WCN said that the nurses completed weekly skin assessments, documented in the EMR and informed [WCN] of any new skin issues or changes. The WCN said that she audited new admission charts to ensure HTT skin assessment was done, weekly, and quarterly. The WCN said that she would complete a HTT assessment if notified by the admitting nurse of any identified skin issues to confirm the findings and documented in the EMR. The WCN stated recalled Resident #1 had a stage 3 PU to the sacrum that reopened. The WCN said that the CNAs look at the skin during baths/showers for skin issues. The WCN stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Thursday morning. The WCN said that she was informed one morning that Resident #1 had an open area to her lower back. The WCN stated the WMD was notified assessed, evaluated, and treated the pressure wound area. The WCN said that the WMD recommended Q2 turn and reposition, LAL mattress, and heel boots when a DTI on the left heel was discovered. The WCN stated blood labs were drawn that resulted a high WBC count, the WMD was notified, and Resident #1 was started on an oral antibiotic for 10 days. The WCN said that a culture was done of the sacral wound that resulted with MRSA. The WCN stated the RP inquired about IV antibiotic therapy, the WCN contacted the PCP and received a new order for a midline insertion and start IV Zosyn. The WCN said that the pharmacy informed Resident #1 had an allergy to active ingredients in Zosyn and would call back with an alternate antibiotic. The WCN stated a new order received from the NP the next day to start Ertapenem (Brand name: Invanz, an antibiotic that treats serious bacterial infections) IV (Intravenously) but the pharmacy notified [Resident #1] is also allergic to that medicine. During an interview on 05/17/23 at 2:39 PM, CNA C indicated he was familiar with Resident #1. CNA C stated Resident #1 liked to sit up in wheelchair for activities and for meals in the dining room. CNA C said that Resident #1 was a two-person assist with a mechanical lift. CNA C said that he would transfer Resident #1 to bed to provide incontinence care after meals and assist Resident #1 back to wheelchair. CNA C stated he first noticed redness, like a rash, and a small open area on Resident #1's lower back, the tailbone area when provided a shower. CNA C said he notified the nurse and documented in the POC. CNA C stated that he did not apply barrier cream because of the open area. CNA C said he provided care to Resident #1 in the past and recalled the open area had healed before. CNA C stated that the nurses provided wound care but did not know what treatment was done to the wound. CNA C said that Resident #1 did not like to lay in the bed, but the nurses said that [Resident #1] should stay in bed all day to keep pressure off the wound. CNA C said that he was unaware of interventions to reposition or offload pressure when a resident was up to the wheelchair. During an interview on 05/18/23 at 2:21 PM, the ADON stated her responsibility was to oversee staff and follow up on dietary recommendation, attend clinical meetings and review documentation for Medicare part A/managed care residents. The ADON said that she is responsible for Angel Rounds to ensure safety and address resident concerns not necessarily done daily but she performed observations throughout the day. The ADON stated that she attended morning meetings when the 24-hour reports are reviewed and residents' needs are discussed to determine interventions needed to be implemented. The ADON said that she was familiar with Resident #1 that she was able to make her wants and needs known. The ADON said that she spoke with the RP that [Resident #1] was hospice appropriate, the wound culture results, allergies to ordered IV medications, and that Resident #1 was getting older. The ADON said she explained to the RP that the disease process with aging was the reason Resident #1 is unable to metabolize food, wound takes longer to heal, but refused to stay in bed throughout the day to allow staff to turn and reposition every two hours. The ADON stated that Resident #1 did not want to stay in bed because it prevented her from playing BINGO, eat in the dining room and socialize. The ADON said that it was necessary for Resident #1 to stay in bed to relieve pressure on the sacrum wound and [Resident #1] had the right to choose when wanted to get in/out of bed and the staff are required to honor resident rights. The ADON replied when asked about pressure relieving devices and offloading when resident is up to wheelchair that the resident was too weak to reposition in the wheelchair. The ADON said that the staff that ordered central supplies was responsible for ordering the LAL mattresses for Resident #1 as indicated on care plan. The ADON stated that Resident #1 had a LAL mattress before, but it was returned when the wound healed. During an interview on 05/18/2023 at 4:08 PM, CNA D said he worked with Resident #1. CNA D stated Resident #1 required two-persons assist with ADLs, mechanical lift for transfers, and he provided bed baths T/Th/S on the 2P - 10P shift. CNA D said that he reviewed the POC to determine the resident's level of functioning and care needs. CNA D said Resident #1 was up to the wheelchair when he came on shift and would transfer to bed after dinner. CNA D said that he noticed a very small area on Resident #1's back side where a wound had healed reopened during a bed bath and now its really big. CNA D stated he documented the open area on the shower sheet and notified the nurse. During an interview on 05/18/2023 at 4:32 PM, LVN A stated that she was the primary nurse for Resident #1, Monday - Friday on the 2P - 10P shift. LVN A said that she did the HTT skin assessments on Tuesdays. LVN A stated that she answered no to skin alterations on the Focused Observation Skin Assessment form because the WCN was aware of the wound. LVN A said that is she answered yes to alterations to skin, the answer would trigger more questions that she did not measure or look at the wound and could not answer the questions. LVN A said that it was known that Resident #1 had a wound and did not need to answer yes to the question on the assessment. LVN A stated that Resident #1 would be up in the wheelchair when she [LVN A] started her shift at 2 PM and during change of shift report about Resident #1 was told that she [Resident #1] sat up in wheelchair throughout the day (6A - 2P shift). LVN stated that she would ask the CNA to place resident in bed after dinner (6:00 PM) to provide incontinence care and to leave in bed to turn and reposition every two hours to relieve pressure of the pressure wounds. LVN A said that Resident #1 would press the call light if she wanted to be repositioned or turned. During an interview on 05/19/2023 at 11:36 AM, LVN B said that she was a nurse assigned to Resident #1 during the weekdays on the 6A - 2P shift. LVN B said that she worked the day Resident #1 went to the hospital. LVN B stated that she did not complete HTT skin assessments because they were scheduled for the 2P - 10P shift but performed wound care when the WCN was not present. LVN B recalled at the end of the week before Resident #1 went to the hospital, the RP voiced concern about [Resident #1] not receiving IV antibiotics for wound infection that the ADON mentioned. LVN B stated that she acknowledged the RPs concern and explained that the pharmacy notified that Resident #1 had allergies to the suggested antibiotics. LVN B said that she informed the DON and PCP about the RP concerns and waited for recommendations for an alternate antibiotic treatment. During an interview on 05/19/2023 at 4:34 PM, the DON stated that nurses on the 2P - 10P shift were responsible for completing weekly HTT skin assessments and providing wound care on the weekends. The DON said that she was aware of missed wound treatments over a few weekends and was resolved when the employee was terminated. When asked about the wound care missed during the week the WCN was out (04/03/23 - 04/10/23), the DON said that the assigned nurse did the wound care but forgot to initial the TAR. The DO [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Residents #1) of five residents reviewed for quality of care. The facility failed to provide necessary care and services to Resident #1 following a change in condition. Resident #1 was identified on 02/05/21 with facial drooping, possible paralysis of the right side, swelling of her right extremity and on 02/08/21 with difficulty speaking. The facility notified the physician of the swelling but did not seek any additional treatment for [REDACTED]. Resident #1 was sent to the hospital on [DATE] at the family's request where she was diagnosed with [REDACTED]. This failure could place residents at risk for not receiving treatment for [REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS), dated [DATE], reflected the resident was an [AGE] year-old-female admitted to the facility on [DATE]. The resident was cognitively impaired and had diagnosed including: [DIAGNOSES REDACTED]. Review of Resident #1's Progress notes reflected the following entries: 1/22/21 4:06 PM Note Text: resident tested for covid 19 with a positive result. 1/28/21 5:57 PM Note Text: resident has been transferred to regular floor post covid 19 negative result per facility protocol in stable condition. 02/06/21 11:20 AM Note Text: Resident noted with swelling to right middle finger, no discoloration noted, resident denies pain, Dr notified gave order for right hand x ray, order noted and carried out, responsible party notified. 2/7/21 9:03 PM Note Text: Resident alert, responsive skin warm to touch denies pain at this moment took all her meds and tol well, on monitoring for rt hand swelling no discoloration noted . 02/09/21 2:47 PM Note Text: Resident alert and oriented x1 to name only, resting quietly in bed with eyes open, no change in mental condition, unable to voice needs, per daughter's request she wants mom to be sent to Hosp (hospital) for stroke evaluation, 911 Paramedics called, transported resident via stretcher and Ambulance to Hosp . Review of Resident #1's Care Plan, dated 01/27/21, reflected Resident has difficult(y) in making self-understood and in understanding other(s) r/t (related to) Alzheimer's, Dementia. The resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia .The resident is at risk (for a) communication problem r/t Hearing deficit, HOH (hard of hearing) Review of Nurse Assessments for Resident #1 reflected: 2/1/21 LVN F documented the resident had clear speech, was understood, and had no neurological issues. 2/2/21 RN G documented the resident had clear speech, was understood, and had no neurological issues. 2/3/21 RN G documented the resident had clear speech, was understood, and had no neurological issues. 2/4/21 RN G documented the resident had clear speech, was understood, and had no neurological issues. 2/6/21 LVN F documented the resident had clear speech, was understood, and had no neurological issues. 2/9/21 RN G documented the resident did not speak, was rarely understood and did not have any neurological issues. An interview on 02/11/21 at 2:25 PM with Resident #1's family member revealed she visited the resident at the facility on 02/05/21 at approximately 10:00 AM. The resident's right hand was swollen and was hanging down by the side of her wheelchair. Her hand was cold and was swollen up her wrist and up her arm. The family member said she kept asking the resident what had happened, but the resident did not respond and would only look at the family member instead of attempting to answer. The resident would not move her right arm which was unusual. The family member said a CNA, unknown name, entered the room and noticed the side of the resident's mouth was also drooping. The family member said the drooping did not look bad to her. The CNA told the family member she would let the nurse know about the findings. An interview on 02/09/21 at 11:10 AM with another family member of Resident #1 revealed she visited the resident on 02/08/21 and noticed the resident was slumped over in her wheelchair and that the resident appeared to have had a stroke with the inability to move her right foot and an injury of unknown origin to her right arm. The resident also could not talk and had drooping to the left side of her mouth . She said she did not notify the facility about her observations, but thought she might have had a stroke. An observation of Resident #1 on 02/09/21 at 9:55 AM revealed the resident was lying in bed asleep. She was in high fowler's position (head of bed elevated as high as possible and upper half of the body is between 60 degrees and 90 degrees in relation to the lower half of the body), leaning towards her left side and she had facial drooping on the left side of her face. She did not wake up when spoken to. A follow-up observation and interview of Resident #1 with LVN A on 02/09/21 at 11:40 AM revealed the resident was still lying in bed, high fowler's position, and was still asleep. The resident's heels were flat on the bed and her toes were visible. The resident still had facial drooping on the left side of her face. LVN A said the resident had a history of [REDACTED]. CNA B and CNA C were changing the resident out of her hospital gown and into a personal shirt. CNA B said the resident's right arm was swollen and that it did not look that way earlier in the shift on 02/09/21. She also said the resident was not moving her right arm. The right forearm and right hand were swollen, and the resident did not move her right arm or right leg as the staff repositioned her. She was able to move her left arm and left leg. LVN A was asked by the surveyor if the resident had an x-ray of her arm and he said he did not know. The resident was not able to speak but did mumble words that were not able to be understood. An interview on 02/09/21 at 12:15 PM with LVN D revealed she provided care to Resident #1 prior to her transfer to the COVID unit and she had a left-sided facial droop at that time. An interview on 02/09/21 at 1:00 PM with the DON revealed Resident #1 did not have a change in condition and she did not think the resident had left-sided facial drooping. She said the resident leaned to her left side and had been that way for a long time. She said the resident had an x-ray of her right arm that showed she had [MEDICAL CONDITION], but that the DON had not looked at the resident's arm. An interview on 02/09/21 at 1:20 PM with CNA E revealed Resident #1's left side of her face was puffy and drooping and that it was a new observation. She said she had reported it to the nurse on either 02/02/21 or 02/03/21. A follow-up interview with the DON on 02/09/21 at 2:20 PM revealed Resident #1 had a decline after leaving the COVID unit. The DON was asked why the nurse assessments indicated the resident was alert to self, verbal, able to understand and make self-understood. She said the assessment documentation was not accurate and that she would need to discuss the assessments with LVN F and RN G. An interview and observation with the DON and Administrator on 02/09/21 at 2:45 PM revealed Resident #1 was being transferred to the hospital per the family's request. The Surveyor asked the Administrator if she was aware of the resident's symptoms of a possible stroke that included a left-sided facial droop and inability to move her right arm and right leg. The Administrator said she was not aware that Resident #1 had a change in condition. The DON entered the room and made the comment that the resident did not have a stroke. Review of the hospital records for Resident #1, dated 02/09/21 reflected, Imaging tests reviewed by the Neurologist, dated 02/10/21, On my review, there is an evolving lacunar infarct (stroke) in left periventricular white matter, appears 3-7 days old in my best estimate .She presented outside the window for any [MEDICAL CONDITION] or [MEDICATION NAME] procedure. The hospital records indicated Resident #1's date of death was 02/20/21. An interview on 02/10/21 at 9:50 AM with the DON revealed the resident did not return to the facility on [DATE], but she did not know why. The Surveyor asked the DON if she thought the resident had a stroke and the DON said, Typically, if you have a stroke you have symptoms, so I doubt she had a stroke. An interview on 02/10/21 at 2:00 PM with RN G revealed she had not noticed anything different with Resident #1 and that her facial drooping was not unusual. She said the resident was never verbal and never moved her extremities. She said she was able to nod her head to answer questions. The Surveyor asked RN G why she had documented on 02/04/21 that the resident had clear speech and could be understood. She said she was just trying to complete her documentation and did not pay attention to the details like she should have. An interview on 02/10/21 at 4:10 PM with LVN H revealed she provided care to the resident while she was in the COVID unit and at that time she did not have facial drooping but did require total assistance to eat. An interview on 02/11/21 at 1:45 PM with LVN F revealed he worked the weekend of 02/06/21 - 02/07/21 and that Resident #1's family member called and reported the resident's right hand had swollen fingers and had observed it on Friday, 02/05/21. He said she did not have facial drooping over the weekend and he did not know if she was able to move her extremities. An interview on 03/04/21 at 1:15 PM with RN I revealed he provided care to Resident #1 on 02/05/21. He said the CNA, unknown name, reported the resident had a droop to the left side of her face and she was leaning to her left side. He said he sat her up in the bed and the drooping was gone. He said she did not have any weakness in her extremities at that time when he did her neurological exam and she did not have any swelling in her arm. An interview on 03/04/21 at 9:25 AM with the DON and ADON revealed Resident #1 was always non-verbal but did have a decline after she left the COVID unit. The ADON said she did not assess the resident on 02/09/21 and was not aware the resident had been diagnosed with [REDACTED]. They said it would not have been possible for the nurses to do neurological assessments with the resident because she was cognitively impaired and unable to perform range of motion exercises. The ADON said she did not think she had discussed the resident's health decline with the family following her [DIAGNOSES REDACTED]. An interview on 03/04/21 at 2:00 PM with the Facility Physician for Resident #1 revealed he knew about her having swelling in her right arm, but was not aware of any other issues with the resident. Review of the facility's policy and procedure titled Quality of Care, revised January 2020 reflected: Policy Statement Quality of care is the extent to which our health care services provided to residents improve desired health outcomes. Our healthcare must be safe, effective, timely, efficient, equitable, and individual - centered care.

Based on interview and record review, the facility failed to ensure residents were free of accident hazards and received adequate supervision and assistive devices to prevent accidents for one (Resident #6) of three residents reviewed for accidents and supervision. 1. The facility failed to ensure the necessary level of assistance and supervision was provided to safely shower Resident #6. On 09/24/19, CNA G left Resident #6 unattended in the shower room resulting in Resident #6 falling and subsequently sustaining a [MEDICAL CONDITION] hemural neck and left femoral neck. 2. LVN I and CNA G failed to keep Resident #6 on the floor and not move her after she sustained an injury to her arm and her leg. This failure placed residents at risk of not receiving the appropriate level of assistance and supervision with the potential for falls and/or injuries. Findings included: 1. Review of Resident #6's admission record, date 0[DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 6's quarterly MDS assessment, dated 12/29/19, reflected a BI[CONDITION] score of 10 which indicated the resident had moderately impaired cognition. She required extensive physical assistance of two or more persons with bed mobility, transferring, dressing and toilet use. She required extensive physical assistance of one person with personal hygiene. Review of Resident #6's care plan reflected the following: -resident was at risk for fall r/t to unsteady gait; -resident had the need of extensive care to total care from staff for care; -resident is at risk of ADL (bathing, hygiene, dressing, grooming) deficit r/t weakness, cognitive impairment-dementia Review of Resident #6's Fall Risk Assessment, dated 09/24/19, reflected a score of 18 which indicated she was a high risk for falls. Review of the facility's Provider Investigation Report, completed by the DON on 09/30/19, reflected aide left resident in shower room alone for 2mins. Resident was found down in shower room floor between wheelchair and shower chair. Nurse entered shower room after being called by aide. Nurse did her head/toe, no skin tears or bruising found. Resident was able to move all extremities but experienced pain when moving arm and leg. Nurse asked if she hit her head, Res stated 'No, just my arm.' Assisted to chair by staff. V/S taken. Informed manager, family, and MD.Gave pain meds. Xrays ordered stat, Xray showed fractures. MD, family and facility notified. Res sent to nearest ER. Safe Surveys were done to determine if any staff member has left them.in shower room alone. Investigation Summary: Statements taken from all staff on 300 hall. Viewed camera of aide during this time. Aide assisted res to shower room. Aide stepped out of shower room for 2 min. to get gloves. Interviewed aide and she admitted stepping out of shower room leaving res. alone in shower room. Aide was suspended pending investigation. Provider Action Taken Post-Investigation reflected aide was terminated from her job. Performed inservice training on giving showers protocol, never leave res. alone in shower room, gathering all supplies before entering shower room, never turn your back on res. In the shower room, abuse/neglect. Made a shower check list for showers. Made laminated sign in shower room as a reminder to gather all supplies before beginning. The findings were confirmed. Review of Resident #6's Radiology Report, dated 09/24/19, reflected .Conclusion: acute fracture involving left humeral neck with moderate angulation and displacement .Conclusion: acute left femoral neck fracture with modest angulation and displacement. Review of Resident #6's Nurses Notes, written by LVN I, reflected the following: On 09/24/2019 at 18:40 This nurse was called into resident's shower room. As i entered the shower room i was able to see the resident laying on her left side. Resident's wheelchair was behind her and the shower chair was located in front of her. This nurse assessed resident from head to toe. No skin tears or bruising found. Resident was able to move all extremities but was having difficulties and experiencing pain when moving her left arm and left leg. This nurse asked resident if she hit her head when she fell , resident stated no, just my arm. Resident then was helped to a sitting position by this nurse and a CNA. Medication aid held the shower chair while this nurse and the CNA helped resident to the shower chair.Vitals were assessed BP 138/74, P [AGE], T 98.0, RR 20, O2 95% at room air. this nurse then informed resident's charge nurse, ADON, DON and MD. Orders received for x-ray to affected side. Review of Resident #6's Incident Report, dated 09/24/19, reflected LVN I was called to the shower room by a CNA. As she stepped into the shower room she was able to see the resident lying on her left side. Resident #6's wheelchair was behind the resident and shower chair was in front of resident. LVN I assessed the resident from head to toe. No skin tears or bruising found. Resident was able to move all extremities but was having difficulties and pain when moving her left arm and leg. LVN I asked the resident if she hit her head when she fell , the resident stated no, just my arm. Resident #6 was then helped to a sitting position by LVN I and CNA G. The resident was then helped to the shower chair. Vitals were assessed. Resident #6's pain level of 4. Interview on 01/31/20 at 1:06 p.m. with CNA G revealed she was getting Resident #6 in the shower. She noticed she did not have gloves. She stated she stepped across the hall to get gloves and by that time she heard Resident #6 yell. She ran back into the shower room and saw Resident #6 on the floor on her side. She stated she hollered down the hall for the nurse and LVN I came in immediately. LVN I assessed Resident #6 and Resident #6 said she was not hurting and wanted to get up off the floor. She and LVN I then assisted Resident #6 from the floor, she gave Resident #6 a shower then assisted Resident #6 into bed. She stated she did not think LVN I administered pain medications to Resident #6 because Resident #6 did not complain of pain. She stated she went to check on Resident #6 45 minutes to an hour later and Resident #6 stated she had pain in her arm and was holding her arm. She then reported to the nurse who went in, assessed Resident #6 and administered pain medications. Interview on 01/31/20 at 3:22 p.m. with LVN I revealed she was called into the shower room by CNA G. When she arrived in the shower room, she saw Resident #6 lying on the floor with her unlocked wheelchair behind her. She completed a head to toe assessment and during the assessment she could tell Resident #6 was in a lot of pain and had facial grimacing. During the range of motion assessment she noticed Resident #6 had weakness on her left side and did not want to move her left leg. She stated Resident #6 complained of pain to her left leg and left arm. After the assessment, she and CNA G assisted Resident #6 into her wheelchair and she went to the nurses station to contact the doctor to request for x-rays. Resident #6 was assisted back into her wheelchair and taken to her room. She did not check on the resident anymore after the fall. She stated she could tell the resident was in a lot of pain. Interview on [DATE] at 8:58 a.m. with the DON revealed CNA G took Resident #6 into the shower room to take a shower. CNA G stepped out and left Resident #6 in the shower room by herself. Resident #6 had dementia. When CNA G returned to the shower, Resident #6 was on the floor. The DON stated LVN I and CNA G went in, assessed Resident #6 and assisted her off the floor. X-rays were completed and showed a fracture. CNA G was immediately suspended. The facility had an in-service regarding having all items for showering before taking resident in the shower room and not leaving residents alone in the shower room the week before, in which CNA G was in attendance. The cameras were reviewed and showed CNA G assisting Resident #6 into the shower room, walking out of the shower room, and returning two minutes later. A chart was setup for Resident #6, every time staff gave a shower they had to complete a check off list to make sure they had all the necessary supplies. There were also signs in the shower rooms not to leave residents alone. Another set of in-services were conducted following the incident regading not leaving residents alone in the shower and having all items for showering before taking residents in the shower room. The DON did not say an in-service was completed regarding what to do when a resident was injured/not injured. The DON stated the nurses were to first assess the resident for injury. She stated if residents showed grimacing or complaints of pain, the nurses were to call 911 immediately. She stated to let the resident lay there until 911 arrives and administer pain medications. She stated if a resident did not have grimacing or complain of pain, it was ok for staff to assist resident from the floor. She stated this was standard for nursing care. Review of CNA G's personnel file reflected a Separation Report, dated [DATE]. The Separation Report reflected CNA G's last work day was on 09/25/19. CNA G was involuntarily terminated for job performance and policy violation. CNA G was not eligible for rehire. Interviews conducted on 01/07/20 at 10:30 a.m.-11:30 a.m. through [DATE] at 9:45 a.m.-5:00 p.m. with seven CNA's revealed staff indicated comprehension of the training regarding the shower protocol, never leaving residents alone in the shower room, gathering all supplies before entering the shower room, and never turning their backs on residents while in the shower room. Competency was established and there were no noted concerns with the training. Review of the How to Shower Correctly, Do Not Leave Resident Alone in Shower in-service, dated 09/20/19, reflected CNA G was in attendance. Review of the facility's Shower/Tub Bath policy, revised October 2010, reflected .2 .Never leave the resident unattended in the tub or shower. Review of the facility's Assessing Falls and Their Causes policy, revised October 2010, reflected .Steps in the Procedure After a Fall: .3. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details.

Based on interview and record review, the facility failed to ensure pain management was provided consistently with professional standards of practice, the comprehensive person-centered care plan, and in accordance with goals and preferences for one (Resident #6) of three residents reviewed for pain. The facility failed to provide timely pain management for Resident #6. Resident #6 complained of pain to her left arm and left leg after a fall that resulted in fractures. Resident #6 did not receive interventions to manage the pain for 1 hour and 15 minutes. This failure could affect residents by placing them at risk for prolonged, uncontrolled pain and discomfort. Findings included: Review of Resident #6's admission record, dated 0[DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 6's quarterly MDS assessment, dated 12/29/19, reflected a BI[CONDITION] score of 10 which indicated the resident had moderately impaired cognition. She required extensive physical assistance of two or more persons with bed mobility, transferring, dressing and toilet use. She required extensive physical assistance of one person with personal hygiene. Review of Resident #6's September 2019 Order Summary Report reflected [MEDICATION NAME] [MED] Tablet 50mg, give 1 tablet by mouth every 6 hours as needed for pain. Review of the facility's Provider Investigation Report, completed by the DON on 09/30/19, reflected the incident occurred on 09/24/19 at 6:40 p.m. Aide left resident in shower room alone for 2mins. Resident was found down in shower room floor between wheelchair and shower chair. Nurse entered shower room after being called by aide. Nurse did her head/toe, no skin tears or bruising found. Resident was able to move all extremities but experienced pain when moving arm and leg. Nurse asked if she hit her head, Res stated No, just my arm. Assisted to chair by staff. V/S taken. Informed manager, family, and MD.Gave pain meds. Xrays ordered stat, Xray showed fractures. MD, family and facility notified. Res sent to nearest ER. Safe Surveys were done to determine if any staff member has left them.in shower room alone. Investigation Summary: Statements taken from all staff on 300 hall. Viewed camera of aide during this time. Aide assisted res to shower room. Aide stepped out of shower room for 2 min. to get gloves. Interviewed aide and she admitted stepping out of shower room leaving res. alone in shower room. Aide was suspended pending investigation. Provider Action Taken Post-Investigation reflected aide was terminated from her job. Performed inservice training on giving showers protocol, never leave res. alone in shower room, gathering all supplies before entering shower room, never turn your back on res. In the shower room, abuse/neglect. Made a shower check list for showers. Made laminated sign in shower room as a reminder to gather all supplies before beginning. The findings were confirmed. Review of Resident #6's Incident Report, dated 09/24/19 at 18:40, reflected LVN I was called to the shower room by a CNA. As she stepped into the shower room she was able to see the resident laying on her let side. Resident #6's wheelchair was behind the resident and shower chair was in front of resident. LVN I assessed the resident from head to toe. No skin tears or bruising found. Resident was able to move all extremities but was having difficulties and pain when moving her left arm and leg. LVN I asked the resident if she hit her head when she fell , the resident stated no, just my arm. Resident #6 was then helped to a sitting position by LVN I and CNA G. The resident was then helped to the shower chair. Vitals were assessed. Resident #6's pain level of 4. Interview on 01/31/20 at 1:06 p.m. with CNA G revealed she was getting Resident #6 in the shower. She noticed she did not have gloves. She stated she stepped across the hall to get gloves and by that time she heard Resident #6 yell. She ran back into the shower room and saw Resident #6 on the floor on her side. She stated she hollered down the hall for the nurse and LVN I came in immediately. LVN I assessed Resident #6 and Resident #6 said she was not hurting and wanted to get up off the floor. She and LVN I then assisted Resident #6 from the floor, she gave Resident #6 a shower then assisted Resident #6 into bed. She stated she did not think LVN I administered pain medications to Resident #6 because Resident #6 did not complain of pain. She stated she went to check on Resident #6 45 minutes to an hour later and Resident #6 stated she had pain in her arm and was holding her arm. She then reported to the nurse who went in, assessed Resident #6 and administered pain medications. Review of Resident #6's Nurses Notes, written by LVN I, reflected the following: On 09/24/2019 at 18:40 This nurse was called into resident's shower room. As i entered the shower room i was able to see the resident laying on her left side. Resident's wheelchair was behind her and the shower chair was located in front of her. This nurse assessed resident from head to toe. No skin tears or bruising found. Resident was able to move all extremities but was having difficulties and experiencing pain when moving her left arm and left leg. This nurse asked resident if she hit her head when she fell , resident stated no, just my arm. Resident then was helped to a sitting position by this nurse and a CNA. Medication aid held the shower chair while this nurse and the CNA helped resident to the shower chair.Vitals were assessed BP 138/74, P [AGE], T 98.0, RR 20, O2 95% at room air. this nurse then informed resident's charge nurse, ADON, DON and MD. Orders received for x-ray to affected side. Interview on 01/31/20 at 3:22 p.m. with LVN I revealed she was called into the shower room by CNA G. When she arrived in the shower room, she saw Resident #6 lying on the floor with her unlocked wheelchair behind her. She completed a head to toe assessment and during the assessment she could tell Resident #6 was in a lot of pain and had facial grimacing. During the range of motion assessment she noticed Resident #6 had weakness on her left side and did not want to move her left leg. She stated Resident #6 complained of pain to her left leg and left arm. After the assessment, she and CNA G assisted Resident #6 into her wheelchair and she went to the nurses station to contact the doctor to request for x-rays. Resident #6 was assisted back into her wheelchair and taken to her room. She did not check on the resident anymore after the fall. She stated she was able to tell Resident #6 was in a lot pain but she did not give her pain medications because she did not have the keys to Resident #6's nurse cart. She stated she could have checked Resident #6's chart for any medications or asked Resident #6 if she wanted [MED]. Review of Resident #6's Radiology Report, dated 09/24/19, reflected .Conclusion: acute fracture involving left humeral neck with moderate angulation and displacement .Conclusion: acute left femoral neck fracture with modest angulation and displacement. Review of Resident #6's Nurses Notes, written by LVN J, reflected the following: On 09/24/2019 at 22:43: resident is alert and oriented X 1-2. resident VS and LOC within normal limit. resident c/o left shoulder and hip pain post fall. RUE and RLE ROM is greater than LUE and LLE. resident slightly able to move her right shoulder and left lower extremities. Physician K notified. New X-ray on right shoulder and hip. order in place. resident, DON and ADON notified. pending x-ray result at this time. administer PRN pain medication and place ice bag on right shoulder. resident encourage to use the call light for any assistance and prior to transfer. resident in bed without any abdominal, cardic, or respiratory distress at this time. bed in low position and call light within reach. Interview on 01/31/20 at 3:00 p.m. with LVN J revealed he was Resident #6's nurse. At the time of the incident he was off campus on break. He received a text from LVN I around 6 something stating that a resident had fallen. When he returned to the facility, he went to check on Resident #6 who was already in the bed. He completed a head to toe assessment. Resident #6 had pain to her shoulder and was unable to move her upper left extremities. Resident #6 was holding her arm and leg. He stated her shoulder was swollen. An ice bag was placed on her shoulder and he administered her prn pain medications between 7:30 PM-7:45 PM. He stated when he spoke with LVN I regarding the incident, LVN I told him Resident #6 did not have pain, but discomfort. He stated Resident #6 did not like to complain of pain so if you asked her about pain, she would just say discomfort. Review of Resident #6's Nurses PRN Notes reflected [MEDICATION NAME] [MED] 50mg was administered on 09/24/19 at 7:55 p.m. for complaints of right shoulder pain. Resident #6 had a pain level of 4. Review of Resident #6's Medication Administration Record [REDACTED]. A pain level of 4 out of 10 was documented by LVN J on the MAR/TAR. This was the only time and date in September 2019 that she received [MEDICATION NAME] for pain. The form was blank and there was no information pertaining to the resident having pain prior to the incident. Interview on 01/31/20 at 9:48 a.m. with the DON revealed her expectations were for the nurses to assess the residents. If the resident complains of pain and there was an order for [REDACTED]. The DON stated nurses should check an hour later for the effectiveness of the medications. She stated if a resident was in a pain, administering pain medications should be their top priority. She stated residents were not sent out to the hospital unless an x-ray was completed and resulted. Review of the facility's undated Pain Management policy reflected .2. Every guest will be assessed for pain using the pain scale 1-10. For non-verbal guests check vital signs and/or grimacing. Recheck pain in one hour for effectiveness .