St. Joseph Manor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #2) reviewed for parenteral fluids The facility failed to ensure Resident #2's PICC line dressing was changed per physician orders. This failure could place residents with PICC line dressing at risk for potential infections.Findings included: Review of Resident #2's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Staphylococcal arthritis, left knee, (infection of knee joint) sepsis (occurs when your immune system has a dangerous reaction to an infection) and methicillin susceptible staphylococcus aureus infection. Review of Resident #2's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to have the administration of IV medications. Review of Resident #2's comprehensive care plan reflected a focus area dated 08/15/2025 for Resident is receiving intravenous (IV) medication for acute treatment. Interventions included .monitor IV site every shift for signs of infiltration (leaking into the skin) . Review of Resident #2's consolidated physician orders dated 09/04/2025 reflected an order dated 08/15/2025 to change PICC line dressing every week and PRN. Review of Resident #2's TAR dated 08/2025 reflected an entry to change Resident #2's PICC line dressing every week. The dressing change was due 08/31/2025 and it was signed off as done by LVN B. Observation and interview on 09/04/2025 at 2:00 pm revealed Resident #2 in room in bed. Observation of PICC line dressing revealed it was dated 08/24/2025, with no signs of infection. Resident #2 stated the site did not hurt, and she stated she did not know when the dressing was changed last. In an interview on 09/04/2025 at 3:30 PM the DON stated after review of Resident #2's TAR that Resident #2's PICC line dressing change was signed off as completed on 08/31/2025 by LVN B. The DON stated LVN B obviously did not change the dressing if the dressing was dated 08/24/2025. The DON stated it was not appropriate to sign off on doing a treatment and not completing the task and it was her expectation that PICC line dressing be changed per MD orders to prevent infections. The DON provided LVN B's phone number and stated she would probably not answer because she was out of the country. Attempt to contact LVN B on 09/04/2025 at 3:45 PM revealed no answer and no voicemail on phone number provided. Review of the facility policy peripheral and midline IV dressing change dated 03/2022 reflected This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised Maintain sterile dressing (transparent semi-permeable membrane dressing or sterile gauze) for all peripheral catheter sites. Change the dressing if it becomes damp, loosened or visibly soiled and: at least every 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1of 4 resident reviewed for pharmacy services. (Resident #213)<BR/>The facility failed to ensure Resident #213 ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. <BR/>These failures could place residents at risk for not receiving medications as prescribed and a decline in health status <BR/>Findings included:<BR/>Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. <BR/>Record review of Resident #213's comprehensive care plan dated 03/21/24 reflected he had the potential for nutritional problem and was provided medication supplements including Thiamine. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs and symptoms of malnutrition through review date. The interventions included: Obtain and monitor lab/diagnostic work as ordered. Report results to my physician and follow up as indicated.<BR/>Record review of Resident #213's admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 had no behaviors or refusal of care. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Ergocalciferol Oral Capsule 1.25mg to be given every week on Wednesday dated 03/20/25. The order summary report also showed an order for Thiamine 100mg 1 tablet to be given 1 time daily dated 03/20/25. <BR/>Record review of the Medication Administration Record for March 2025 reflected Resident #213 did not receive his Thiamine and his Ergocalciferol because the medication was on order. <BR/>During an observation and interview of medication pass on 03/26/25 at 10:35am MA E prepared Resident #213's medications except the Thiamine and Ergocalciferol. MA E stated those medications were not available. She proceeded to administer his medications and document the medications that were not given were on order. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility for 1 year. She stated she has received training related for medication administration from her ADON and DON. The MA stated that she had reported to the charge nurse that Resident #213 was out of his Thiamine medication and his Ergocalciferol . She stated she was not sure why the medications had not come into the facility yet. She stated not having medication available to resident could lead to not being able to treat their diseases appropriately. <BR/>In an interview on 3/27/25 at 10:11am with LVN C she stated she was never told that Resident #213 was out of his medication or did not have it available. LVN C stated verbally the nurses and Medication aides give report to each other and communicate on medications needed. She stated the medication aides were encouraged to ask questions, and they do ask questions when they are uncertain about an order. Negative outcomes for Resident #213 not receiving his medications as order included sickness and getting worse disease progression. <BR/>In an interview on 3/27/25 at 11:45am he DON stated he MAs should report all unavailable medications to the nurse . The nurse then would look for the medication. She stated if it was an over the counter the nurse can pull it from the stock medications room. If it is a script the nurse would verify it was not delivered check the order and call the pharmacy. The DON stated the nurse would report all unavailable medications to the DON and doctor. She stated negative effects could include the resident not receiving what medications they need leading to prolonged sickness.<BR/>Surveyor was not provided a policy on medication availability during survey dates of 3/26/25 and 3/27/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of two medication aides (MA E) observed for infection control practices <BR/>MA E failed to sanitize her hand, put on gloves prior to administration of eye drops to Resident #213 on 03/26/25 at 10:30am. <BR/>This failure could place residents at risk for healthcare associated cross-contamination and infections.<BR/>Findings included:<BR/>Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and Glaucoma (an increased pressure inside the eye). <BR/>Record review of Resident #213's history and physical dated 03/21/25 reflected he had a diagnosis of Glaucoma wore Correction lenses and was prescribed eye drops Timolol Maleate Ophthalmic (eye) Solution 0.5 % (a medication to decrease eye pressure related to glaucoma), Instill 1 drop in both eyes two times a day. <BR/>Record review of Resident #213's in progress admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 visual assessment was not answered. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Timolol Maleate Ophthalmic Solution 0.5 % 1 drop in both eyes two times a day related to Glaucoma. <BR/>Observation on 03/26/2025 at 10:35am revealed, MA E prepared Resident #213's medications, she knocked on the door, entered the room and proceeded to administer Timolol eye drops 1 drop in each eye. MA E did not wash her hands or put on gloves prior to the administering eye drops. MA E did not wash her hands after administration of eye drops. <BR/>In an interview on 03/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated she should have washed her hands and placed gloves on before giving Resident #213 his eye drops. She stated she was just nervous and forgot. She stated not washing your hands could lead to spreading germs and infections. <BR/>In an interview on 03/27/25 at 11:45am the DON stated it was her expectation for staff to wash her hands and apply gloves prior to giving eye drops. She stated staff should wash their hands after removing gloves as well. She stated all staff had been educated on handwashing. The DON stated handwashing was part of the nursing competency check offs annually that was completed by all nursing staff. She stated not washing hands could lead to spreading germs or getting germs from resident to resident.<BR/>Record review of undated facility policy titled Hand Hygiene reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.<BR/>Before performing resident care procedures. <BR/>Record review of undated facility policy titled Infection Prevention and Control Program reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.<BR/>1. <BR/>Standard Precautions:<BR/>a. <BR/>All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.<BR/>b. <BR/>Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.<BR/>c. <BR/>All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.<BR/>d. <BR/>Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.<BR/>e. <BR/>Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 3 residents (Resident #1) reviewed unnecessary drugs. The facility failed to ensure PT/INR laboratory tests (to measure blood clotting time and thus ensure safe blood levels of the anticoagulant, warfarin) were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death.Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference range for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was not in discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects, and the surveyor may not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalUnnecessary Drugs, F-757 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1 (R1) was assessed upon return from the hospital following diagnosis of Coumadin (Warfarin) overdose. Physician was notified, and R1's Warfarin order was discontinued. PT/INR monitoring updated to reflect daily labs per new order.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: R1's care plan updated to include risk for medication-related adverse effects, monitoring for bleeding/bruising, and ongoing INR surveillance.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: Action: Conducted audit of all residents receiving anticoagulants (e.g., Warfarin) to review appropriateness of medication, frequency of PT/INR monitoring, and compliance with physician orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: Reviewed pharmacy consultant reports and prior medication regimen reviews to ensure unnecessary medications were not continued without indication.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 by 12PM Action: The Director of Nursing and the Assistant Director of Nursing will utilize the Clinical Meeting form (includes section for laboratory and diagnostic studies) to list all laboratory studies that were to be drawn that day. The Director of Nursing and the Assistant Director of Nursing will put a check next to the laboratory study once the test is resulted. The Director of Nursing and the Assistant Director of Nursing will then validate that the MAR/TAR reflect accurate documentation that the laboratory study was collected. 3. Measures Put into Place/System Changes to Remove the Immediacy Action: The Director of Nurses was educated on the Side Effects of High-Risk Medications and recognition of adverse effects and High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy. The Director of Nursing will validate understanding of the training material by summarizing the information she was educated on. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 7PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on Side Effects of High-Risk Medications and recognition of adverse effects prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 - 7/10/2025 by 12 noon Action: Facility policies on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy reviewed by VP of Clinical Operations with no changes identified. All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F757, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure laboratory services were provided or obtained to meet the needs of its residents for 1 of 3 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure PT/INR laboratory tests were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference rage for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. i A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was in not discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects and the surveyor did not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalLaboratory Services, F-770 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1's (R1) care plan was immediately updated to reflect enhanced monitoring for signs/symptoms of bleeding, adherence to anticoagulant lab schedules, and dietary precautions. All current lab orders were reviewed, and a daily PT/INR was obtained.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: An audit of all residents receiving anticoagulant therapy (including Warfarin) was completed. Orders were reviewed to ensure that laboratory monitoring, including PT/INR, was in place and being followed. Any discrepancies were corrected immediately. No other residents were identified to have missed required labs.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 8 PM 3. Measures Put into Place/System Changes to Remove the Immediacy Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified, the physician will be notified, and the facility will follow orders. No other laboratory studies were missed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PMAction: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by VP of Clinical Operations and Sr. VP of Operations and no changes are identified as needed at this time.Person(s) Responsible: VP of Clinical Operations and Sr. VP of OperationsDate/Time: 7/9/2025 by 10PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated over reviewing scheduled laboratory tests and validating that the lab requisition is completed and placed in the laboratory binder at each of the nursing stations. If the laboratory requisition is not located in the laboratory binder the Charge Nurse is responsible for completing the laboratory requisition immediately and notifying the Director of Nurses. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All educated staff will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 11PM Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing all scheduled clinical labs in daily clinical meeting, Monday thru Friday, to ensure labs that were ordered have been drawn and that results for labs have been received prior to leaving their scheduled shift, that appropriate lab communication to the MD and/or their extender have occurred when labs have been received, and any labs that were scheduled and not drawn will be drawn by the Director of Nursing or the Assistant Director of Nursing immediately and transported to the laboratoryPerson(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F770, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at each shift and check that lab requisitions had been done and labs completed. The binder was for lab services and there was one at the nurse's station. The nurse who received the order wrote the lab order in the binder and then filled out a requisition form. She stated then the lab tech looked at that and determined who to draw labs for. She stated side effects of anticoagulant medicine would be unexplained bruising, pain, bleeding especially, sometimes diarrhea, sometimes shortness of breath. She stated she learned that tongue swelling, and bruising could be an adverse effect. She stated she no longer had any patients receiving warfarin, but if she did, she knew she had to check for side effects every shift. During an interview on 07/11/25 at 09:03 AM, LVN J stated she worked exclusively overnight on the lower level and she was not the nurse for Resident #1 although she did know her. She stated she did not have any residents on warfarin or high-risk anticoagulant. She stated they did in-servicing at the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1of 4 resident reviewed for pharmacy services. (Resident #213)<BR/>The facility failed to ensure Resident #213 ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. <BR/>These failures could place residents at risk for not receiving medications as prescribed and a decline in health status <BR/>Findings included:<BR/>Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. <BR/>Record review of Resident #213's comprehensive care plan dated 03/21/24 reflected he had the potential for nutritional problem and was provided medication supplements including Thiamine. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs and symptoms of malnutrition through review date. The interventions included: Obtain and monitor lab/diagnostic work as ordered. Report results to my physician and follow up as indicated.<BR/>Record review of Resident #213's admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 had no behaviors or refusal of care. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Ergocalciferol Oral Capsule 1.25mg to be given every week on Wednesday dated 03/20/25. The order summary report also showed an order for Thiamine 100mg 1 tablet to be given 1 time daily dated 03/20/25. <BR/>Record review of the Medication Administration Record for March 2025 reflected Resident #213 did not receive his Thiamine and his Ergocalciferol because the medication was on order. <BR/>During an observation and interview of medication pass on 03/26/25 at 10:35am MA E prepared Resident #213's medications except the Thiamine and Ergocalciferol. MA E stated those medications were not available. She proceeded to administer his medications and document the medications that were not given were on order. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility for 1 year. She stated she has received training related for medication administration from her ADON and DON. The MA stated that she had reported to the charge nurse that Resident #213 was out of his Thiamine medication and his Ergocalciferol . She stated she was not sure why the medications had not come into the facility yet. She stated not having medication available to resident could lead to not being able to treat their diseases appropriately. <BR/>In an interview on 3/27/25 at 10:11am with LVN C she stated she was never told that Resident #213 was out of his medication or did not have it available. LVN C stated verbally the nurses and Medication aides give report to each other and communicate on medications needed. She stated the medication aides were encouraged to ask questions, and they do ask questions when they are uncertain about an order. Negative outcomes for Resident #213 not receiving his medications as order included sickness and getting worse disease progression. <BR/>In an interview on 3/27/25 at 11:45am he DON stated he MAs should report all unavailable medications to the nurse . The nurse then would look for the medication. She stated if it was an over the counter the nurse can pull it from the stock medications room. If it is a script the nurse would verify it was not delivered check the order and call the pharmacy. The DON stated the nurse would report all unavailable medications to the DON and doctor. She stated negative effects could include the resident not receiving what medications they need leading to prolonged sickness.<BR/>Surveyor was not provided a policy on medication availability during survey dates of 3/26/25 and 3/27/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for medication administration, treatment administration, and wound administration. <BR/>1. <BR/> The facility failed to complete Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. <BR/>2. <BR/>The facility failed to accurately document Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. <BR/>3. <BR/>The facility failed to accurately document Resident #1's Controlled Drug Record for Hydrocodone-Acetaminophen 5-325 MG on 01/20/2025 at 5:00 PM with 58 tablets remaining and next entry on 01/21/2025 at 12:01 AM reflecting 56 tablets remaining,<BR/>4. <BR/>The facility failed to complete Resident #2's Medication Administration Record (MAR) for Lorazepam 0.5 MG for 12/1/2024 thru 12/31/2024 and 1/1/2025 thru 1/31/2025. <BR/>5. <BR/>The facility failed to complete Resident #2's Medication Administration Record (MAR) for Lorazepam 0.5 MG to reflected wrong dose of 2 tablets administered on 4/21/2024 as reflected on Resident #2's Controlled Drug Record for Hydrocodone. <BR/>6. <BR/>The facility failed to accurately document Resident #3's Medication Administration Record (MAR) for Hydrocodone for 04/21/2025 of three doses administered for the day as reflected on Resident #3's Controlled Drug Record for Hydrocodone. <BR/>7. <BR/>The facility failed to follow facility procedures to document a medication error in Resident #1, Resident #2, and Resident #3's electronic medical record, notify the physician, and notify the Resident's Representative. <BR/>This deficient practice placed residents who receive medications, treatments, and wound care from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications, treatment, or wound care due to inaccurate documentation of administration. <BR/>Findings included: <BR/>Review of Resident #1's face sheet reflected a [AGE] year old woman with an initial admission date of 1/17/2025 with diagnoses of cellulitis of abdominal wall, end stage renal disease (a medical condition where the kidneys have permanently lost their ability to function adequately), dependence on renal dialysis, morbid obesity due to excess calories (a medical condition where Body Mass Index (BMI) of 40 or higher), essential (primary) hypertension (a medical condition where a person's abnormally high blood pressure that's not the result of a medical condition), and anemia in chronic kidney disease (a medical condition where a person's blood has a lower-than-normal amount of red blood cells or hemoglobin). <BR/>Review of Resident #1's MDS dated [DATE] reflected a BIMS of 11 and had an active pain management regimen for frequent pain, documented surgical wounds and open lesion(s) other than ulcers, rashes, cuts, and taking antidepressants. <BR/>Review of Resident #1 active orders as of 01/21/2025 reflected resident had order for abdomen wound cleanse for wound healing three times a week with an order date of 01/21/2025. Further review reflected an order for <BR/>Review of 48-hour baseline care plan dated 01/17/2025 reflected resident had pain goal to experience less pain with medications, Norco, Tramadol, Acetaminophen and Pregabalin. Further review reflected resident had a pressure sore/skin at risk goal: prevent/heal pressure sores, resolve skin condition with treatment of Vacuum-Assisted Wound Closure (VAC) (a method of decreasing air pressure around a wound to assist the healing). Additional care plan summary reflected, We will monitor for signs of infection, manage pain, maintain hygiene around the wound .emphasizing the importance of maintaining a clean, airtight seal around the wound to ensure optimal healing with the vacuum therapy .as well as understanding the importance of regular monitoring and not missing treatment days. <BR/>Review of Resident #1 active orders as of 01/17/2025 reflected resident had order for Norco 5-325 MG (narcotic) every 4 hours as need for moderate to severe pain (6-10) for cellulitis of abdominal wall with a start date of 01/17/2025. Further review reflected active orders as of 01/21/2025 for Norco 10-325 MG (narcotic) every 4 hours as needed for pain with a start date of 01/21/2025.<BR/>Review of Resident #1 active orders as of 01/17/2025 reflected resident had order for Pregabalin (narcotic) two time a day for end stage renal disease with a start date of 01/18/2025. <BR/>Review of Resident #1 active orders as of 01/18/2025 reflected resident had order for tramadol (narcotic) every 8 hours as needed for pain (PRN) with a start date of 01/18/2025. Further review reflected active orders of 01/22/2025 for tramadol (narcotic) three times a day for cellulitis of abdominal wall with a start date of 01/22/2025. <BR/>Review of Resident #1 active orders as of 01/18/2025 reflected resident had order for abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 125 one time a day three times a week for wound healing with a start date of 01/20/2025. Further review reflected active orders as of 01/21/2025 reflected resident had order for abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 150 one time a day three times a week for wound healing with a start date of 01/22/2025.<BR/>Review of Resident #1 active order as of 01/22/2025 reflected resident had order for left groin cleanse wound with NS/wound cleanser Primary Dressing: Calcium Alginate, Santyl Secondary Dressing: ABD pad Secure with: tape as needed one time a day for wound healing with a start date of 01/22/2025. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected tramadol every 8 hours PRN had no administration entries. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected tramadol three times a day was administered once on 01/22/2025, three times on 01/23/2025 to 01/30/2025, and once on 01/31/2025. <BR/>Review of Resident #1 Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 125 for January 2025 reflected no order data found. Further review reflected Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 150 for January 2025 reflected no order data found.<BR/>Review of Resident #1 Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected left groin cleanse wound with NS/wound cleanser Primary Dressing: Calcium Alginate, Santyl Secondary Dressing: ABD pad Secure with: tape for January 2025 reflected no order data found.<BR/>Review of Resident #1 Medication Administration Record (MAR) reflected Norco 5-325 MG (Hydrocodone-Acetaminophen) was administered on 01/20/2025 at 9:03 AM with pain level of 3 and 01/20/2025 at 5:50 PM with pain level of 3. Further review of Resident #1 Medication Administration Record (MAR) reflected Norco 10-325 MG (Hydrocodone-Acetaminophen) was administered on 01/21/2025 at 12:48 PM, 01/21/2025 at 11:37 PM, 01/22/2025 at 7:54 AM, 01/22/2025 at 1:56 PM, 01/23/2025 at 2:09 PM, 01/25/2025 at 6:33 AM, 01/26/2025 at 9:10 AM, and 01/28/2025 at 6:54 AM. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected Pregabalin was administered on twice on 01/19/2025, twice on 01/20/2025, twice on 01/21/2025, twice on 01/22/2025, twice on 01/23/2025, twice on 01/24/2025, twice on 01/25/2025, twice on 01/26/2025, twice on 01/27/2025, twice on 01/28/2025, twice on 01/29/2025, twice on 01/30/2025, twice on 01/31/2025. <BR/>Review of Resident #1 Controlled Drug Record reflected tramadol every 8 hours (three times) was administered once on 01/21/2025, once on 01/22/2025, three times on 01/23/2025 to 01/24/2025, twice on 01/25/2025, once on 01/26/2025, and once on 01/27/2025 with 18 tablets remaining. <BR/>Review of Resident #1 Controlled Drug Record reflected Pregabalin was administered on twice on 01/19/2025, twice on 01/20/2025, twice on 01/21/2025, twice on 01/22/2025, twice on 01/23/2025, twice on 01/24/2025, twice on 01/27/2025, and once on 01/28/2025 with a remaining capsule amount of 45. <BR/>Review of Resident #1 Controlled Drug Record reflected Hydrocodone-Acetaminophen 5-325 MG was administered on 01/20/2025 at 9:00 AM with 59 tablets remaining, 01/20/2025 at 5:00 PM with 58 tablets remaining, 01/21/2025 at 12:01 AM with 56 tablets remaining, 01/21/2025 at 7:00 AM with 55 tablets remaining, 01/21/2025 at 6:00 PM with 54 tablets remaining, 01/21/2025 at 11:48 PM with 53 tablets remaining, 01/22/2025 at 6:00 AM with 52 tablets remaining, 01/22/2025 at 8:00 AM with 50 tablets remaining, and 1/22/2025 at 12:00 PM with 48 tablets remaining. <BR/>Review of Resident #1 Controlled Drug Record reflected Hydrocodone-Acetaminophen 10-325 MG was administered on 01/23/2025 at 2:00 PM with 29 tablets remaining, 01/25/2025 at 6:00 AM with 28 tablets remaining, 01/26/2025 at 10:00 AM with 27 tablets remaining, and 01/28/2025 at 6:55 AM with 26 tablets remaining. <BR/>Review of Resident #2's face sheet reflected a [AGE] year-old male with an admission date of 03/12/2025 and initial admission date of 07/27/2022 with diagnoses of schizoaffective disorder, bipolar type, unspecified dementia, severe, with psychotic disturbance. <BR/>Review of Resident #2's MDS dated [DATE] reflected a BIMS of 04 and an active diagnosis of schizophrenia, depression, and bipolar disorder. <BR/>Review of Resident #2 active orders as of 05/30/2024 reflected resident had order for Lorazepam 0.5 MG (narcotic) every 4 hours as needed for anxiety with start date of 05/30/2024. <BR/>Review of Resident #2 Medication Administration Record (MAR) for 12/1/2024 thru 12/31/2024 and 1/1/2025 thru 1/31/2025 reflected Lorazepam 0.5 MG had no order data found. <BR/>Review of Resident #2 Controlled Drug Record reflected Lorazepam 0.5 MG was administered three times on 10/16/2024 with 2 tablets administered at 11:30 PM, once on 10/23/2024, once on 10/25/2024, once on 11/12/2024, once on 12/19/2024, and once on 1/21/2025 with 27 tablets remaining. <BR/>Review of Resident #3's face sheet reflected a [AGE] year-old female with an admission date of 01/10/2023 with diagnoses of unspecified dementia (is not specified by a doctor), low back pain, and pain unspecified. <BR/>Review of Resident #3's MDS dated [DATE] reflected a BIMS of 08 and an active diagnosis of unspecified dementia and low back pain, unspecified. <BR/>Review of Resident #3 active orders as of 11/12/2024 reflected resident had order for Hydrocodone 5-325 MG two times a day for pain management with a start date of 11/12/2024. <BR/>Review of Resident #3 Medication Administration Record (MAR) for 04/1/2025 - 04/30/2025 reflected Hydrocodone was administered twice a day from 04/01/2025 thru 04/30/2025. <BR/>Review of Resident #3 Controlled Drug Record reflected Hydrocodone was administered three times on 4/21/2025 with two does at 7:00 PM. <BR/>In an interview on 6/6/2025 at 9:58 AM LPN C stated the procedures of administering medication includes prescribed by physician, right patient, right medication, right dose. She stated if the wrong medication was administered immediately notify doctor of what was administered vs. what should have been administered, report to DON, a medication error report should be filled out, this was a paper form as it requires signatures, but the facility was currently transitioning out of this process. The least there should an incident report on the medication error. LPN C stated she feels there is room for improvement, current process needs to change. She stated she doesn't want to get anyone in trouble, but the current Medication Administration Record (MAR) and narcotic record logs are not being done correctly and this needs to be corrected. This practice could have a serious effect on a resident and their care. <BR/>In an interview on 6/6/2025 at 10:28 AM MA stated the procedures if a medication error occurred is to notify the charge nurse, the nurse notifies the DON, notify the physician, watch the resident for the next 24 hours, do vitals every 3-4 hours and submit an error report to the DON. The DON would then follow-up with staff who made the medication error and provide individual counseling. She stated not notifying the charge nurse of medication errors can have serious consequences for residents and can have serious harm on them. <BR/>In an interview on 6/6/2025 at 11:12 AM LPN B stated if she were to identify a medication error, she would notify the DON and physician, investigate why dose was missed or not given, determine if the resident refused and review resident's record to see if information was documented in progress notes. She stated all medication errors could be harmful to the resident and should always be documented and DON should always be notified. <BR/>In an interview on 6/6/2025 at 1:24 PM DON stated she provides staff with medication administration in-services. She stated she has not had any medication errors reported or documented by staff. She stated medication administration procedures includes the 6 rights - right does, right resident, right time. She stated she has trained staff to make sure delayed medication is not given to resident as this would be a wrong dose. A medication error as such would require staff to contact the nurse practitioner and stated staff have not reported medication errors to her. She stated not following these procedures can pose a safety issue for residents. She stated the narcotics require a Medication Administration Record (MAR) and a count sheet, which helps staff to keep medications counted for, correct times, documenting should be on count sheet and PCC. Reasons for Medication Administration Record (MAR) and count sheet is to ensure safety for residents. She stated that the pharmacist reviews resident's narcotic records. <BR/>In an interview and observation on 6/6/2025 at 2:54 PM DON stated she was unaware prior, but the narcotics that are PRN are separated from the narcotics that are scheduled. DON stated there are two different carts that carry narcotics and scheduled medications separately. She added that there are also different narcotic record count logs for scheduled and for PRN narcotics. She was observed searching through the carts and searching for the narcotic blister packs and narcotic logs for Resident #3. DON was able to locate the narcotic blister packs for both the PRN and scheduled narcotics for Resident #3; however, she was unable to locate the narcotic record logs for discontinued medications and discharged residents are kept. <BR/>In an interview on 6/6/2025 at 3:21 PM ADON stated medication administration timeframe window is one hour before and one hour after, staff is to document Medication Administration Record (MAR) after it is administered. Depending on the medication and orders staff may need to get blood pressure and pulse before administering. ADON stated narcotics documentation of pain scale may be required before and after administering, checking resident vital signs and will not give narcotics if blood pressure and/or pulse is low as respiratory system can be compromised with narcotics. She stated PRN narcotics require follow up. She stated if staff have a medication error they are required to report it to the DON. She stated staff would be required to self-report, make progress notes of medication error on the Medication Administration Record (MAR) and notify physician for directions. She stated she is not aware of any medication errors since her employment with the facility, beginning April 2025. she has been employed at this facility. <BR/>In an interview on 6/6/2025 at 3:37 PM MEDRC stated facility medical records retention policy was 7 years. She stated that she was tasked with locating the records of discharged residents and of discontinued narcotic records and she was unable to locate them. She stated she was not sure what the direct care staff did with these records, and she relies on the DON to submit them to her. <BR/>In an interview on 6/6/2025 at 3:41 PM DON stated she believes the missing narcotic logs are a process issue and the medications were administered as prescribed. She stated she was not aware that she should turn in discharge records or discontinued medication logs to the records staff. <BR/>In a phone interview on 6/6/2025 at 4:35 PM Clinical [NAME] President (CL VP) stated she was working on mapping the current issue onsite regarding medical records. She stated staff are working on producing missing logs. She stated she understands the facility needs to put a new system in place for the facility to ensure this doesn't occur in the future. She stated the current process regarding the retention of narcotic medication count needs to be corrected. She stated the DON should be responsible for the discontinued and discharge narcotic records She also stated staff will be ensuring only one narcotic record log is used for all residents being administered narcotics moving forward. She stated she would be working with the team to include ADM and DON in making these necessary changes to ensure resident safety. <BR/>In an interview on 6/11/2025 at 4:14 PM LPN WC stated the nursing staff have been in-serviced to document all medication administration, treatment administration, and wound care administration in the resident's Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR). If there is any deviation of the administration to notify the charge nurse to take the necessary steps to correct the issue. <BR/>In an interview on 6/12/2025 at 11:55 AM LPN WC B was asked by the DON to help verify wound care documentation that could not be located for Resident #1. LPN WC B stated she was responsible for wound care treatment and left employment at the facility at the end of February 2025. She stated she had documented Resident #1's Treatment Administration Record (TAR), and Wound Administration Record (WAR) with treatments she was given orders for. She stated she also entered progress notes surrounding any wound care treatment provided. LPN WC B stated she worked with the DON to locate these records and she was unsuccessful. She stated there was a lot of tension and friction working here at the facility because her treatment notes would be removed from the medical record. She stated she reported these issues directly to the ADM and DON and believes the Clinical [NAME] President (CL VP) was responsible for editing medical records and removing progress notes, deleting Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR). She believes this was being done only to her entries. She stated she ultimately decided to leave this facility because of these challenges. <BR/>Interview on 6/12/2025 at 12:51 PM DON stated she was familiar with Resident #1's care while she was a resident at the facility. She stated the Resident #1 was receiving wound care treatment and narcotics related to wound care. She stated she has reviewed the full chart for Resident #1, and she has not been able to locate the Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) for the month of January 2025 when she was a resident. She stated she cannot locate any treatment notes provided by LPN WC B. She stated the orders are present and accounted for, but not listed on the Treatment Administration Record (TAR), DON stated that LPN WC B reported wound care treatment to WC PH, but there is no supporting documentation of this progress. DON stated that she believes the wound care treatment was performed and documented, but for some reason the documentation is not accessible. <BR/>Interview on 6/12/2025 at 12:51 PM ADON stated she has been searching through Resident #1's medical records and she is unable to locate the Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) for wound care treatment, and she was not able to locate the narcotic record either. She stated the wound care was provided for Resident #1, but the administration records are not present. <BR/>Interview on 6/12/2025 at 1:41 PM RG RN stated she reviewed Resident #1, Resident #2, and Resident #3'sprogress notes, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) and she is unable to determine why there is documentation missing or not saved in the medical record. She stated there are physician notes to verify treatment and medication orders are present; however, there is no documentation to support the treatment or medication was administered. She stated the missing, incomplete, inaccurate, and unorganized documentation can be a serious problem for the care provided to residents and this is an area that needs to be worked on. She stated staff are being in-serviced on the importance of documenting the administration of medications, treatments, and wound care. <BR/>In an interview on 6/12/2025 at 2:33 PM LPN A stated if he is performing wound care on a new admission the procedure is to follow standing orders if no orders come with the resident. Standing orders include cleaning the wound, putting dressing, putting in orders for treatment, documenting progress notes the treatment provided, entering information on medication, treatment, and wound administration records. He stated the administration records are important to the care of the resident and need to be entered. All staff receive training on the importance of these records. <BR/>Interview on 6/12/2025 at 3:20 PM DON stated she was aware of previous issues with skin concerns and felt it necessary to conduct a full skin sweep of all residents at the facility. This skin sweep was conducted on 6/10/2025. She stated she does believe the wound care treatment was provided to Resident #1 and the ordered medications were administered correctly to Resident #1, Resident #2, and Resident #3 despite the unsporting documentation. DON stated the main issue here is the documentation. She stated staff will get better with documenting their progress, the treatments and medications provided to the residents. She stated the staff have received medication administration in-services within the last 30 days and will continue to in-service on the importance of complete, accurate, and organized documentation. <BR/>In a phone interview on 6/12/2025 at 4:24 PM PCP stated he has been in contact with the ADM and DON regarding Resident #1's missing documentation. He stated the team reached out to him and they were able to complete a QAPI meeting. He stated the team emphasized the wound care was done for the resident and the concern is the wound care wasn't documented as detailed as it should have been. He she the facility now has a wound care nurse that is different and documenting more and staying on top of it. He stated the wound care was getting done, not getting worse, treatment was being done using the standing order process. He understands documenting care was little to none. In his opinion if after seeing the wound if he believed the wound was not getting better or declining, he would have extended the course of antibiotics Resident #1 was on. PCP stated his NP tends to use a standard template, which he has counseled her against. He stated at times the standard template will not fully capture the full visit with the resident. He will remind his NP to not use a template for progress notes as this can get her and the facility into issues. He asked for additional time to review additional medical file to give opinion on. <BR/>In a phone interview on 6/12/2025 at 5:22 PM PCP stated he is a firm believer that just because you provided the care of treatment without it being documented it is as if you didn't perform it. He stated he will stress to the facility and the administration staff the importance of documenting all administration for a resident, they will be in-servicing on this topic, also to include standing orders, what steps to take when a new wound is noticed, automatically documenting the chart. He stated a lot of in-servicing is needed and the staff needs to be better with documenting in PCC. He stated the documentation and records retention for narcotic records needs to be a priority and will also be in-serviced and part of the<BR/>quality assurance and performance improvement (QAPI). He stated that he did speak to the team to include the corporate nurse regarding complete, accurate, and organized documentation in PCC. <BR/>Record review of Medication Administration Policy, reference date 2024 revealed, <BR/>10. Ensure that the six rights of medication administration are followed: <BR/>a. <BR/>Right resident<BR/>b. <BR/>Right drug<BR/>c. <BR/>Right dosage<BR/>d. <BR/>Right route<BR/>e. <BR/>Right time <BR/>f. <BR/>Right documentation <BR/>11. Review Medication Administration Record (MAR) to identify medication to be administered. <BR/>12. Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time. <BR/>20. Sign Medication Administration Record (MAR) after administered. For those medications requiring vital signs, record vital signs on the Medication Administration Record (MAR). <BR/>21. If medication is a controlled substance, sign narcotic book. <BR/>23. Correct any discrepancies and report to nurse manager. <BR/>Record review of Wound Treatment Management Policy, reference date 2019, revealed 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. <BR/>Record review of documented titled, Controlled Drug Receipt/Proof-Of-Use/Disposition form, no date provided, revealed the form provided a reminder to the staff administering medication, Each dose signed for here requires charting on the medication record. <BR/>Record review of the facility's (3) narcotic record logs in use, Controlled Drug Receipt/Proof-Of-Use/Disposition, Controlled Drug Record Individual Patient's Narcotic Record and Controlled Drug Receipt/Proof-Of-Use/Disposition forms, revealed facility staff do not have a uniformed and organized system to record narcotics administered to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 2 (Resident #209 and Resident #212) of 5 residents records reviewed for comprehensive assessment accuracy and timing.<BR/>Resident #209 and Resident #212 did not have completed admission/comprehensive MDS assessments within 14 days following their admissions to the facility.<BR/>This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>Review of Resident #209's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: acute kidney failure, altered mental status, primary osteoarthritis of knee (degenerative joint disease that results from breakdown of joint cartilage and underlying bones), low potassium, hyperosmolality (loss of water fluid).<BR/>Review of Resident #209's MDS summary screen in his EHR on 03/26/25 revealed Resident #209's admission MDS was still in progress. It had an ARD date of 3/24/2025 and was noted as being 2 days overdue. <BR/>Review of Resident #212's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: unspecified dementia, diabetes, sleep apnea (breathing disorder caused by repeated interruptions during sleep), high blood pressure, atrial fibrillation (irregular heart rhythm), congestive heart failure, and gastro-esophageal reflux disease. <BR/>Review of Resident #212's MDS summary screen in his EHR HER on 03/26/2025 revealed Resident #212's admission MDS was still in progress. It had an ARD date of 3/17/2025 and was noted as being 9 days overdue. <BR/>In an interview on 03/27/25 at 09:42 AM with MDS A she stated that the timeframe for submitting admission MDS assessments was within 14 days after admission. She stated that Resident #209 was a long term admit and his was not one she was working on (the MDS B was assigned to work it), she had been the only MDS person employed at the facility until recently, and she had become overwhelmed with new admissions. <BR/>In an interview on 03/27/25 at 10:12 AM with MDS B she stated she started working at the facility on 2/17/2025. She stated that the timeframe for getting an admission MDS assessment submitted was 14 days after admission. She has been trying to orient due to recently starting and was trying to catch up on her workload. <BR/>Review of the MDS's job description dated 2024 reflected, The MDS Coordinator-RN, under the direction of the DON, accurately develops and completes resident MDS assessments and Care Plans to assure compliance with regulatory practices and accurate representation of residents' plan of care to assure superlative care of [Facility] residents. Develops admitting processes, and related financial and reimbursement functions. Accurately and timely completes (MCR, quarterly, annual, and change in condition) resident MDS and LTCMI assessments, participates in weekly Care Plan meeting to represent nursing on the Care Plan team.<BR/>An email request to the ADM on 3/27/2025 at 11:58 AM for a policy on timing for completion of MDS was made by the TC of the survey team. A relative policy on this subject was never received. <BR/>Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 dated last revised October 2024, required OBRA Assessments for the MDS table reflected that the admission (comprehensive) assessment reference date is due no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 3 (Resident #13, Resident #53, and Resident #212) of 12 residents reviewed for care plans.<BR/>The facility failed to develop and implement the comprehensive person-centered care plan for Resident #13's refusal to be weighted monthly. <BR/>The facility failed to develop and implement the comprehensive person-centered care plan for Resident #53's refusal to sit up out of bed at a 90-degree angle during all meals. <BR/>The facility failed to develop and implement the comprehensive person-centered care plan for Resident #212's use of a CPAP machine. <BR/>These failures could place residents at risk for not receiving appropriate care and treatment.<BR/>Findings included: <BR/>Record review of Resident #13's Face Sheet reflected an [AGE] year-old female who was admitted on [DATE] with a diagnosis of Nontoxic Multinodular Goiter (an enlarged thyroid gland with multiple lumps that cause the thyroid to produce too much hormone), Muscle Wasting and Atrophy, Cognitive communication Deficit (difficulty communicating needs and thoughts), and Contracture of Muscle Multiple Sites. <BR/>Record review of Resident #13's Annual MDS dated [DATE], reflected a BIMs score of 15 indicating resident #13 was cognitively intact. The MDS also reflected that Resident #13's weight was dashed out on the MDS. Resident #13 was marked no or unknown for weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. <BR/>Record review of Resident #13's care plan initiated 11/04/24 and updated 12/13/24 reflected Resident #13 had a had a nutritional problem or potential nutritional problem related to disease processes and co-morbidities. Resident #13's goal was to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs or symptoms of malnutrition through the review date. Interventions included on the care plan were monitor report to medical doctor as needed signs and symptoms of malnutrition including emaciation, muscle wasting, significant weight loss (greater than 3 pounds in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months or greater than 10% in 6 months).<BR/>Record review of Resident 13's Progress notes dated 01/27/25 reflected Resident refuses to be weighed, RP and MD aware.<BR/>Record review of Resident 13's Mini Nutrition Evaluation dated 03/06/25 reflected Resident #13 had had no weight loss during the last 3 months. <BR/>Record review of Resident #13's Physicians Order Summary for March 2025 reflected an order to weight monthly unless otherwise noted, dated 09/13/24.<BR/>Record review of Resident #13's Weight Summary Dated March 2025 reflected there were no documented weights since 09/07/24 of 115 pounds. <BR/>Record review of Resident #53's Face Sheet reflected a [AGE] year-old male who was admitted on [DATE] with a diagnosis of Bartons Fracture of Left Radius (left arm fracture), Diabetes Mellitus (elevated blood sugars), Unspecified Protein Calorie Malnutrition, and Dysphagia (difficulty swallowing). <BR/>Record review of Resident #53's PPS MDS dated [DATE], reflected a BIMS score of 08 indicating moderate cognitive impairment. The MDS also reflected that Resident #53s had no symptoms of a swallowing disorder and he was on a mechanically altered diet. <BR/>Record review of Resident #53's care plan initiated 11/23/24 and updated 01/23/25 reflected Resident #53 had a nutritional problem or potential nutritional problem related to multiple injuries after a motor vehicle accident. The goal was for Resident #53 to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs or symptoms of malnutrition through the review date. Interventions included: monitor/document/report as needed any signs or symptoms of dysphagia (pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals). Registered Dietician to evaluate and make diet change recommendations as needed.<BR/>Record review of Resident #53s Active Physicians Orders dated 3/25/25 reflected an order that Resident #53 must be out of bed sitting at a 90-degree angle for all meals dated 12/08/24. <BR/>Record review of Resident #53's Speech Therapy Encounter note dated 12/04/24 reflected Patient seen for dysphagia treatment while seated upright in chair with TLSO brace on. He was very upset to be up in chair and required max cueing and education regarding rehab goals to participate. He refused to self-feed but when bites administered, patient showed good tolerance for po with slow mastication and effective pharyngeal swallow.<BR/>Record review of Resident #53's Speech Therapy Discharge Summary note dated 12/18/24 reflected: Patient initially struggled with motivation to participate but his endurance and participation improved dramatically across the course of treatment, until he was regularly self-feeding while seated upright with brace on and managing a soft bite sized diet without signs or symptoms of aspiration. Resident #53 was discharged with Goals Met.<BR/>Record review of Resident #53's Medication Administration Record for March 2025 reflected Resident #53 refused to be out of bed sitting at a 90-degree angle for all meals on 3/1/25, 3/2/25, 3/9/25, 3/10/25, 3/11/25, 3/13/25, 3/16/25, 3/22/25, 3/23/25. <BR/>In an observation and interview of Resident #53 on 03/25/25 at 12:03pm he was in bed with the head of his bed elevated eating his lunch. Resident #53 stated sitting up in his wheelchair makes him dizzy. Resident #53 denied any difficulty swallowing his food. He stated he does not normally sit up in his chair while he eats. He stated the staff did mention sitting up one time but that was the only time he was offered to sit up for his meal. He stated his head of the bed should be a little higher. Observation of meal reflected it was mechanical soft texture with ground meats. <BR/>Record review of Resident #212's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: unspecified dementia, diabetes, sleep apnea (breathing disorder caused by repeated interruptions during sleep), high blood pressure, atrial fibrillation (irregular heart rhythm), congestive heart failure, and gastro-esophageal reflux disease. <BR/>Record review of Resident #212's care plan initiated 3/04/2025 reflected Resident #212 had congestive heart failure. His interventions included: Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. <BR/>Record review of Resident #212's Active as of 3/04/2025 Physician's Orders reflected an order to observe if Resident #212 exhibits shortness of breath on exertion, shortness of breath at rest, and an order for Albuterol 0.833-0.167mg/ml sol-1 vial every 6 hours as needed for SOB/wheezing. <BR/>In an observation on 03/25/25 at 11:23 AM of Resident #212 he was observed to be exhibiting labored breathing and was using a nebulizer mask. The resident was unable to verbally answer the surveyors' questions due to labored breathing but was able to nod yes or no. A CPAP machine and nebulizer were both observed to be sitting in a chair next to Resident #212's bed. He nodded yes to confirm which was a nebulizer and which was the CPAP. <BR/>In an interview on 03/27/25 at 10:12 AM with MDS B she stated that she started working at the facility on 2/17/2025. She confirmed that Resident #212 had a CPAP and a nebulizer and that he should have an order for both. <BR/>In an interview on 03/27/25 at 10:47 AM with LVN C who was the charge nurse for unit 4, she stated that Resident #212 used the CPAP every night and the nebulizer was to be used prn. She stated that when the residents admit to the facility the nurse on duty or the nurse in the next shift would add the physicians' orders to the residents EHR. She confirmed with the surveyor that an order for a CPAP and an order for a nebulizer machine were not in Resident #212'sEHR , but they just knew the machines were in the resident's room and that he put them on himself and takes them off himself. The resident's FM had recently asked LVN C to find the resident a pulmonologist to get a new CPAP machine, and a new order should be put in the EHR soon. There was no documentation of replacement parts or a cleaning schedule for either machine in the resident's EHR.<BR/>In an interview on 03/27/25 at 11:00 AM with Resident #212's FM revealed that Resident #212 had always used a CPAP machine and the facility was in the process of getting him a new one due to the resident having had the current one for approximately 15 years. He stated that Resident #212 used a nebulizer as well, when needed, and the resident was able to administer them to himself without help from the staff. <BR/>In an interview on 03/27/25 at 11:00am MDS Coordinator A stated care plans should be updated to reflect individual needs. She stated responsibility as an MDS nurse is to care plan the areas that trigger after completion of the MDS. She stated the IDT team was responsible for the compressive care plan. She stated all departments put the residents needs into the care plan. She stated MDS was considered more financial resources instead of clinical. She stated MDS is not 100% responsible for the care plan, it is a collaborative effort amongst everyone. She stated if she were to see a concern with a resident at the time of assessment, she would contact the department head and ask if they would like it to care planned. She stated if a resident was refusing care, it should be care planned. If refusals of care were not care planned it could lead to confusion and not meeting the residents needs and wants. <BR/>In an interview on 3/27/25 at11:45am the DON said the care plan was a collaborative IDT team effort. She stated the MDS nurse initiated the care plan, she stated the department heads meet every day to discuss resident changes, incidents, wounds, and new orders. The DON stated the MDS was responsible for updating the care plan as they see the need . She stated if a resident was refusing services it needed to be care planned. The DON stated the care plan should paint a picture of the residents needs and be individualized. The DON stated not updating the care plan could lead to residents needs not being met.<BR/>Record review of facility undated policy titled Care Plans, Comprehensive Person-Centered reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 1 of 27 residents (Resident #18) reviewed for ADL activities <BR/>The facility failed to ensure Resident #18 was monitored for assistance needs and failed to ensure she was positioned in a manner that would allow her to feed herself while in bed. <BR/>This failure could place residents at risk for weight loss, ADL decline and poor self-esteem. <BR/>Findings included:<BR/>Review of Resident #18's face sheet dated 03/26/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), chronic obstructive pulmonary disease (Is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) and anorexia (an eating disorder that can lead to severe weight loss and an intense fear of weight gain.). <BR/>Review of Resident #18's annual MDS assessment dated [DATE] reflected Resident #18 was assessed to have a BIMS score of eight indicating moderate cognitive impaired. Resident #18 was assessed to require setup or clean up assist with eating. Resident #18 was assessed to not have a swallowing disorder or weight loss. <BR/>Review of Resident #18's comprehensive care reflected a focus area dated 02/26/2025 reflected Resident #18 has an ADL self-care performance deficit. Interventions included The resident requires assistance with by staff to eat.<BR/>Observation and interview on 03/26/2025 at 10:20 AM revealed Resident #18 in bed with her breakfast tray in front of her. Resident #18's overbed table was at Resident #18's chin level. Resident #18 had not eaten any of her food. Resident #18 stated she could not see or reach her food. Resident #18 asked if she could be pulled up in bed. <BR/>In an interview on 03/26/2025 at 10:31 AM the DON stated after seeing Resident #18 the resident could not reach her food and needed to be repositioned in the bed.<BR/>In an interview on 03/26/2025 at 10:40 AM CNA G stated she was working on Resident #18's hall. CNA G stated she did not put Resident #18's breakfast in front of her.<BR/>In an interview on 03/26/2025 at 10:42 AM CNA H stated she was working on Resident #18's hall. CNA H stated she did not put Resident #18's breakfast in front of her. CNA H stated she was unsure who put Resident #18's tray in front of her. <BR/>In an interview on 03/26/2025 at 10:50 AM the DON stated she was not sure who put Resident #18's tray in front of her but it had to be CNA H or G. She stated Resident #18 should have absolutely be positioned so she could reach her food and have her tray set up. She stated she was going to in service the staff to make sure they are setting up the residents' trays and making sure the residents are positioned so they can feed themselves. <BR/>Review of the facility's policy ADLs dated 08/2024 reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services will be provided for the following activities of daily living .Eating to include meals and snacks .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #5, Resident #209, Resident #212) of five residents reviewed for bathing. <BR/>The facility failed to provide showers to Resident #5, Resident #209, Resident #212 in compliance with their shower schedules.<BR/>This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, and at risk for skin breakdown.<BR/>Findings included:<BR/>Review of Resident #5's comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction high blood pressure, stroke, high blood lipids, seizure disorder, depression, partial weakness on one side of the body, dysphagia, abnormal posture, muscle weakness. Resident #5 had a BIMS score of 08, which indicated moderately impaired cognition. She was physically dependent on staff for showers/baths.<BR/>Review of Resident #5's care plan, dated last reviewed 3/23/2025, reflected she had an ADL self-care performance deficit r/t contracture, pressure injury, required assistance with ADL's, with an intervention of requiring assistance with bathing/showering.<BR/>Review of Resident #5's bathing task in her EHR reflected that she was to receive showers on Mondays, Wednesdays, and Fridays once an evening between the hours of 2:00 PM and 10:00 PM.<BR/>Review of Resident #5's bathing tasks in her EHR, from 2/26/25 - 3/26/25, reflected the following:<BR/>2/28/25-CNA H indicated total dependence at 11:34am.<BR/>3/2/24-CNA H indicated total dependence at 10:23am.<BR/>3/3/25-CNA H indicated total dependence at 11:51am.<BR/>3/6/25-CNA H indicated total dependence at 10:27am.<BR/>3/11/25- CNA H indicated total dependence at 9:32am.<BR/>3/13/25- CNA H indicated total dependence at 11:01am.<BR/>3/16/25- CNA H indicated total dependence at 12:15pm.<BR/>3/19/25- CNA L indicated physical help in part of bathing activity at 1:59pm.<BR/>3/21/25- CNA L indicated physical help in part of bathing activity at 1:59pm.<BR/>3/23/25-CNA H indicated total dependence at 11:16am.<BR/>3/24/25- CNA H indicated total dependence at 1:43pm.<BR/>Review of the facility's Unit 3 shower binder reflected no completed shower sheets for Resident #5 for the past 30 days.<BR/>Observation and interview on 3/25/25 at 11:06 AM revealed Resident #5 laying in her bed covered in a thick blanket. A FM was present at the time and stated that the facility does not bathe Resident #5 as they should, the resident stated that she does not refuse showers when offered. They both informed the surveyor that the resident required a mechanical lift to get out of bed. The resident stated that not receiving her showers made her feel dirty. She was unable to recall her last shower. <BR/>An interview on 3/26/25 at 10:43 AM with CNA H revealed that the CNA's on unit 3 use shower sheets to document showers as some new residents did not have a shower task in their EHR. She stated that shower sheets are the most accurate form of documentation on that unit. The CNA helped the surveyor look through the binder for the dates where Resident #5 was scheduled to be showered and no shower sheets were found for Resident #5. When CNA H was asked about the documentation in the EHR where she documented total dependence for Resident #5 during her shifts (6-2), she stated that they have to click the bath on ADL or it'll show red as if they didn't do the task, but they do the paper trail as its easier and they won't lose it if the computer shuts down. She stated the RN must sign the sheet at the end of the shift. Their last in-service for showering (how to give them, filling out the shower sheet, and documenting in PCC) was done last week by the DON. She stated that although her name was in the EHR for Resident #5 she did not bathe the resident because she was not scheduled for showers during CNA H's shift. She stated that the CNA on the 2-10 shift can put a shower note in the EHR during their shift as well, but it was most accurate to fill out a shower sheet.<BR/>An interview on 3/26/25 at 10:45 AM with CNA L revealed that she did not give Resident #5 showers because of the room number the resident was in. She stated that she only showered residents up to a certain number on the unit and Resident #5 was not included in those numbers. She stated that she uses the shower sheets and that her name in the EHR would have been there to remove the red banner from the computer screen. <BR/>Review of Resident #209's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: acute kidney failure, altered mental status, primary osteoarthritis of knee (degenerative joint disease that results from breakdown of joint cartilage and underlying bones), low potassium, hyperosmolality (loss of water fluid).<BR/>Review of Resident #209's care plan date initiated 3/11/2025, reflected he had an ADL self-care performance deficit and required assistance with ADL's, with an intervention of requiring staff participation with bathing/showering. He was totally dependent on staff for repositioning and turning in bed, and totally dependent on staff for getting dressed. <BR/>Review of Resident #209's bathing task in his EHR reflected that he was to receive showers on Mondays, Wednesdays, and Fridays once an evening between the hours of 2:00 PM and 10:00 PM.<BR/>Review of Resident #209's bathing tasks in his EHR, from 3/11/25 - 3/26/25, reflected No Data Found for the period selected.<BR/>Review of the facility's Unit 3 shower binder reflected 1 completed shower sheet for Resident #209, however there was no date present on the shower sheet.<BR/>An observation and interview on 3/25/2025 at 10:08 AM revealed Resident #209 laying in his bed, he had 2 FM's present who stated that the resident was very hard of hearing. The FM's stated that they were onsite with the resident almost 24/7. When the resident was first admitted they waited a week before the facility gave the resident a shower. They stated it took the PA telling the staff to shower the resident for him to get the shower. The FM stated that the DR visited on 3/24 and observed a yeast infection on the resident's bottom, which had to get treated. <BR/>Review of Resident #212's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: unspecified dementia, diabetes, sleep apnea (breathing disorder caused by repeated interruptions during sleep), high blood pressure, atrial fibrillation (irregular heart rhythm), congestive heart failure, and gastro-esophageal reflux disease . <BR/>Review of Resident #212's bathing task in his EHR reflected that he was to receive showers on Mondays, Wednesdays, and Fridays once an evening between the hours of 2:00 PM and 10:00 PM.<BR/>Review of Resident #212's bathing tasks in his EHR, from 3/4/25 - 3/26/25, reflected No Data Found for the period selected.<BR/>Review of the facility's Unit 4 shower binder reflected 2 completed shower sheets dated 3/19/2025 and 3/26/2025 for Resident #212.<BR/>Observation on 3/25/2025 at 11:23 AM revealed Resident #212 laying in his bed in his room using a nebulizer. Resident was observed to be breathing heavily and was unable to answer the surveyor's questions. <BR/>An interview on 3/26/25 at 10:50 AM with CNA I (who is the facility scheduler) she stated that she felt that they needed more CNA's on the 2-10 shift, she said sometimes that the 2-10 shift cannot get to certain tasks like showers when they are shorthanded. She stated the DON oversaw hiring and that she had been made aware of the staffing concerns. CNA I stated that the CNA's are responsible for showering the residents. CNA I stated that not by resident not getting their showers they get frustrated, their families get frustrated, and that no one wants to sit and be dirty, everyone wants to be clean.<BR/>An interview on 3/26/25 at 11:29 AM with the DON she stated if a CNA went to ask a resident if they wanted a shower and the resident refused, then the RN would need to go offer the shower, if the resident refused to the RN, then it would be documented in the progress notes in the EHR. She stated that Resident #5 had good recall and would be able to say when her last shower was.<BR/>An interview on 03/26/25 at 2:53 PM with CNA K revealed that she felt that 2 people on 1 floor during a shift would be short staffing, and that showers are one of the tasks that don't get done if the CNA's felt short staffed during a shift. She also stated that when they felt short-staffed attending to residents who want independence was challenging, she felt that 3 CNA's, with 2 RN's on each shift would allow enough time and delegation to complete all tasks needed.<BR/>An interview on 03/27/25 at 10:47 AM with LVN C revealed that they use shower sheets to document resident showers, but they had recently started putting the showers in the EHR as well. No shower sheets or EHR documentation was found for Resident #212. <BR/>An interview on 3/27/2025 at 11:00 AM with Resident #212's FM revealed Resident #212 had a spinal stimulator implanted, so standing was painful for him, and he could only take a couple steps using assistance, so the facility would usually give him a bed bath. The FM stated that 1 particular CNA would give the resident the bed bath and do the showers as well.<BR/>Review of the facility's undated Resident Showers policy reflected, <BR/>It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.<BR/>1. <BR/>Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.<BR/>2. <BR/>Partial baths may be given between regular shower schedules as per facility policy.<BR/>Review of the facility's undated Documentation in Medical Record policy reflected, <BR/>Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. <BR/>1. <BR/>Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. <BR/>2. <BR/>Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.<BR/>3. <BR/>Documentation may be performed manually or as per the facility's specific electronic medical record software program.<BR/>6. <BR/>Corrections to a medical record shall be made to clarify inaccurate information.<BR/>a. <BR/>Only the individual who made the original entry shall correct the entry.<BR/>b. <BR/>The original content shall remain legible, with a notation that the entry has been corrected.<BR/>c. <BR/>The date and time of the new entry shall be recorded and annotated as a correction or addendum.<BR/>7. <BR/>Contradictory information may be clarified by a new entry in the medical record.<BR/>a. <BR/>Date and time the entry.<BR/>b. <BR/>Provide sufficient details to support that the current information is accurate. <BR/>c. <BR/>Sign each entry with name and credentials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (Resident #5) of 5 residents reviewed for quality of care. <BR/>The facility failed to ensure MA F waited for Resident #5 to consume her nighttime medications before leaving the resident's room. <BR/>This failure could affect residents by putting them at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included:<BR/>Review of Resident #5's comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction, high blood pressure, stroke, high blood lipids, seizure disorder, depression, partial weakness on one side of the body, dysphagia (difficulty swallowing), abnormal posture, and muscle weakness. Resident #5 had a BIMS score of 08, which indicated moderately impaired cognition. The assessment stated none of the above under swallowing disorders.<BR/>Review of Resident #5's physician's orders in her EHR revealed a standing order dated 1/9/2025 stating, May crush crushable medications, and/or open capsules and mix with food or jelly<BR/>Review of Resident #5's MAR for the month of March 2025 reflected that MA F administered nighttime medications on 3/24/25 and 3/25/25 and CNA J administered morning medications to Resident #5 on 3/26/2025. <BR/>Observation on 3/25/25 at 11:06 AM revealed Resident #5 laying in her bed covered in a thick blanket. A FM was present at the time and was assisting the resident with an outside meal brought in by the FM. <BR/>An additional observation and interview on 3/26/25 at 2:10 PM revealed Resident #5 laying in her bed and a different FM was present with her. The FM expressed frustration with the MA not allowing Resident #5 the time to consume her medications without being rushed or ensuring safe consumption. The FM told the surveyor that Resident #5 was unable to swallow her medications on the night of 3/25/2025 and she spit them out and put them in her bedside table. The FM then opened Resident #5 bedside table drawer and revealed 6 pills (1 round white tablet, 1 oblong white tablet, 2 round brown tablets, 2 round red tablets) the resident stated that she spit them out last night when the MA was rushing her to take her medications and she was unable to swallow them. The FM made a call to the FM who was present with Resident #5 on 3/25/25 who confirmed the medications were not present during that FM's visit. <BR/>An interview on 3/26/2025 at 3:05 PM with LVN D who was the charge nurse on unit 3 she stated she had never been made aware of Resident #5 spitting out medication. She stated she would let the DON know and take the pills out of the resident's room. <BR/>An observation of the medication cart on 3/26/2025 at 3:05 PM with LVN D it was discovered that the medications in Resident #5's room were the following:<BR/>Senna (2 brown pills) used as a laxative for short term treatment of constipation<BR/>Cranberry (2 red pills) used to treat/prevent bladder problems<BR/>Labetalol (1 small round pill) used to treat high blood pressure<BR/>Atorvastatin (1 large white pill) used to treat high cholesterol<BR/>In an interview on 3/26/2025 at 3:20 PM with the DON she stated that she was not aware of a history of Resident #5 not being able to swallow her medications. She stated the crush order in the resident's EHR would depend on a swallow assessment .<BR/>In an interview on 3/26/2025 at 3:45 PM with CNA J she stated that she gave Resident #5 her medication on the morning of 3/26/2025 and she crushed them for the resident. <BR/>In a telephone interview on 3/27/2025 at 11:04 AM with MA F she stated that she observed Resident #5 swallow her nighttime pills on 3/24/25 and 3/25/25. She stated the process for her administering medication is that she would hand the residents their pills, wait, let them take drinks, have them open their mouth, and then she would look around in their mouth to ensure they were swallowed. She stated she had never had any instances with Resident #5 spitting out pills. She stated she did not crush her medications due to the resident not having had a crush order. The surveyor informed the MA that Resident #5 had a may crush crushable medications order and the MA expressed her unawareness of the order. The MA stated that Resident #5 had no history of refusing medications during her times of administration.<BR/>Review of the facility's undated Medication Administration policy revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. <BR/>17. <BR/>Administer medication as ordered in accordance with manufacturer specifications.<BR/>a. <BR/>Provide appropriate amount of food and fluid.<BR/>b. <BR/>Shake well to mix suspensions.<BR/>c. <BR/>Crush medications as ordered. Do not crush medications with do not crush' instructions.<BR/>18. <BR/>Observe resident consumption of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #18) of 4 residents reviewed for respiratory care.<BR/>The facility failed to ensure that Resident #18's Nebulizer tubing and mouthpiece, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), were dated and replaced every seven (7) days. <BR/>The facility failed to ensure that Resident #18's Nebulizer mouthpiece was bagged when not in use.<BR/>These failures could place residents at risk for respiratory compromise and infection.<BR/>Findings included:<BR/>Review of Resident #18's Face Sheet dated 02/06/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Severe Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Dysphagia (swallowing difficulties), and Gastro-Esophageal Reflux Disease (stomach contents come back up into the esophagus).<BR/>Review of Resident #18's MDS Quarterly Assessment, dated 12/06/2023 revealed Resident #18 had a BIMS Score of 00 indicating severe cognitive impairment. <BR/>Review of Resident #18's Comprehensive Care Plan revealed a focus area dated 05/31/2022, The resident has altered respiratory status r/t cough / congestion / wheezing. Intervention with a revision date of 06/30/2023 indicated, Administer medication / puffers / NEBS / oxygen as ordered. Monitor for effectiveness and side effects.<BR/>Review of Resident #18's Consolidated Physician Orders reflected an order dated 05/07/2023, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), Directions - 2 puff inhale orally every 4 hours as needed for Wheezing. There was no order for the care of Resident #18's Nebulizer, tubing, or mouthpiece.<BR/>Observation on 02/05/2024 at 11:13 AM, Resident #18 was in her room lying in the bed with a private caretaker present. Resident #18 had a nebulizer on her nightstand, which had tubing, and a mouthpiece attached, which contained a nebulizing chamber. Observed that the mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview on 02/05/2024 at 11:15 AM, Private Caretaker for Resident #18 stated that she does not administer nebulizer treatments to Resident #18 and that care of the nebulizer is the facility's responsibility. <BR/>Observation on 02/06/2024 at 8:00 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Observation on 02/07/2024 at 8:16 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was noted bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview and observation on 02/07/2024 at 9:00 AM, LVN A stated that she primarily works the day shift on the hallway of Resident #18. LVN A stated that their policy is to change oxygen tubing every Sunday and Wednesday night. LVN A stated they are to place their initials and the date on the tubing and mask. LVN A stated that nebulizer tubing / mouthpieces are to be treated the same as oxygen tubing and mask. LVN A stated that both mask and mouthpieces are to be always placed in bags when not in use. LVN A stated that failure to properly care for respiratory equipment could result in respiratory issues and posed an infection control issue. LVN A entered the room of Resident #18 and stated that it was not correct because the mouthpiece was not bagged, and nothing was dated. LVN A removed the tubing and mouthpiece and stated they were being changed out immediately. LVN A was unable to state how long the tubing and mouthpiece had been in the room of Resident #18. <BR/>Interview on 02/07/2024 at 9:13 AM, LVN B stated that their policy is to change out tubing and mask every Sunday night. LVN B stated that nebulizer tubing and mouthpieces are to be treated the same and changed out on Sunday night. LVN B stated that failure to change out tubing and mask / mouthpieces could result in bacteria growth and possibly lead to respiratory infection.<BR/>Interview on 02/07/2024 at 9:19 AM, the DON stated that respiratory tubing and mask / mouthpieces are to be changed out every Sunday night. The DON stated that failure to change out tubing and to properly date them could possibly lead to respiratory issues.<BR/>Interview on 02/07/2024 at 3:48 PM, the ADMINISTRATOR stated that it was his expectation that respiratory items be changed out weekly and dated. The Administrator stated that failure to do so could result in a Respiratory Infection. The ADMINSTRATOR provided the Oxygen Policy for the facility. <BR/>Review of the facility's TAR from February 1 - 7, 2024 revealed no documentation in reference to Resident #18's nebulizer tubing or mouthpiece and was not recorded as a treatment in their records.<BR/>Review of the facility's Oxygen Administration Policy, review date of 1/23, POLICY: The purpose of this procedure is to provide guidelines for safe oxygen administration. The Policy provided did not address nebulizers or oxygen tubing in reference to dating or replacement of tubing and mask / mouthpiece.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1of 4 resident reviewed for pharmacy services. (Resident #213)<BR/>The facility failed to ensure Resident #213 ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. <BR/>These failures could place residents at risk for not receiving medications as prescribed and a decline in health status <BR/>Findings included:<BR/>Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. <BR/>Record review of Resident #213's comprehensive care plan dated 03/21/24 reflected he had the potential for nutritional problem and was provided medication supplements including Thiamine. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs and symptoms of malnutrition through review date. The interventions included: Obtain and monitor lab/diagnostic work as ordered. Report results to my physician and follow up as indicated.<BR/>Record review of Resident #213's admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 had no behaviors or refusal of care. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Ergocalciferol Oral Capsule 1.25mg to be given every week on Wednesday dated 03/20/25. The order summary report also showed an order for Thiamine 100mg 1 tablet to be given 1 time daily dated 03/20/25. <BR/>Record review of the Medication Administration Record for March 2025 reflected Resident #213 did not receive his Thiamine and his Ergocalciferol because the medication was on order. <BR/>During an observation and interview of medication pass on 03/26/25 at 10:35am MA E prepared Resident #213's medications except the Thiamine and Ergocalciferol. MA E stated those medications were not available. She proceeded to administer his medications and document the medications that were not given were on order. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility for 1 year. She stated she has received training related for medication administration from her ADON and DON. The MA stated that she had reported to the charge nurse that Resident #213 was out of his Thiamine medication and his Ergocalciferol . She stated she was not sure why the medications had not come into the facility yet. She stated not having medication available to resident could lead to not being able to treat their diseases appropriately. <BR/>In an interview on 3/27/25 at 10:11am with LVN C she stated she was never told that Resident #213 was out of his medication or did not have it available. LVN C stated verbally the nurses and Medication aides give report to each other and communicate on medications needed. She stated the medication aides were encouraged to ask questions, and they do ask questions when they are uncertain about an order. Negative outcomes for Resident #213 not receiving his medications as order included sickness and getting worse disease progression. <BR/>In an interview on 3/27/25 at 11:45am he DON stated he MAs should report all unavailable medications to the nurse . The nurse then would look for the medication. She stated if it was an over the counter the nurse can pull it from the stock medications room. If it is a script the nurse would verify it was not delivered check the order and call the pharmacy. The DON stated the nurse would report all unavailable medications to the DON and doctor. She stated negative effects could include the resident not receiving what medications they need leading to prolonged sickness.<BR/>Surveyor was not provided a policy on medication availability during survey dates of 3/26/25 and 3/27/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.69% based on 2 out of 26 opportunities, which involved 1 of 4 residents (Resident #213) observed during medication administration reviewed for medication error. <BR/>The facility failed to ensure Resident #213's ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. <BR/>These failures could place residents at risk of not receiving medications as ordered <BR/>Findings included:<BR/>Record review of Resident #213s face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. <BR/>Record review of Resident #213s comprehensive care plan dated 03/21/24 reflected he had the potential for nutritional problem and was provided medication supplements including Thiamine. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline and no signs and symptoms of malnutrition through review date. The interventions included: Obtain and monitor lab/diagnostic work as ordered. Report results to my physician and follow up as indicated.<BR/>Record review of Resident #213s admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 had no behaviors or refusal of care. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Ergocalciferol Oral Capsule 1.25mg to be given every week on Wednesday dated 03/20/25. The order summary report also showed an order for Thiamine 100mg 1 tablet to be given 1 time daily dated 03/20/25. <BR/>Record review of the Medication Administration Record for March 2025 reflected Resident #213 did not receive his Thiamine and his Ergocalciferol on 03/26/25 because the medication was on order. <BR/>During an observation and interview of medication pass on 03/26/25 at 10:35am MA E prepared Resident #213s medications except the Thiamine and Ergocalciferol. MA E stated those medications were not available. She proceeded to administer his medications and document the medications that were not given were on order. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility for 1 year. She stated she has received training related for medication administration from her ADON and DON. MA E stated that she had reported to the charge nurse that Resident #213 was out of his Thiamine and Ergocalciferol medications. She stated she was not sure why the medications had not come into the facility yet. She stated not having medication available to resident could lead to not being able to treat their diseases appropriately. <BR/>In an interview on 3/27/25 at 10:11am with LVN C she stated she was never told that Resident #213 was out of his medication or did not have it available. LVN C stated verbally the nurses and Medication aides give report to each other and communicate on medications needed. She stated the medication aides were encouraged to ask questions, and they do ask questions when they are uncertain about a medication order. Negative outcomes for Resident #213 not receiving his medications as order included sickness and getting worse disease progression. <BR/>In an interview on 3/27/25 at11:45am The DON stated The MAs should report all unavailable medications to the nurse. The nurse then would look for the medication. She stated if it was an over the counter the nurse can pull it from the stock medications room. If it is a script the nurse would verify it was not delivered check the order and call the pharmacy. The DON stated the nurse would report all unavailable medications to the don and dr. The DON stated staff were given constant reminders to lock the cart. She stated nursing staff had skills check off yearly for competency training on medication pass completed by the ADON. She stated MAs were required to participated in the skills check off. She stated the Pharmacists also completes a medication pass with the staff to ensure competency. She stated negative effects could include the resident not receiving what medications they need leading to prolonged sickness. <BR/>Record review of facility policy titled Medication Administration dated April 2024 reflected: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's nourishment refrigerators for 3 (Nourishment room [ROOM NUMBER], #3, and #4) of 5 nourishment room refrigerators reviewed for food and nutrition services.<BR/>1. <BR/>The facility failed to ensure the nourishment room refrigerator temperature logs were maintained in dining room [ROOM NUMBER], and nourishment refrigerators #3 and #4. <BR/>2. <BR/>The facility failed to ensure the dining room's refrigerator's cleanliness was maintained. <BR/>3. <BR/>The facility failed to ensure the nourishment refrigerator in unit 1 was free of pests. <BR/>These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. <BR/>Findings include: <BR/>Observation of the unit 3 and 4 dining room's refrigerator on 3/25/2025 at 12:18 PM revealed a lone sign posted to the front of the refrigerator notifying residents, families, and staff that the refrigerator was for residents only. No temperature log was visible on the front or either side of the refrigerator unit or on the surrounding countertops. Inside the refrigerator, the shelves were covered in stains, a single human hair was observed on the shelf, and on the inside door, 3 expired (12/2/2024 X2, 3/18/2024) sour cream packets and 4 expired half & half (1/15/23) cups were all in a bottom drawer.<BR/>Observation of the unit 4 nourishment refrigerator on 3/25/2025 at 12:30 PM revealed a sign notifying residents and staff that no outside food was allowed in the refrigerator or freezer, and a sleeve of 3 blank temperature logs and 2 temperature logs from November and December 2024 were fixed to the front of the refrigerator. <BR/>Observation of the unit 3 nourishment refrigerator on 3/25/2025 at 12:54 PM revealed a sign notifying residents and staff that no outside food was allowed in the refrigerator or freezer. No temperature log was visible on the front or either side of the refrigerator unit or on the surrounding countertops. Inside the freezer was a multi-use &frac12; gallon tub of homemade vanilla flavored ice cream with no resident's name or date visible. <BR/>Observation on 03/26/25 at 09:30 AM of the nourishment refrigerator in unit 1 revealed sugar ants crawling all along the seal of the freezer door when opened. When LVN C was notified of the bugs she asked the surveyor what she should do. The surveyor advised her to do whatever it was she would do if she noticed the bugs on her own. LVN C stated she would contact the DON and maintenance.<BR/>Observation on 03/26/25 at 09:35 AM revealed the ADON placing an Out of Order sign on unit 1's refrigerator and she was overheard to be contacting maintenance for service and the contracted kitchen for resident's replacement food and beverages. <BR/>Interview with the ADON on 3/25/2025 at 9:23 AM revealed that the contracted vendor for dietary is responsible for maintaining the temperature log and disposing of expired or unused foods. The facility was responsible for cleaning them.<BR/>Interview with the DON on 3/26/2025 at 9:35 AM revealed that the facility was responsible for maintaining the temperature logs, the CNA's were responsible for cleaning, and the night shift would maintain the cleanliness and temperatures. She stated that all residents, unless they have an NPO order, may have food and beverages from the nourishment refrigerators. <BR/>Interview with the ADM on 3/27/2025 at 10:23 AM revealed that the facility's kitchen would not be up and running for another 60 days. She stated they had gone back and forth between who was responsible for refrigerator cleanliness and maintenance. Originally, the contracted kitchen was responsible for maintaining it, but then the facility was told it would be their responsibility. She stated the contract between the facility and the contracted kitchen shows the facility as being responsible for temperature monitoring, and the contracted kitchen responsible for stock and cleanliness. She stated that overnight staff would be responsible for cleaning the dining room refrigerator. Her last understanding was that nursing staff would be responsible for maintaining temperature logs. <BR/>Record review of the facility's contract with the contracted kitchen revealed that {The contracted kitchen} will manage nutrition room stock and cleanliness with temperature monitoring to be done by {The facility} with a due date: to be determined by 9/9/24.<BR/>Record review of the facility's last 3 months of pest control invoices revealed the facility had a pest control company come out and administer various kinds of insect repellant's indoors and outdoors on 1/23/2025, 2/24/2025, and 3/25/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of two medication aides (MA E) observed for infection control practices <BR/>MA E failed to sanitize her hand, put on gloves prior to administration of eye drops to Resident #213 on 03/26/25 at 10:30am. <BR/>This failure could place residents at risk for healthcare associated cross-contamination and infections.<BR/>Findings included:<BR/>Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and Glaucoma (an increased pressure inside the eye). <BR/>Record review of Resident #213's history and physical dated 03/21/25 reflected he had a diagnosis of Glaucoma wore Correction lenses and was prescribed eye drops Timolol Maleate Ophthalmic (eye) Solution 0.5 % (a medication to decrease eye pressure related to glaucoma), Instill 1 drop in both eyes two times a day. <BR/>Record review of Resident #213's in progress admission MDS assessment, dated 03/27/25, reflected he had a BIMS score of 0, which indicated severely impaired cognition. The MDS reflected Resident #213 visual assessment was not answered. <BR/>Record review of the order summary report for March 2025 reflected Resident #213 had an order for Timolol Maleate Ophthalmic Solution 0.5 % 1 drop in both eyes two times a day related to Glaucoma. <BR/>Observation on 03/26/2025 at 10:35am revealed, MA E prepared Resident #213's medications, she knocked on the door, entered the room and proceeded to administer Timolol eye drops 1 drop in each eye. MA E did not wash her hands or put on gloves prior to the administering eye drops. MA E did not wash her hands after administration of eye drops. <BR/>In an interview on 03/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated she should have washed her hands and placed gloves on before giving Resident #213 his eye drops. She stated she was just nervous and forgot. She stated not washing your hands could lead to spreading germs and infections. <BR/>In an interview on 03/27/25 at 11:45am the DON stated it was her expectation for staff to wash her hands and apply gloves prior to giving eye drops. She stated staff should wash their hands after removing gloves as well. She stated all staff had been educated on handwashing. The DON stated handwashing was part of the nursing competency check offs annually that was completed by all nursing staff. She stated not washing hands could lead to spreading germs or getting germs from resident to resident.<BR/>Record review of undated facility policy titled Hand Hygiene reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.<BR/>Before performing resident care procedures. <BR/>Record review of undated facility policy titled Infection Prevention and Control Program reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.<BR/>1. <BR/>Standard Precautions:<BR/>a. <BR/>All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.<BR/>b. <BR/>Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.<BR/>c. <BR/>All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.<BR/>d. <BR/>Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.<BR/>e. <BR/>Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use appropriate alternatives prior to installing a side or bed rails, assess the resident for risk of entrapment, review the risk and benefits, and obtain informed consent prior to installation for 3 out of 6 residents (Residents #1, #2, and #3) reviewed for bedrails. <BR/>The facility failed to assess and get signed consents for Residents #1, #2, and #3 prior to installing bed rails. <BR/>This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck, or limbs, restraints, and injuries. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 08/28/24 reflected a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of polyosteoarthritis (is a diagnosis of having arthritis in five or more joints at the same time), muscle weakness, difficulty in walking, altered mental status and cognitive communication deficit. <BR/>Record review of Resident #1's admission MDS dated [DATE] reflected no BIMS summary score. <BR/>Record review of Resident #1's care plan reflected no mention of bed rails.<BR/>Record review of Resident #1's clinical physician orders reflected no orders for the use of side rails. <BR/>Record review of Resident #1's consents reflected no informed consent on file for the use of bedrails.<BR/>Record review of Resident #1's assessments reflected that there was no assessment completed for the risk of entrapment from bed rails prior to installation.<BR/>An observation on 08/28/24 at 12:09 PM revealed Resident #1 was asleep in her bed with &frac14; length side rails in the up position on both sides at the head of the bed. <BR/>Record review of Resident #2's face sheet dated 08/28/24 reflected a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of chronic diastolic (congestive) heart failure (a condition in which the left ventricle of the heart becomes stiff and unable to fill properly), hypertension (high blood pressure), COPD (a chronic lung disease that makes breathing difficult), hyperlipidemia (high cholesterol), and chronic atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart). <BR/>Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. <BR/>Record review of Resident #2's care plan reflected no mention of bed rails prior to 08/28/24.<BR/>Record review of Resident #2's clinical physician orders reflected no orders for the use of side rails. <BR/>Record review of Resident #2's consents reflected no informed consent on file for the use of bedrails.<BR/>Record review of Resident #2's assessments reflected that there was no assessment completed for the risk of entrapment from bed rails prior to installation.<BR/>An observation and interview on 08/28/24 at 4:19 PM revealed Resident #2 sitting in her recliner at bedside. Her bed was observed to have &frac14; length side rails on the up position on both sides at the head of the bed. Resident #2 stated that she did not consent to have the side rails up and that she did not get an assessment for them; she stated they were just like that when she arrived. Resident #2 said that she will sometimes sleep in her recliner because in the past she had an accident that she believed was caused due to the side rails and so she was nervous about sleeping in her bed. Resident #2 stated the accident did not result in an injury and she fell onto the bed but that it still frightened her. <BR/>Record review of Resident #3's face sheet dated 08/28/24 reflected a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to embolism of right middle cerebral artery (also known as ischemic stroke, results in an area of necrotic or dead tissue in the brain), dysphagia following cerebral infarction (difficulty swallowing), hyperlipidemia (high cholesterol), and hypertension (high blood pressure).<BR/>Record review of Resident #3's admission MDS dated [DATE] revealed no BIMS summary score. <BR/>Record review of Resident #3's care plan revealed no mention of bed rails prior to 08/28/24.<BR/>Record review of Resident #3's clinical physician orders revealed no orders for the use of side rails. <BR/>Record review of Resident #3's consents revealed no informed consent on file for the use of bedrails.<BR/>Record review of Resident #3's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation.<BR/>An observation on 08/28/24 at 4:35 PM revealed Resident #3 was asleep in her bed with &frac14; length side rails in the up position on both sides at the head of the bed. <BR/>An interview on 08/28/24 at 2:07 PM with the VPCO who stated that it was her expectation that all residents had an order for the use of side rails and that residents should be assessed and should be care planned for bed rails. She stated that PT will be doing assessments for those residents with side rails to ensure they are being safely used. <BR/>An interview on 08/28/24 at 4:41 PM with the DON who stated that the bed rails were already on the beds prior to the residents being admitted . She stated that they are hospital beds that the facility had when the company acquired them, and they were not removed because the residents had been using them as enablers in assisting the residents to adjust themselves in bed. The DON stated that they are a no restraint facility and that they did not consider the bed rails as a restraint. She stated there was not a risk assessment completed for the side rails and no order on file. The DON stated that it was her expectation moving forward that all residents have a risk assessment completed when using side rails. She said they should also have an informed consent on file either by the representative or the RP. The DON also stated that there should be an order on file for the use of side rails, none of which she said these residents had. The DON stated that a potential negative outcome when using siderails when there was no consent or risk assessment was the potential for entrapment, risk for fractures or debilitations, and could be considered a restraint. The DON stated that they are working on making the side rails information a part of the admission packet and are immediately working with PT to assess the residents and their risk, as well as obtaining consents. <BR/>An interview on 08/28/24 at 05:01 PM with the ADM who stated the bed rails were on the beds when the current facility company took over. She stated that the residents were currently being reviewed for the risk of entrapment and those that have no risk will keep them to use as enablers. The ADM stated that it was her expectation that there be a resident assessment on anyone with side rails to assess their risk for entrapment. She said, there has to be an order from the doctor and a consent from their RP if they are not own. She also said she expected bed rails to be care planned and that failure to do any of those steps could result in a resident being injured or entrapped. The ADM stated that to her knowledge there had not been any injuries resulting from the bed rail use. <BR/>Review of the undated facility policy Proper Use of Bed Rails reflected:<BR/>Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. <BR/>The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the residents' assessed needs.<BR/>The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include:<BR/>- <BR/>Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard).<BR/>- <BR/>Barrier to residents from safely getting out of bed.<BR/>- <BR/>Physical restraint (e.g., hinders residents from independently getting out of bed or performing routine activities).<BR/>- <BR/>Decline in resident function, such as muscle functioning/balance.<BR/>The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself.<BR/>The facility will assess to determine if the bed rail meets the definition of a restraint. A bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently. If it is determined to be a restraint, the facility will follow their procedures related to physical restraints.<BR/>Informed Consent<BR/>Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion.<BR/>Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.<BR/>Appropriate Alternatives<BR/>The facility will attempt to use appropriate alternatives prior to installing or using bed rails.<BR/>Alternatives include, but are not limited to:<BR/>- <BR/>Roll guards<BR/>- <BR/>Foam bumpers<BR/>- <BR/>Lowering the bed<BR/>- <BR/>Concave mattresses<BR/>- <BR/>Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms, or behavioral patterns for which a bed rail was considered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor the residents right to choose his or her attending physician for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) and the entire facility reviewed for resident rights.<BR/>The facility did not honor Resident #1, #2, #3, #4, and #5's right to choose his/her primary care physician after the facility terminated their Medical Director's agreement and changed the attending physician without notice to the residents or their representatives effective 07/04/24.<BR/>This deficient practice could place residents at risk of decreased quality of care and treatment due to their lack of free choice for their attending physician care while in the facility.<BR/>Findings included:<BR/>Resident #1<BR/>Review of Resident #1's Face Sheet dated 07/30/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Schizoaffective Disorder (mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and milder form of mania called hypomania) and Atherosclerotic Heart Disease (build up of fats, cholesterol and other substances in an on the artery walls, which can cause arteries to narrow, blocking blood flow). Further review indicated that Resident #1's primary physician was Medical Director B.<BR/>Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected that she had a BIMS Score of 14, indicating cognition was intact. <BR/>Interview and observation on 07/30/2024 at 12:00 PM, revealed Resident #1 was in her room seated on her bed and was conversational. Resident #1 stated that she just saw her new doctor (Medical Director B) and that it was usually a female doctor who saw her. Resident #1 stated she knew that someone new took over the facility and that there were going to be changes but was not told about a change in medical director or her primary physician. Resident #1 stated that the change and lack of notice did not matter as long as she was being seen by a doctor. <BR/>Resident #2<BR/>Review of Resident #2's Face Sheet dated 07/30/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Anoxic Brain Damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), and Hypokalemia (lower than normal potassium level in the bloodstream). Further review indicated that Resident #1's primary physician was Medical Director B.<BR/>Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected that he had a BIMS Score of 13, indicating cognition was intact. <BR/>Interview on 07/30/2024 at 4:51 PM, Resident #2's RP stated that she did not receive a letter or notification that the facility was changing medical director's. Resident #2's RP stated that she did receive a letter informing her of the facility's change in ownership. Resident #2's RP stated that she would have liked to have been notified of the change because she did not know who to contact now if she had questions or concerns with Resident #2's care. <BR/>Resident #3 <BR/>Review of Resident #3's Face Sheet dated 07/30/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), and Heart Failure (heart does not pump enough blood for the body's needs). Further review indicated Resident #3's primary physician was Medical Director B.<BR/>Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected that she had a BIMS Score of 08, indicating moderate cognitive impairment. <BR/>Interview on 07/31/2024 at 10:10 AM, Resident #3's RP stated he was not notified of a change in the facility's medical director or in Resident #3's primary physician. Resident #3 RP stated the only correspondence he received was a letter on 03/05/2024 notifying him of the facility changing ownership. Resident #3 RP stated the change of medical director and physician did not bother him but he would have liked to have been notified in case he needed to contact someone for Resident #3's care.<BR/>Resident #4<BR/>Review of Resident #4's Face Sheet dated 07/30/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Unspecified Cerebral Infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Unspecified Dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Aphasia (disorder that affects how you communicate). Further review indicated Resident #4's primary physician was not Medical Director A or B.<BR/>Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected that he had a BIMS Score of 15, indicating cognition was intact. <BR/>Interview and observation on 07/30/2024 at 3:54 PM, revealed Resident #4 was in his room seated in a wheelchair and was conversational and happy. Resident #4 stated that he was the Resident Council President and has been in the facility for 2 years. Resident #4 stated he was not provided with a letter or notified that the facility changed medical director's but was unsure if his RP was notified. Resident #4 stated that his regular physician came to see him this week and that he did not have a new physician. <BR/>Interview on 07/30/2024 at 4:01 PM, Resident #4's RP stated that she was not notified of the facility changing medical director's. Resident #4 RP stated that Resident #4 maintained the primary physician he had, who was not associated with Medical Director A or B.<BR/>Resident #5<BR/>Review of Resident #5's Face Sheet dated 07/30/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia, Severe (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), and Hypotension (press of blood circulating around the body is lower than normal or lower than expected). Further review indicated Resident #5's primary physician was not Medical Director A or B.<BR/>Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected that she had a BIMS Score of 0, indicating severe cognitive impairment.<BR/>Interview on 07/30/2024 at 4:19 PM, Resident #5's RP stated that Resident #5's primary physician is not associated with Medical Directors A or B. Resident #5 RP stated that she was not informed verbally or in writing of the facility changing medical director's. Resident #5 RP stated that she felt she should have been notified that the facility changed medical director's. <BR/>Interview on 07/30/2024 at 2:15 PM, the Administrator stated that she was new to the facility and that the transition from Medical Director A to Medical Director B had already taken place. The Administrator stated that Medical Director A should have been proved with a thirty-day notice of termination and the residents should have been notified of the pending change as well. The Administrator was requested to provide proof that Medical Director A and the residents were notified.<BR/>Record Review of forwarded email from the Director of Operations to the Administrator on 07/30/2024 at 2:36 PM, which contained an email from the Director of Operations to Medical Director A on 06/03/2024 at 3:50 PM revealed, [Medical Director A], please accept this note as the 30-day notice of termination for the Medical Director Contract at both [Nursing Facility] and [Nursing Facility]. We have enjoyed working with you all but are looking to move in a different direction with the Medical Director contract. We look forward to continuing our partnership with you through the month of June with the last effective date of July 2, 2024. Please let me know if you have any questions. Sincerely, [Director of Operations]. The Administrator also attached a letter from the Director of Operations addressed to Resident dated June 4, 2024, which revealed, The [Company] would like to share an upcoming change coming to [The Facility]. We are excited to announce that we will begin working with [Medical Director B] as the new Medical Director starting July 4, 2024. We appreciate the great care that the [Company] and [Doctor C] have provided the residents and team for many years. However, we work with [Medical Director B] and his team at several other centers and have experienced wonderful care from each of them. [Medical Director B] is passionate about senior living, has incredible communications skills, is available any time we need him, is supportive of our teams, and caring with all residents. [Medical Director B] plays an active role in educating our nurses as well as participating in any meetings he is asked to attend. He develops wonderful relationships with our residents, team, families, and friends. We look forward to you meeting [Medical Director B] and being part of his wonderful services. I would be happy to answer any questions or provide more information upon request. Please feel free to email me at [Director of Operations email address] or call my cell phone at [number provided with no area code]. Sincerely, [Director of Operations].<BR/>Interview on 07/30/2024 at 3:02 PM, the Director of Operations stated that she did prepare and provide Medical Director A with the above reviewed letter of termination. The Director of Operations stated she did prepare the above referenced letter to the residents notifying them of the change in medical director's and Doctor C. The Director of Operations stated the resident letter was provided to the Previous Administrator for distribution to the residents/responsible parties of the facility. The Director of Operations stated that she had no proof like the termination letter to Medical Director A to show that the residents were provided with the notification and assumed it was.<BR/>Interview on 07/30/2024 at 3:10 PM, the Previous Administrator stated he was not provided with a letter by the Director of Operations to provide to the residents. The Previous Administrator stated that he did not notify the residents of the change in medical director's and left the facility prior to the change in medical director's.<BR/>Interview on 07/30/2024 at 3:20 PM, the DON stated she started in the facility after Medical Director A would have been provided with notice. The DON stated she was informed that the residents were notified of the pending change but stated she never observed that a letter or notification was provided to the residents and/or their responsible parties.<BR/>Interview on 07/30/2024 at 3:30 PM, the AD stated that she did discuss the change of medical director's in resident council but could not recall when the conversation took place. The AD stated that Resident #4 was the President of the council. The AD stated that no residents discussed the change of medical director/physicians with her and would normally speak about it would the MDS Coordinator.<BR/>Interview on 07/30/2024 at 3:38 PM, the MDS Coordinator stated she was told that the residents were notified of the change in medical director's but did not know by whom, how, or when. The MDS Coordinator stated that she did not have any residents, or their responsible parties contact her with questions after the change, which she stated was not common because usually someone would contact her with questions about a change like that.<BR/>Interview on 07/30/2024 at 5:11 PM, the Administrator stated residents and/or their responsible parties should have been notified thirty days in advance of a change in medical director's/physician's. The Administrator stated that residents' notifications should have been made to ensure they were informed of care and who would be providing it. <BR/>Interview on 07/30/2024 at 5:18 PM, the DON stated she would expect residents to be notified thirty days prior to a change in medical director's/physician's. The DON stated that notification is important to allow the resident to choose. The DON stated that regardless of who the Medical Director is they will always contact the resident's primary physician, but that the medical director may be contacted if they are unable to reach the resident's physician. <BR/>Interview on 07/30/2024 at 5:28 PM, LVN D stated she never heard of or saw a letter that was distributed to residents notifying them of a change in Medical Directors or Physician's. LVN D stated that prior to this date it was Doctor D that saw the residents. LVD D stated that they were notified there was going to be a change of the medical director and then someone posted a notice in the nurses' station providing them with Medical Director B and a nurse practitioner's information. LVN D stated that notification of changes in medical director's and physician's was very important because it involved the resident's care, and they needed to know who to contact with questions or concerns.<BR/>Interview on 07/31/2024 at 12:43 PM, Doctor C stated that she provided care for many residents at the facility for over a year. Doctor C stated that she was concerned because she was notified approximately July 4, 2024, that she was no longer providing care to residents in the facility. Doctor C stated that she knew the facility terminated the contract with Medical Director A, who she worked with, but that termination did not end her relationship with the residents as their physician. Doctor C stated that residents should have been provided with a thirty-day notice for her primary care and had the choice to retain her as a physician if they chose to do so. Doctor C stated that residents should have been notified to prevent feelings of abandonment and ensure that a proper transition takes place to the next physician. Doctor C stated that it was important that she be able to provide the new physician with care notes and history of progress or decline under her care. <BR/>Interview on 07/31/2024 at 1:32 PM, Medical Director B stated he started with the facility on July 4, 2024, and that there were not transition issues. Medical Director B stated residents do have a choice in who their physician is and should be notified of changes. Medical Director B stated he had no reason to believe that residents were not notified of the change to him as medical director of the facility. Medical Director B stated that a change in the facility's medical director does not mean a change of physician for the residents.<BR/>Follow-up interview on 07/31/2024 at 2:03 PM, the Director of Operations was notified there was no proof or evidence that the letter she stated she prepared was ever provided to the residents of the facility or their responsible parties. The Director of Operations stated she could only say she made sure the Previous Administrator received it but no not ensure that he distributed it to the residents. The Director of Operations stated that the residents did not like Doctor C and were happy to have Medical Director B.<BR/>Interview on 07/31/2024 at 2:37 PM, Medical Director A stated that he was provided with proper thirty-day notice via email of contract termination. Medical Director A stated that he did notify Doctor C and the Nurse Practitioners of the termination. Medical Director A stated that his termination as medical director did not apply to Doctor C seeing residents as their physician. Medical Director A stated the facility should have notified the residents of the change in medical directors and allowed them to chose Doctor C, who to his knowledge was not provided with a notice that residents no longer wanted her as their physician. <BR/>Review of Resident Council minutes provided by the AD revealed in the meeting on 06/06/2024 there was no reference to the facility changing medical director's or choice of physician's. Review of a meeting on 07/11/2024 reflected New Staff and identified Medical Director B.<BR/>Review of the facility's Resident Rights Policy dated 9/1/2023 revealed, Policy: Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Choice of attending physician. The resident has the right to choose his or her attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to report incidents of injury of unknown sources to HHSC's state office within 24 hours for 1 (Resident #1) of 3 residents reviewed for unwitnessed falls.<BR/>The facility failed to report allegations to the State Agency when Resident #1 had an unwitnessed fall and was sent out to a local hospital.<BR/>This failure placed residents at risk of further injuries not being reported timely for a thorough prompt investigation to be conducted immediately. <BR/>Findings Included:<BR/>Review of Resident #1's face sheet dated 05/16/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing(broken hip), dementia in other diseases classified elsewhere(memory loss), and hypertension(high blood pressure).<BR/>Review of Resident #1's care plan was not available as the incident occurred less than 48 hours after admission.<BR/>Review of Resident #1's MDS assessment was not available as the incident occurred less than 72 hours after admission.<BR/>Review of Resident #1's incident report, dated 05/15/2024 at 7:23 PM and documented by RN A , reflected the following:<BR/>Nursing Description<BR/>Patient was found on the floor with blood on the side of his head and on his arms. Patient was unable to tell what happened. The last time he was checked by the Aide was at 4:45 AM and patient was asleep in bed. He had slept all night without any difficulties. I had just come from upstairs to deliver medications and the lab tech met me and stated that patient was on the floor and that there was blood everywhere. I went into the room and assessed patient and applied pressure to the bleeding area on head. Patient was able to move all his extremities and the only thing he said that he could not get up. Patient was log rolled unto a blanket and pillow placed behind his head. EMS was called and staff helped EMS lift patient onto stretcher. His RP was notified of what happened.<BR/>Resident Description<BR/>Patient confused and only thing that he had said was that he could not get up. I reassured him that we would get him up but that I needed to assess him and make sure there were no other areas bleeding as I had been holding pressure to the wound on his head. Patient the whole time was calm. The bleeding had stopped by the time EMS arrived.<BR/>Review of hospital records dated 05/15/2024 reflected [AGE] year-old male was discharged to the nursing facility on 05/14/2024 for a ground-level fall with a left hip fracture status post open reduction internal fixation. Patient had an unwitnessed fall this morning. Unknown loss of consciousness. Sustained a complex scalp laceration with active arterial bleeding .<BR/>During an interview on 05/17/2024 at 12:10 PM, the MDS Nurse stated Resident # 1 was in the facility less than 24 hours when the incident had occurred. Resident # 1 was admitted on [DATE] at 8:26 PM and the assessments had been started. The baseline care plan is to be completed in 48 hours and the MDS assessment in 72 hours. Resident # 1 was found on the floor in his room around 5:45 AM on 05/15/2024. <BR/>During an interview on 05/17/2024 at 5:56 PM, the Administrator stated that corporate made a decision for him to self-report the incident on 5/16/2024. The Administrator stated RN A contacted him on 5/15/2024 at 7:14 AM and notified him of the incident and a report was made to corporate. The Administrator stated when facility incidents occur corporate makes the determination if it is reportable to the state and corporate contacted him by text message on 5/16/2024 to self-report to the state . The administrator stated the policy is to report unwitnessed falls with injuries within 24 hours, but he was waiting on the corporate to determine if the incident was a state reportable.<BR/>During an interview on 05/17/2024 at 6:20 PM, the Corporate Nurse Stated that injury of unknown origin is a state reportable. The Corporate Nurse stated she was not made aware of Resident #1's fall on 05/15/2024. The Corporate Nurse stated she did not know until 5/16/2024 and that was when she stated to make the report to the state. The Corporate Nurse stated incidents to the state are to be reported within 24 hours. The corporate Nurse stated any unwitnessed fall with injury is reportable to the state and she was unable to give a reason why she was not notified when the incident occurred on 5/15/2024.<BR/>Review of the facility's compliance with reporting allegations of abuse, neglect, and exploitation policy undated, reflected the following:<BR/>It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.<BR/>Reporting/Response<BR/>The Administrator or designee will notify the appropriate agencies immediately as soon as possible, but no later than 24 hours after discovery of the incident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #18) of 4 residents reviewed for respiratory care.<BR/>The facility failed to ensure that Resident #18's Nebulizer tubing and mouthpiece, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), were dated and replaced every seven (7) days. <BR/>The facility failed to ensure that Resident #18's Nebulizer mouthpiece was bagged when not in use.<BR/>These failures could place residents at risk for respiratory compromise and infection.<BR/>Findings included:<BR/>Review of Resident #18's Face Sheet dated 02/06/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Severe Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Dysphagia (swallowing difficulties), and Gastro-Esophageal Reflux Disease (stomach contents come back up into the esophagus).<BR/>Review of Resident #18's MDS Quarterly Assessment, dated 12/06/2023 revealed Resident #18 had a BIMS Score of 00 indicating severe cognitive impairment. <BR/>Review of Resident #18's Comprehensive Care Plan revealed a focus area dated 05/31/2022, The resident has altered respiratory status r/t cough / congestion / wheezing. Intervention with a revision date of 06/30/2023 indicated, Administer medication / puffers / NEBS / oxygen as ordered. Monitor for effectiveness and side effects.<BR/>Review of Resident #18's Consolidated Physician Orders reflected an order dated 05/07/2023, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), Directions - 2 puff inhale orally every 4 hours as needed for Wheezing. There was no order for the care of Resident #18's Nebulizer, tubing, or mouthpiece.<BR/>Observation on 02/05/2024 at 11:13 AM, Resident #18 was in her room lying in the bed with a private caretaker present. Resident #18 had a nebulizer on her nightstand, which had tubing, and a mouthpiece attached, which contained a nebulizing chamber. Observed that the mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview on 02/05/2024 at 11:15 AM, Private Caretaker for Resident #18 stated that she does not administer nebulizer treatments to Resident #18 and that care of the nebulizer is the facility's responsibility. <BR/>Observation on 02/06/2024 at 8:00 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Observation on 02/07/2024 at 8:16 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was noted bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview and observation on 02/07/2024 at 9:00 AM, LVN A stated that she primarily works the day shift on the hallway of Resident #18. LVN A stated that their policy is to change oxygen tubing every Sunday and Wednesday night. LVN A stated they are to place their initials and the date on the tubing and mask. LVN A stated that nebulizer tubing / mouthpieces are to be treated the same as oxygen tubing and mask. LVN A stated that both mask and mouthpieces are to be always placed in bags when not in use. LVN A stated that failure to properly care for respiratory equipment could result in respiratory issues and posed an infection control issue. LVN A entered the room of Resident #18 and stated that it was not correct because the mouthpiece was not bagged, and nothing was dated. LVN A removed the tubing and mouthpiece and stated they were being changed out immediately. LVN A was unable to state how long the tubing and mouthpiece had been in the room of Resident #18. <BR/>Interview on 02/07/2024 at 9:13 AM, LVN B stated that their policy is to change out tubing and mask every Sunday night. LVN B stated that nebulizer tubing and mouthpieces are to be treated the same and changed out on Sunday night. LVN B stated that failure to change out tubing and mask / mouthpieces could result in bacteria growth and possibly lead to respiratory infection.<BR/>Interview on 02/07/2024 at 9:19 AM, the DON stated that respiratory tubing and mask / mouthpieces are to be changed out every Sunday night. The DON stated that failure to change out tubing and to properly date them could possibly lead to respiratory issues.<BR/>Interview on 02/07/2024 at 3:48 PM, the ADMINISTRATOR stated that it was his expectation that respiratory items be changed out weekly and dated. The Administrator stated that failure to do so could result in a Respiratory Infection. The ADMINSTRATOR provided the Oxygen Policy for the facility. <BR/>Review of the facility's TAR from February 1 - 7, 2024 revealed no documentation in reference to Resident #18's nebulizer tubing or mouthpiece and was not recorded as a treatment in their records.<BR/>Review of the facility's Oxygen Administration Policy, review date of 1/23, POLICY: The purpose of this procedure is to provide guidelines for safe oxygen administration. The Policy provided did not address nebulizers or oxygen tubing in reference to dating or replacement of tubing and mask / mouthpiece.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the residents environment remained as free of accident hazards as was possible in 14 of 50 resident room sinks (room [ROOM NUMBER], 226, 230, 303, 307, 310, 313, 317 319, 320, 325 329, 335, and 342) and 2 of 2 common shower areas (2nd and 3rd floor) reviewed for hot water.<BR/>The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident use hot water was not reliably controlled and ranged from between 118.4 F and 129.4 in reviewed locations. <BR/>This failure could place residents at risk for sustaining scalding injuries when using resident-use / resident accessible hot water. <BR/>Findings included:<BR/>Observation on 02/07/2024 at 8:16 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122 F. <BR/>Observation on 02/07/2024 at 8:46 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.1 F. <BR/>Observation on 02/07/2024 at 8:48 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 129.4 F. <BR/>Observation on 02/07/2024 at 9:51 AM, the hot water from the shower head in the 2nd floor shower room was checked with a digital thermometer and found to be 118.4 F.<BR/>Observation on 02/07/2024 at 9:55 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 125.6 F. <BR/>Observation on 02/07/2024 at 9:59 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.4 F. <BR/>Observation on 02/07/2024 at 10:10 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.8 F. <BR/>Observation on 02/07/2024 at 10:12 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.5 F. <BR/>Observation on 02/07/2024 at 10:35 AM, the hot water from the shower head in the 3rd floor shower room was checked with a digital thermometer and found to be 122.4 F.<BR/>Observation on 02/07/2024 at 10:37 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 125.4 F. <BR/>Observation on 02/07/2024 at 10:41 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 126.5 F. <BR/>Observation on 02/07/2024 at 10:44 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.4 F. <BR/>Interview and record review on 02/07/2024 at 10:50 AM, the Maintenance Director stated that they wanted to make sure they maintained safe water temperature in the facility. The Maintenance Director stated that they perform a daily hot water temperature check of at least one room in the facility and want the temperature to be 110 F or less. The Maintenance Director stated that if the reading does show high they do not adjust the boiler immediately because the temperatures can fluctuate but will make adjustments if it becomes a pattern. The Maintenance Director stated that he knew hot water could lead to skin burns in residents but could not state to what degree and time. The Maintenance Director provided their hot water log, which indicated a desired hot water temperature of between 105 F and 110 F and indicated a recording 02/07/2024 of 117.5. The Maintenance Director stated that they did raise the boiler temperature recently due to cooler weather but could not recall a date. The Maintenance Director stated that the reading today (2/7/24) was too high.<BR/>Interview on 02/07/2024 at 11:04 AM, the Plant Operator stated that he recorded the daily room hot water temperature check 02/07/2024 and recorded it in the log. The Plant Operator stated that if he remembered correctly he checked room [ROOM NUMBER] (no residents currently on the first floor) between 9:30 AM and 10:30 AM. The Plant Operator stated that the reading was above 110 F and they would continue to monitor and if a change was needed they would lower the boiler temperature. The Plant Manager stated that elevated water temperatures could result in skin burns depending on the water temperature and time of exposure. <BR/>Interview and observation on 02/07/2024 from 11:17 AM until 11:43 AM with the Maintenance Director as he conducted hot water temperature checks in the facility. The Maintenance Director stated that in order to obtain a proper temperature reading they are to hold their digital thermometer under the water until it remains unchanged. room [ROOM NUMBER] sink hot water tested and as the temperature raised on the thermometer the Maintenance Director stated, it's going up big time and then upon the final reading of 127.6 F stated that it was too hot. room [ROOM NUMBER] sink hot water was tested and displayed 126.5 F. room [ROOM NUMBER] sink hot water was tested and displayed 118.5 F. room [ROOM NUMBER] sink hot water was tested and displayed 122.4. room [ROOM NUMBER] sink hot water was tested and displayed 121.3 F. Shower room on the 3rd floor hot water was tested and displayed 120.2 F. room [ROOM NUMBER] sink hot water was tested and displayed 128.6 F. room [ROOM NUMBER] sink hot water was tested and displayed 126.2 F. Shower room on the 2nd floor hot water was tested and displayed 118.6 F. The Maintenance Director stated that they were going to have to change their policy / procedures to test multiple rooms on all floors daily to ensure temperatures were not out of range. The Maintenance Director stated that he was going immediately to the boiler to lower it and ensure the temperatures were at or below 110 F. <BR/>Interview on 02/07/2024 at 12:15 PM, the Division [NAME] President stated that a notice was sent throughout the facility for no hot water use until temperatures were returned to proper temperature. Division [NAME] President stated that staff were currently conducting skin assessments on every resident in the facility to ensure none were negatively affected by the hot water 02/07/2024. The Division [NAME] President stated that extended exposure to elevated water temperatures could result in skin burns. <BR/>Follow-up interview on 02/07/2024 at 12:36 PM, the Division [NAME] President stated that they not only lowered the boiler temperatures, but maintenance was bleeding the hot water tanks to speed the water-cooling process.<BR/>Interview on 02/07/2024 at 12:59 PM, the DON stated that skin assessments are routinely completed at shower time and there have been no reports of skin burns due to hot water. The DON stated that she completed an in-service with all staff for no hot water usage until the water temperatures are returned to a safe temperature. The DON stated that staff were currently finishing their skin assessments of residents. The DON stated residents could be burned by hot water depending on temperature and duration. <BR/>Follow-up interview and observation on 02/07/2024 from 1:40 PM to 1:56 PM with the Maintenance Director to verify water temperatures in various areas of the facility. Shower room on the 3rd floor hot water tested and displayed 103.8. room [ROOM NUMBER] sink hot water tested and displayed 106.4 F. room [ROOM NUMBER] sink hot water tested and displayed 106.2. room [ROOM NUMBER] sink hot water tested and displayed 110.3 F. Shower room on the 2rd floor hot water tested and displayed 93.7, which the Maintenance Director stated was probably an issue with a malfunctioning mixer. room [ROOM NUMBER] sink hot water tested and displayed 107.8 F. <BR/>Interview on 02/07/2024 at 3:48 PM, the ADMINISTRATOR stated that the water temperatures in the resident rooms and shared shower rooms should be at 110 F or less. The ADMINISTRATOR stated that water temperatures above 110 F could result in skin burns. <BR/>Review of in-service conducted on 02/07/2024 by the DON for RE: No usage of hot water at present All staff is to not use the hot water until further notice. (Temp adjustments in progress), which was signed by fourteen staff members.<BR/>Review of skin monitoring sheets provided by the DON from 02/07/2024. Assessments present for Census Residents totaling 55 with documentation of negative findings for burns or blisters being found on any resident.<BR/>Review of daily round logs indicated the following recorded dates and hot water temperatures, which are to be from any patient room and between (105-110 F). Recording of temperatures from 1/21/2024 through 2/7/2024 reflect: 1/21 of 117.1, 1/22 of 110.1, 1/23 of 110.1, 1/24 of 116, 1/25 of 117.0, 1/26 of 118.0, 1/27 of 121.0, 1/28 of 118.0, 1/29 of 117.0, 1/30 no temp recorded, 1/31 of 110.1, 2/1 of 110.1, 2/2 of 110, 2/3 of 110.1, 2/4 of 116.1, 2/5 of 111.1, 2/6 of 115.1 and 2/7 of 117.5.<BR/>Review of facility's Hot Water Temperature Policy, revised on 02/2024 revealed, POLICY It is the policy of [facility] to ensure the safety of patients and associates by regulating hot water temperature, in accordance with State Health Department regulations. PROCEDURE 1. The temperature of hot water used by patients (domestic hot water) in [facility] shall be maintained in accordance with state health department regulations (DOH). Absent state regulations, the following limits shall apply: a. 95-110 degrees Fahrenheit in residential treatment buildings / spaces (e.g. Nursing Homes and Long Term Care Units). 3. The temperature of domestic hot water is tested monthly as part of environmental maintenance checks.<BR/>Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F caused third degree burns in 1 minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #18) of 4 residents reviewed for respiratory care.<BR/>The facility failed to ensure that Resident #18's Nebulizer tubing and mouthpiece, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), were dated and replaced every seven (7) days. <BR/>The facility failed to ensure that Resident #18's Nebulizer mouthpiece was bagged when not in use.<BR/>These failures could place residents at risk for respiratory compromise and infection.<BR/>Findings included:<BR/>Review of Resident #18's Face Sheet dated 02/06/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Severe Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Dysphagia (swallowing difficulties), and Gastro-Esophageal Reflux Disease (stomach contents come back up into the esophagus).<BR/>Review of Resident #18's MDS Quarterly Assessment, dated 12/06/2023 revealed Resident #18 had a BIMS Score of 00 indicating severe cognitive impairment. <BR/>Review of Resident #18's Comprehensive Care Plan revealed a focus area dated 05/31/2022, The resident has altered respiratory status r/t cough / congestion / wheezing. Intervention with a revision date of 06/30/2023 indicated, Administer medication / puffers / NEBS / oxygen as ordered. Monitor for effectiveness and side effects.<BR/>Review of Resident #18's Consolidated Physician Orders reflected an order dated 05/07/2023, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), Directions - 2 puff inhale orally every 4 hours as needed for Wheezing. There was no order for the care of Resident #18's Nebulizer, tubing, or mouthpiece.<BR/>Observation on 02/05/2024 at 11:13 AM, Resident #18 was in her room lying in the bed with a private caretaker present. Resident #18 had a nebulizer on her nightstand, which had tubing, and a mouthpiece attached, which contained a nebulizing chamber. Observed that the mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview on 02/05/2024 at 11:15 AM, Private Caretaker for Resident #18 stated that she does not administer nebulizer treatments to Resident #18 and that care of the nebulizer is the facility's responsibility. <BR/>Observation on 02/06/2024 at 8:00 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was not bagged and there were no dates present on the tubing or mouthpiece.<BR/>Observation on 02/07/2024 at 8:16 AM, Resident #18 was in her room lying in bed with the nebulizer present on her nightstand. The mouthpiece was noted bagged and there were no dates present on the tubing or mouthpiece.<BR/>Interview and observation on 02/07/2024 at 9:00 AM, LVN A stated that she primarily works the day shift on the hallway of Resident #18. LVN A stated that their policy is to change oxygen tubing every Sunday and Wednesday night. LVN A stated they are to place their initials and the date on the tubing and mask. LVN A stated that nebulizer tubing / mouthpieces are to be treated the same as oxygen tubing and mask. LVN A stated that both mask and mouthpieces are to be always placed in bags when not in use. LVN A stated that failure to properly care for respiratory equipment could result in respiratory issues and posed an infection control issue. LVN A entered the room of Resident #18 and stated that it was not correct because the mouthpiece was not bagged, and nothing was dated. LVN A removed the tubing and mouthpiece and stated they were being changed out immediately. LVN A was unable to state how long the tubing and mouthpiece had been in the room of Resident #18. <BR/>Interview on 02/07/2024 at 9:13 AM, LVN B stated that their policy is to change out tubing and mask every Sunday night. LVN B stated that nebulizer tubing and mouthpieces are to be treated the same and changed out on Sunday night. LVN B stated that failure to change out tubing and mask / mouthpieces could result in bacteria growth and possibly lead to respiratory infection.<BR/>Interview on 02/07/2024 at 9:19 AM, the DON stated that respiratory tubing and mask / mouthpieces are to be changed out every Sunday night. The DON stated that failure to change out tubing and to properly date them could possibly lead to respiratory issues.<BR/>Interview on 02/07/2024 at 3:48 PM, the ADMINISTRATOR stated that it was his expectation that respiratory items be changed out weekly and dated. The Administrator stated that failure to do so could result in a Respiratory Infection. The ADMINSTRATOR provided the Oxygen Policy for the facility. <BR/>Review of the facility's TAR from February 1 - 7, 2024 revealed no documentation in reference to Resident #18's nebulizer tubing or mouthpiece and was not recorded as a treatment in their records.<BR/>Review of the facility's Oxygen Administration Policy, review date of 1/23, POLICY: The purpose of this procedure is to provide guidelines for safe oxygen administration. The Policy provided did not address nebulizers or oxygen tubing in reference to dating or replacement of tubing and mask / mouthpiece.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's nourishment refrigerators for 3 (Nourishment room [ROOM NUMBER], #3, and #4) of 5 nourishment room refrigerators reviewed for food and nutrition services.<BR/>1. <BR/>The facility failed to ensure the nourishment room refrigerator temperature logs were maintained in dining room [ROOM NUMBER], and nourishment refrigerators #3 and #4. <BR/>2. <BR/>The facility failed to ensure the dining room's refrigerator's cleanliness was maintained. <BR/>3. <BR/>The facility failed to ensure the nourishment refrigerator in unit 1 was free of pests. <BR/>These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. <BR/>Findings include: <BR/>Observation of the unit 3 and 4 dining room's refrigerator on 3/25/2025 at 12:18 PM revealed a lone sign posted to the front of the refrigerator notifying residents, families, and staff that the refrigerator was for residents only. No temperature log was visible on the front or either side of the refrigerator unit or on the surrounding countertops. Inside the refrigerator, the shelves were covered in stains, a single human hair was observed on the shelf, and on the inside door, 3 expired (12/2/2024 X2, 3/18/2024) sour cream packets and 4 expired half & half (1/15/23) cups were all in a bottom drawer.<BR/>Observation of the unit 4 nourishment refrigerator on 3/25/2025 at 12:30 PM revealed a sign notifying residents and staff that no outside food was allowed in the refrigerator or freezer, and a sleeve of 3 blank temperature logs and 2 temperature logs from November and December 2024 were fixed to the front of the refrigerator. <BR/>Observation of the unit 3 nourishment refrigerator on 3/25/2025 at 12:54 PM revealed a sign notifying residents and staff that no outside food was allowed in the refrigerator or freezer. No temperature log was visible on the front or either side of the refrigerator unit or on the surrounding countertops. Inside the freezer was a multi-use &frac12; gallon tub of homemade vanilla flavored ice cream with no resident's name or date visible. <BR/>Observation on 03/26/25 at 09:30 AM of the nourishment refrigerator in unit 1 revealed sugar ants crawling all along the seal of the freezer door when opened. When LVN C was notified of the bugs she asked the surveyor what she should do. The surveyor advised her to do whatever it was she would do if she noticed the bugs on her own. LVN C stated she would contact the DON and maintenance.<BR/>Observation on 03/26/25 at 09:35 AM revealed the ADON placing an Out of Order sign on unit 1's refrigerator and she was overheard to be contacting maintenance for service and the contracted kitchen for resident's replacement food and beverages. <BR/>Interview with the ADON on 3/25/2025 at 9:23 AM revealed that the contracted vendor for dietary is responsible for maintaining the temperature log and disposing of expired or unused foods. The facility was responsible for cleaning them.<BR/>Interview with the DON on 3/26/2025 at 9:35 AM revealed that the facility was responsible for maintaining the temperature logs, the CNA's were responsible for cleaning, and the night shift would maintain the cleanliness and temperatures. She stated that all residents, unless they have an NPO order, may have food and beverages from the nourishment refrigerators. <BR/>Interview with the ADM on 3/27/2025 at 10:23 AM revealed that the facility's kitchen would not be up and running for another 60 days. She stated they had gone back and forth between who was responsible for refrigerator cleanliness and maintenance. Originally, the contracted kitchen was responsible for maintaining it, but then the facility was told it would be their responsibility. She stated the contract between the facility and the contracted kitchen shows the facility as being responsible for temperature monitoring, and the contracted kitchen responsible for stock and cleanliness. She stated that overnight staff would be responsible for cleaning the dining room refrigerator. Her last understanding was that nursing staff would be responsible for maintaining temperature logs. <BR/>Record review of the facility's contract with the contracted kitchen revealed that {The contracted kitchen} will manage nutrition room stock and cleanliness with temperature monitoring to be done by {The facility} with a due date: to be determined by 9/9/24.<BR/>Record review of the facility's last 3 months of pest control invoices revealed the facility had a pest control company come out and administer various kinds of insect repellant's indoors and outdoors on 1/23/2025, 2/24/2025, and 3/25/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for medication administration, treatment administration, and wound administration. <BR/>1. <BR/> The facility failed to complete Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. <BR/>2. <BR/>The facility failed to accurately document Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. <BR/>3. <BR/>The facility failed to accurately document Resident #1's Controlled Drug Record for Hydrocodone-Acetaminophen 5-325 MG on 01/20/2025 at 5:00 PM with 58 tablets remaining and next entry on 01/21/2025 at 12:01 AM reflecting 56 tablets remaining,<BR/>4. <BR/>The facility failed to complete Resident #2's Medication Administration Record (MAR) for Lorazepam 0.5 MG for 12/1/2024 thru 12/31/2024 and 1/1/2025 thru 1/31/2025. <BR/>5. <BR/>The facility failed to complete Resident #2's Medication Administration Record (MAR) for Lorazepam 0.5 MG to reflected wrong dose of 2 tablets administered on 4/21/2024 as reflected on Resident #2's Controlled Drug Record for Hydrocodone. <BR/>6. <BR/>The facility failed to accurately document Resident #3's Medication Administration Record (MAR) for Hydrocodone for 04/21/2025 of three doses administered for the day as reflected on Resident #3's Controlled Drug Record for Hydrocodone. <BR/>7. <BR/>The facility failed to follow facility procedures to document a medication error in Resident #1, Resident #2, and Resident #3's electronic medical record, notify the physician, and notify the Resident's Representative. <BR/>This deficient practice placed residents who receive medications, treatments, and wound care from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications, treatment, or wound care due to inaccurate documentation of administration. <BR/>Findings included: <BR/>Review of Resident #1's face sheet reflected a [AGE] year old woman with an initial admission date of 1/17/2025 with diagnoses of cellulitis of abdominal wall, end stage renal disease (a medical condition where the kidneys have permanently lost their ability to function adequately), dependence on renal dialysis, morbid obesity due to excess calories (a medical condition where Body Mass Index (BMI) of 40 or higher), essential (primary) hypertension (a medical condition where a person's abnormally high blood pressure that's not the result of a medical condition), and anemia in chronic kidney disease (a medical condition where a person's blood has a lower-than-normal amount of red blood cells or hemoglobin). <BR/>Review of Resident #1's MDS dated [DATE] reflected a BIMS of 11 and had an active pain management regimen for frequent pain, documented surgical wounds and open lesion(s) other than ulcers, rashes, cuts, and taking antidepressants. <BR/>Review of Resident #1 active orders as of 01/21/2025 reflected resident had order for abdomen wound cleanse for wound healing three times a week with an order date of 01/21/2025. Further review reflected an order for <BR/>Review of 48-hour baseline care plan dated 01/17/2025 reflected resident had pain goal to experience less pain with medications, Norco, Tramadol, Acetaminophen and Pregabalin. Further review reflected resident had a pressure sore/skin at risk goal: prevent/heal pressure sores, resolve skin condition with treatment of Vacuum-Assisted Wound Closure (VAC) (a method of decreasing air pressure around a wound to assist the healing). Additional care plan summary reflected, We will monitor for signs of infection, manage pain, maintain hygiene around the wound .emphasizing the importance of maintaining a clean, airtight seal around the wound to ensure optimal healing with the vacuum therapy .as well as understanding the importance of regular monitoring and not missing treatment days. <BR/>Review of Resident #1 active orders as of 01/17/2025 reflected resident had order for Norco 5-325 MG (narcotic) every 4 hours as need for moderate to severe pain (6-10) for cellulitis of abdominal wall with a start date of 01/17/2025. Further review reflected active orders as of 01/21/2025 for Norco 10-325 MG (narcotic) every 4 hours as needed for pain with a start date of 01/21/2025.<BR/>Review of Resident #1 active orders as of 01/17/2025 reflected resident had order for Pregabalin (narcotic) two time a day for end stage renal disease with a start date of 01/18/2025. <BR/>Review of Resident #1 active orders as of 01/18/2025 reflected resident had order for tramadol (narcotic) every 8 hours as needed for pain (PRN) with a start date of 01/18/2025. Further review reflected active orders of 01/22/2025 for tramadol (narcotic) three times a day for cellulitis of abdominal wall with a start date of 01/22/2025. <BR/>Review of Resident #1 active orders as of 01/18/2025 reflected resident had order for abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 125 one time a day three times a week for wound healing with a start date of 01/20/2025. Further review reflected active orders as of 01/21/2025 reflected resident had order for abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 150 one time a day three times a week for wound healing with a start date of 01/22/2025.<BR/>Review of Resident #1 active order as of 01/22/2025 reflected resident had order for left groin cleanse wound with NS/wound cleanser Primary Dressing: Calcium Alginate, Santyl Secondary Dressing: ABD pad Secure with: tape as needed one time a day for wound healing with a start date of 01/22/2025. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected tramadol every 8 hours PRN had no administration entries. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected tramadol three times a day was administered once on 01/22/2025, three times on 01/23/2025 to 01/30/2025, and once on 01/31/2025. <BR/>Review of Resident #1 Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 125 for January 2025 reflected no order data found. Further review reflected Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected abdomen cleanse wound/wound cleanser Peri wound VAC drape [NAME] 150 for January 2025 reflected no order data found.<BR/>Review of Resident #1 Medication Administration Record (MAR), Treatment Administration Record (TAR) and Wound Administration Record reflected left groin cleanse wound with NS/wound cleanser Primary Dressing: Calcium Alginate, Santyl Secondary Dressing: ABD pad Secure with: tape for January 2025 reflected no order data found.<BR/>Review of Resident #1 Medication Administration Record (MAR) reflected Norco 5-325 MG (Hydrocodone-Acetaminophen) was administered on 01/20/2025 at 9:03 AM with pain level of 3 and 01/20/2025 at 5:50 PM with pain level of 3. Further review of Resident #1 Medication Administration Record (MAR) reflected Norco 10-325 MG (Hydrocodone-Acetaminophen) was administered on 01/21/2025 at 12:48 PM, 01/21/2025 at 11:37 PM, 01/22/2025 at 7:54 AM, 01/22/2025 at 1:56 PM, 01/23/2025 at 2:09 PM, 01/25/2025 at 6:33 AM, 01/26/2025 at 9:10 AM, and 01/28/2025 at 6:54 AM. <BR/>Review of Resident #1 Medication Administration Record (MAR) reflected Pregabalin was administered on twice on 01/19/2025, twice on 01/20/2025, twice on 01/21/2025, twice on 01/22/2025, twice on 01/23/2025, twice on 01/24/2025, twice on 01/25/2025, twice on 01/26/2025, twice on 01/27/2025, twice on 01/28/2025, twice on 01/29/2025, twice on 01/30/2025, twice on 01/31/2025. <BR/>Review of Resident #1 Controlled Drug Record reflected tramadol every 8 hours (three times) was administered once on 01/21/2025, once on 01/22/2025, three times on 01/23/2025 to 01/24/2025, twice on 01/25/2025, once on 01/26/2025, and once on 01/27/2025 with 18 tablets remaining. <BR/>Review of Resident #1 Controlled Drug Record reflected Pregabalin was administered on twice on 01/19/2025, twice on 01/20/2025, twice on 01/21/2025, twice on 01/22/2025, twice on 01/23/2025, twice on 01/24/2025, twice on 01/27/2025, and once on 01/28/2025 with a remaining capsule amount of 45. <BR/>Review of Resident #1 Controlled Drug Record reflected Hydrocodone-Acetaminophen 5-325 MG was administered on 01/20/2025 at 9:00 AM with 59 tablets remaining, 01/20/2025 at 5:00 PM with 58 tablets remaining, 01/21/2025 at 12:01 AM with 56 tablets remaining, 01/21/2025 at 7:00 AM with 55 tablets remaining, 01/21/2025 at 6:00 PM with 54 tablets remaining, 01/21/2025 at 11:48 PM with 53 tablets remaining, 01/22/2025 at 6:00 AM with 52 tablets remaining, 01/22/2025 at 8:00 AM with 50 tablets remaining, and 1/22/2025 at 12:00 PM with 48 tablets remaining. <BR/>Review of Resident #1 Controlled Drug Record reflected Hydrocodone-Acetaminophen 10-325 MG was administered on 01/23/2025 at 2:00 PM with 29 tablets remaining, 01/25/2025 at 6:00 AM with 28 tablets remaining, 01/26/2025 at 10:00 AM with 27 tablets remaining, and 01/28/2025 at 6:55 AM with 26 tablets remaining. <BR/>Review of Resident #2's face sheet reflected a [AGE] year-old male with an admission date of 03/12/2025 and initial admission date of 07/27/2022 with diagnoses of schizoaffective disorder, bipolar type, unspecified dementia, severe, with psychotic disturbance. <BR/>Review of Resident #2's MDS dated [DATE] reflected a BIMS of 04 and an active diagnosis of schizophrenia, depression, and bipolar disorder. <BR/>Review of Resident #2 active orders as of 05/30/2024 reflected resident had order for Lorazepam 0.5 MG (narcotic) every 4 hours as needed for anxiety with start date of 05/30/2024. <BR/>Review of Resident #2 Medication Administration Record (MAR) for 12/1/2024 thru 12/31/2024 and 1/1/2025 thru 1/31/2025 reflected Lorazepam 0.5 MG had no order data found. <BR/>Review of Resident #2 Controlled Drug Record reflected Lorazepam 0.5 MG was administered three times on 10/16/2024 with 2 tablets administered at 11:30 PM, once on 10/23/2024, once on 10/25/2024, once on 11/12/2024, once on 12/19/2024, and once on 1/21/2025 with 27 tablets remaining. <BR/>Review of Resident #3's face sheet reflected a [AGE] year-old female with an admission date of 01/10/2023 with diagnoses of unspecified dementia (is not specified by a doctor), low back pain, and pain unspecified. <BR/>Review of Resident #3's MDS dated [DATE] reflected a BIMS of 08 and an active diagnosis of unspecified dementia and low back pain, unspecified. <BR/>Review of Resident #3 active orders as of 11/12/2024 reflected resident had order for Hydrocodone 5-325 MG two times a day for pain management with a start date of 11/12/2024. <BR/>Review of Resident #3 Medication Administration Record (MAR) for 04/1/2025 - 04/30/2025 reflected Hydrocodone was administered twice a day from 04/01/2025 thru 04/30/2025. <BR/>Review of Resident #3 Controlled Drug Record reflected Hydrocodone was administered three times on 4/21/2025 with two does at 7:00 PM. <BR/>In an interview on 6/6/2025 at 9:58 AM LPN C stated the procedures of administering medication includes prescribed by physician, right patient, right medication, right dose. She stated if the wrong medication was administered immediately notify doctor of what was administered vs. what should have been administered, report to DON, a medication error report should be filled out, this was a paper form as it requires signatures, but the facility was currently transitioning out of this process. The least there should an incident report on the medication error. LPN C stated she feels there is room for improvement, current process needs to change. She stated she doesn't want to get anyone in trouble, but the current Medication Administration Record (MAR) and narcotic record logs are not being done correctly and this needs to be corrected. This practice could have a serious effect on a resident and their care. <BR/>In an interview on 6/6/2025 at 10:28 AM MA stated the procedures if a medication error occurred is to notify the charge nurse, the nurse notifies the DON, notify the physician, watch the resident for the next 24 hours, do vitals every 3-4 hours and submit an error report to the DON. The DON would then follow-up with staff who made the medication error and provide individual counseling. She stated not notifying the charge nurse of medication errors can have serious consequences for residents and can have serious harm on them. <BR/>In an interview on 6/6/2025 at 11:12 AM LPN B stated if she were to identify a medication error, she would notify the DON and physician, investigate why dose was missed or not given, determine if the resident refused and review resident's record to see if information was documented in progress notes. She stated all medication errors could be harmful to the resident and should always be documented and DON should always be notified. <BR/>In an interview on 6/6/2025 at 1:24 PM DON stated she provides staff with medication administration in-services. She stated she has not had any medication errors reported or documented by staff. She stated medication administration procedures includes the 6 rights - right does, right resident, right time. She stated she has trained staff to make sure delayed medication is not given to resident as this would be a wrong dose. A medication error as such would require staff to contact the nurse practitioner and stated staff have not reported medication errors to her. She stated not following these procedures can pose a safety issue for residents. She stated the narcotics require a Medication Administration Record (MAR) and a count sheet, which helps staff to keep medications counted for, correct times, documenting should be on count sheet and PCC. Reasons for Medication Administration Record (MAR) and count sheet is to ensure safety for residents. She stated that the pharmacist reviews resident's narcotic records. <BR/>In an interview and observation on 6/6/2025 at 2:54 PM DON stated she was unaware prior, but the narcotics that are PRN are separated from the narcotics that are scheduled. DON stated there are two different carts that carry narcotics and scheduled medications separately. She added that there are also different narcotic record count logs for scheduled and for PRN narcotics. She was observed searching through the carts and searching for the narcotic blister packs and narcotic logs for Resident #3. DON was able to locate the narcotic blister packs for both the PRN and scheduled narcotics for Resident #3; however, she was unable to locate the narcotic record logs for discontinued medications and discharged residents are kept. <BR/>In an interview on 6/6/2025 at 3:21 PM ADON stated medication administration timeframe window is one hour before and one hour after, staff is to document Medication Administration Record (MAR) after it is administered. Depending on the medication and orders staff may need to get blood pressure and pulse before administering. ADON stated narcotics documentation of pain scale may be required before and after administering, checking resident vital signs and will not give narcotics if blood pressure and/or pulse is low as respiratory system can be compromised with narcotics. She stated PRN narcotics require follow up. She stated if staff have a medication error they are required to report it to the DON. She stated staff would be required to self-report, make progress notes of medication error on the Medication Administration Record (MAR) and notify physician for directions. She stated she is not aware of any medication errors since her employment with the facility, beginning April 2025. she has been employed at this facility. <BR/>In an interview on 6/6/2025 at 3:37 PM MEDRC stated facility medical records retention policy was 7 years. She stated that she was tasked with locating the records of discharged residents and of discontinued narcotic records and she was unable to locate them. She stated she was not sure what the direct care staff did with these records, and she relies on the DON to submit them to her. <BR/>In an interview on 6/6/2025 at 3:41 PM DON stated she believes the missing narcotic logs are a process issue and the medications were administered as prescribed. She stated she was not aware that she should turn in discharge records or discontinued medication logs to the records staff. <BR/>In a phone interview on 6/6/2025 at 4:35 PM Clinical [NAME] President (CL VP) stated she was working on mapping the current issue onsite regarding medical records. She stated staff are working on producing missing logs. She stated she understands the facility needs to put a new system in place for the facility to ensure this doesn't occur in the future. She stated the current process regarding the retention of narcotic medication count needs to be corrected. She stated the DON should be responsible for the discontinued and discharge narcotic records She also stated staff will be ensuring only one narcotic record log is used for all residents being administered narcotics moving forward. She stated she would be working with the team to include ADM and DON in making these necessary changes to ensure resident safety. <BR/>In an interview on 6/11/2025 at 4:14 PM LPN WC stated the nursing staff have been in-serviced to document all medication administration, treatment administration, and wound care administration in the resident's Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR). If there is any deviation of the administration to notify the charge nurse to take the necessary steps to correct the issue. <BR/>In an interview on 6/12/2025 at 11:55 AM LPN WC B was asked by the DON to help verify wound care documentation that could not be located for Resident #1. LPN WC B stated she was responsible for wound care treatment and left employment at the facility at the end of February 2025. She stated she had documented Resident #1's Treatment Administration Record (TAR), and Wound Administration Record (WAR) with treatments she was given orders for. She stated she also entered progress notes surrounding any wound care treatment provided. LPN WC B stated she worked with the DON to locate these records and she was unsuccessful. She stated there was a lot of tension and friction working here at the facility because her treatment notes would be removed from the medical record. She stated she reported these issues directly to the ADM and DON and believes the Clinical [NAME] President (CL VP) was responsible for editing medical records and removing progress notes, deleting Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR). She believes this was being done only to her entries. She stated she ultimately decided to leave this facility because of these challenges. <BR/>Interview on 6/12/2025 at 12:51 PM DON stated she was familiar with Resident #1's care while she was a resident at the facility. She stated the Resident #1 was receiving wound care treatment and narcotics related to wound care. She stated she has reviewed the full chart for Resident #1, and she has not been able to locate the Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) for the month of January 2025 when she was a resident. She stated she cannot locate any treatment notes provided by LPN WC B. She stated the orders are present and accounted for, but not listed on the Treatment Administration Record (TAR), DON stated that LPN WC B reported wound care treatment to WC PH, but there is no supporting documentation of this progress. DON stated that she believes the wound care treatment was performed and documented, but for some reason the documentation is not accessible. <BR/>Interview on 6/12/2025 at 12:51 PM ADON stated she has been searching through Resident #1's medical records and she is unable to locate the Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) for wound care treatment, and she was not able to locate the narcotic record either. She stated the wound care was provided for Resident #1, but the administration records are not present. <BR/>Interview on 6/12/2025 at 1:41 PM RG RN stated she reviewed Resident #1, Resident #2, and Resident #3'sprogress notes, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Wound Administration Record (WAR) and she is unable to determine why there is documentation missing or not saved in the medical record. She stated there are physician notes to verify treatment and medication orders are present; however, there is no documentation to support the treatment or medication was administered. She stated the missing, incomplete, inaccurate, and unorganized documentation can be a serious problem for the care provided to residents and this is an area that needs to be worked on. She stated staff are being in-serviced on the importance of documenting the administration of medications, treatments, and wound care. <BR/>In an interview on 6/12/2025 at 2:33 PM LPN A stated if he is performing wound care on a new admission the procedure is to follow standing orders if no orders come with the resident. Standing orders include cleaning the wound, putting dressing, putting in orders for treatment, documenting progress notes the treatment provided, entering information on medication, treatment, and wound administration records. He stated the administration records are important to the care of the resident and need to be entered. All staff receive training on the importance of these records. <BR/>Interview on 6/12/2025 at 3:20 PM DON stated she was aware of previous issues with skin concerns and felt it necessary to conduct a full skin sweep of all residents at the facility. This skin sweep was conducted on 6/10/2025. She stated she does believe the wound care treatment was provided to Resident #1 and the ordered medications were administered correctly to Resident #1, Resident #2, and Resident #3 despite the unsporting documentation. DON stated the main issue here is the documentation. She stated staff will get better with documenting their progress, the treatments and medications provided to the residents. She stated the staff have received medication administration in-services within the last 30 days and will continue to in-service on the importance of complete, accurate, and organized documentation. <BR/>In a phone interview on 6/12/2025 at 4:24 PM PCP stated he has been in contact with the ADM and DON regarding Resident #1's missing documentation. He stated the team reached out to him and they were able to complete a QAPI meeting. He stated the team emphasized the wound care was done for the resident and the concern is the wound care wasn't documented as detailed as it should have been. He she the facility now has a wound care nurse that is different and documenting more and staying on top of it. He stated the wound care was getting done, not getting worse, treatment was being done using the standing order process. He understands documenting care was little to none. In his opinion if after seeing the wound if he believed the wound was not getting better or declining, he would have extended the course of antibiotics Resident #1 was on. PCP stated his NP tends to use a standard template, which he has counseled her against. He stated at times the standard template will not fully capture the full visit with the resident. He will remind his NP to not use a template for progress notes as this can get her and the facility into issues. He asked for additional time to review additional medical file to give opinion on. <BR/>In a phone interview on 6/12/2025 at 5:22 PM PCP stated he is a firm believer that just because you provided the care of treatment without it being documented it is as if you didn't perform it. He stated he will stress to the facility and the administration staff the importance of documenting all administration for a resident, they will be in-servicing on this topic, also to include standing orders, what steps to take when a new wound is noticed, automatically documenting the chart. He stated a lot of in-servicing is needed and the staff needs to be better with documenting in PCC. He stated the documentation and records retention for narcotic records needs to be a priority and will also be in-serviced and part of the<BR/>quality assurance and performance improvement (QAPI). He stated that he did speak to the team to include the corporate nurse regarding complete, accurate, and organized documentation in PCC. <BR/>Record review of Medication Administration Policy, reference date 2024 revealed, <BR/>10. Ensure that the six rights of medication administration are followed: <BR/>a. <BR/>Right resident<BR/>b. <BR/>Right drug<BR/>c. <BR/>Right dosage<BR/>d. <BR/>Right route<BR/>e. <BR/>Right time <BR/>f. <BR/>Right documentation <BR/>11. Review Medication Administration Record (MAR) to identify medication to be administered. <BR/>12. Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time. <BR/>20. Sign Medication Administration Record (MAR) after administered. For those medications requiring vital signs, record vital signs on the Medication Administration Record (MAR). <BR/>21. If medication is a controlled substance, sign narcotic book. <BR/>23. Correct any discrepancies and report to nurse manager. <BR/>Record review of Wound Treatment Management Policy, reference date 2019, revealed 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. <BR/>Record review of documented titled, Controlled Drug Receipt/Proof-Of-Use/Disposition form, no date provided, revealed the form provided a reminder to the staff administering medication, Each dose signed for here requires charting on the medication record. <BR/>Record review of the facility's (3) narcotic record logs in use, Controlled Drug Receipt/Proof-Of-Use/Disposition, Controlled Drug Record Individual Patient's Narcotic Record and Controlled Drug Receipt/Proof-Of-Use/Disposition forms, revealed facility staff do not have a uniformed and organized system to record narcotics administered to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop policies and procedures to ensure that each resident is offered a pneumococcal immunization, for 1 of 5 residents (Resident #17) reviewed for compliance for receiving the pneumococcal immunization, in that:<BR/>Resident #17 did not receive a pneumococcal vaccine as prescribed.<BR/>This failure could have placed residents at risk for contracting and spreading an infectious and potentially serious bacterial lung disease.<BR/>The findings include:<BR/>A record review of Resident #17's admission record dated 12/7/2022, revealed an admission date of 3/11/2021, with diagnoses which included chest pain, essential hypertension [high blood pressure], and dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities].<BR/>A record review of Resident #17s annual MDS, dated [DATE], revealed Resident #17 was an [AGE] year-old female, admitted for long term care with needs for health status improvement and or maintenance specific for medically complex conditions.<BR/>A record review of Resident #17's December 2022 physician's order summary, dated 12/6/2022, revealed orders for Resident #17 to receive a prevnar13 [a pneumococcal conjugate vaccine which helps protect against bacteria that cause pneumococcal disease] vaccination at least 1 year after the administration of a pneumococcal vaccine. [note- there CDC recommends 2 vaccines to prevent a pneumonia infection to be given at least 1 year apart]. <BR/>A record review of Resident #17's immunization summary dated 12/6/2022, revealed Resident #17 was administered a pneumovax23 [a vaccine that helps protect against infection by 23 types of pneumococci in people [AGE] years of age and older] vaccine on 3/7/3021. Further review did not evidence another pneumococcal vaccine was administered.<BR/>During an interview on 12/6/2023 at 5:17 PM Resident #17 stated she could not recall if she had received the pneumococcal vaccine but would not be opposed to receiving the vaccine if it was offered to her. <BR/>During an interview on 12/7/2022 at 1:40 PM LVN G stated he was Resident #17's charge nurse. LVN G stated he did not find any documentation to reveal Resident #17 received a subsequent pneumococcal vaccine after the pneumovax23 vaccination on 3/7/2021. <BR/>During a joint interview with the DON and The ADON on 12/7/2022 at 4:30 PM the ADON and the DON stated they were responsible for administering vaccinations as ordered by physicians. The ADON and the DON stated they were responsible for a monthly review of the vaccination status of all residents, which would include the pneumococcal vaccinations. The ADON stated Resident #17 was admitted [DATE] and had received a pneumovax23 [a pneumococcal vaccine] vaccine upon admission and received orders for another pneumococcal vaccine at least 1 year after the pneumovax23 vaccine. The ADON stated Resident #17 would have been eligible for the pneumococcal vaccine as early as March 2022. The ADON stated she had no evidence Resident #17 was reviewed for compliance with the physician's order for the pneumococcal vaccine from March to November 2022. The ADON stated Residents who are not offered the vaccine could be at risk for contracting pneumonia [an infection that inflames the air sacs in one or both lungs]. The DON stated Resident #17 was eligible for the pneumococcal vaccine as early as March 2021 but as of 12/6/2022 had not been offered or received the pneumococcal vaccine. The DON stated she and her ADON did not review Resident #17 for receiving the pneumococcal vaccine due to the COVID-19 pandemic and general workloads. The DON stated their failure to offer residents the vaccines placed residents at risk for contracting pneumonia.<BR/>A record review of the facility's Immunizations, Pneumococcal policy, dated July 2022, revealed, this describes the protocol for vaccinating patients who meet the criteria established by the Centers for Disease control and prevention advisory committee on immunization practice. Procedures: nurse assesses and documents the patient's pneumococcal vaccine history on admission. based on screening information the following protocol will provide a profile for vaccination administration. Patients eligible for pneumococcal conjugate vaccine (PVC13 or Prevnar13): patient 65 years and older, who have previously received a pneumococcal vaccine more than a year ago and before the age of 65 . nurse will administer vaccine and document in patient record: administration of PCV13 two eligible patients, document date, time, manufacturer, lot number, site, and route. Patients' vaccination information will appear in the electronic health record for multidisciplinary access.<BR/>A record review of the CDC's website https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm<BR/>accessed 12/14/2022, titled Morbidity and Mortality Weekly Report (MMWR); Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP); September 4, 2015, revealed, The recommended intervals between PCV13 and PPSV23 given in series differ by age and risk group and the order in which the two vaccines are given (1-4).<BR/>On June 25, 2015, ACIP changed the recommended interval between PCV13 followed by PPSV23 (PCV13-PPSV23 sequence) from 6-12 months to ?1 year for immunocompetent adults aged ?65 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area, each resident's bedside; and toilet and bathing facilities for 1 of 15 residents (Resident #49) reviewed for nurse alert call system, in that:<BR/>Resident #49 was placed in a room where the nurse alert call system was inoperable.<BR/>This failure could have placed residents at risk for neglect by not having a way to alert staff when care was needed. <BR/>The findings included:<BR/>A record review of Resident #49's admission record revealed an admission date of 11/16/2022, with diagnoses which included COVID-19, cerebral infarction due to embolism of bilateral cerebellar arteries [occurs when a blood clot that forms elsewhere in the body breaks loose and travels to the brain via the bloodstream], and anxiety disorder.<BR/>A record review of Resident #49's admission MDS, dated [DATE], revealed Resident #49 was a [AGE] year-old female admitted with needs for hospice care, and COVID-19 recovery complicated by a history of cerebral infarction resulting in limited functional abilities. Resident #49 was assessed not able to self-ambulate or self-transfer out of bed. Resident #49 needed assistance for all activities of daily living complicated by bowel and bladder incontinence. Further review revealed Resident #49 was at risk for falls and at risk for development of pressure ulcers. <BR/>A record review of Resident #49's care plan, dated 12/7/2022, revealed, the resident has a communication problem related to hearing deficit; ensure and provide a safe environment; the resident is at risk for falls related to weakness; be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. the resident needs prompt response to all requests for assistance .<BR/>A record review of Resident #49's physicians order summary, dated 12/7/2022, revealed, placed on COVID hot isolation unit for COVID-19 positive status .<BR/>During an observation and interview on 12/6/2022 at 5:30 PM revealed Resident #49 lying in bed in her COVID-19 isolation room with the door closed. Further observation revealed Resident #49 was not supported with a nurse call alert button and or cord. The wall plate which would connect the nurse call light button and cord presented with a broken plug without a cord or button attached. Resident #49 stated she did not have a way to call staff. <BR/>During an observation and interview on 12/6/2022 at 5:34 PM revealed CNA H in Resident #49's room and repositioned Resident #49 searching for Resident #49 nurse alert call light device. CNA H stated Resident #49 did have a call light button, but it was not like anyone else's, She has a wireless call light button. CNA H stated the call light button alerts at the nurse's station on a separate device. CNA H stated Resident #49 uses her call light button. CNA H stated the call light for Resident #49's room has been inoperable for more than a month. Upon assessment of Resident #49, CNA H could not find Resident #49's nurse alert wireless pendant.<BR/>During an observation and interview on 12/6/2022 at 5:37 PM revealed RN I in Resident #49's room assisting CNA H with the search for Resident #49's wireless nurse alert pendant. Further observation revealed the wireless nurse alert pendant was discovered among the sheets tucked into the bedside and was returned to Resident #49 for use. RN I stated the call light for Resident #49's room was inoperable, and the staff and Resident #49 relied on a wireless pendant nurse alert button Resident #49 wore around her neck. RN I stated she did not know how long Resident #49's nurse call light was inoperable. RN I stated Resident #49's wireless pendant alert button sounded at the separate device located at the nurse's station, it is a separate box at the nurse station. RN I stated the nurse call light outside of Resident #49 room was inoperable and if Resident #49 used her wireless call light pendant it would not illuminate the nurse call light outside of Resident #49 room.<BR/>During an interview on 12/8/2022 at 11:40 AM the DON stated the call light system for Resident #49's room was inoperable and was unrepairable. The DON referred to the Administrator for more information. The DON stated the wireless call light pendant was issued to Resident #49 as a fill in for the faulty installed nurse call light system. The DON stated the nurse call light outside of Resident #49 room was inoperable and if Resident #49 used her wireless call light pendant it would not illuminate the nurse call light outside of Resident #49 room.<BR/>During an interview on 12/8/2022 at 1:50 PM the Administrator stated the nurse call light outside of Resident #49 room was inoperable and if Resident #49 used her wireless call light pendant it would not illuminate the nurse call light outside of Resident #49 room. The Administrator stated Resident #49's nurse call alert system has been repaired (12/8/2022) and was now fully functional as designed. The Administrator stated he was alerted to Resident #49's isolation COVID-19 room's nurse call light system was inoperable at the beginning of the COVID-19 outbreak around 11/26/2022. The Administrator stated the room was needed to care for COVID-19 positive residents and a wireless call light device was utilized while repairs were under way. <BR/>A record review of the facility's Call Light policy, dated 6/14/2006, revealed, Purpose: To respond promptly to patients call for assistance and to ensure call system is in proper working order . Equipment: bedside call light and functioning order emergency call light in functioning order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #46 and Resident #48).<BR/>A) The facility failed to ensure Resident #46's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. <BR/>B) The facility failed to ensure Resident 48's catheter was secured to his body with a catheter secure device per the physician's orders and facility policy.<BR/>This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.<BR/>Findings included:<BR/>A) Review of Resident #46's Face Sheet dated 02/07/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) and obstructive and reflux uropathy (Is a term that refers to conditions that affect the urinary tract due to blockage or backward flow of urine).<BR/>Review of Resident #46's Annual MDS assessment dated [DATE] reflected Resident #46 was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #46 was assessed to be dependent on staff for all ADLs. Resident #46 was further assessed to have an indwelling catheter. <BR/>Review of Resident #46's Comprehensive Care plan reflected a focus area dated 01/13/2023 The resident has a Foley Catheter 22 French . Further review reflected an intervention Check foley stabilization device placement every shift . <BR/>Review of Resident #46's Consolidated physician orders reflected an order dated 01/28/2024 Foley Catheter 22 French 10 ml bulb change every month . further review reflected an order dated 01/13/2023 Check foley Stabilization device placement every shift. <BR/>Review of Resident #46's TAR dated February 2024 reflected an entry for the Foley catheter to be changed every month on the 28th. Further review reflected no entry for monitoring the foley stabilization every shift.<BR/>Observation on 02/06/2024 at 10:00 AM revealed CNA C and D in Resident #46's room to perform catheter care. Observation revealed Resident #46 had a catheter secure device taped to his right thigh however the catheter tubing was not secured into the device. <BR/>In an interview on 02/06/2024 at 10:05 AM CNA C stated that the secure catheter device for Resident #46 comes open all the time and was not working. She stated she would get the nurse to put the catheter back into the device since she had not been trained on the device and was not sure how to put the catheter back into the device.<BR/>B) Review of Resident #48's Face sheet dated 02/07/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Malignant Neoplasm of the prostate (A cancer of the prostate gland, a part of the male reproductive system. Prostate is a small walnut-shaped gland in males that produces the seminal fluid that nourishes and transports sperm. This causes blood in urine, blood in semen, painful ejaculation, and erectile dysfunction.), and Obstructive and reflux uropathy (Obstructive uropathy is a hindrance to normal urinary flow that can be caused by a variety of structural and functional etiologies.). <BR/>Review of Resident #48's Quarterly MDS dated [DATE] reflected Resident #48 was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #48 was further assessed to be dependent on staff for ADL assistance and was assessed to have an indwelling catheter. <BR/>Review of Resident #48 Comprehensive Care Plan reflected a focus area dated 09/13/2023 which reflected The resident has Foley Catheter 18 French related to prostate cancer and obstructive uropathy. Interventions included .position catheter bag and tubing below the level of bladder .Monitor for pain/discomfort due to catheter . Resident #48's care plan did not address securing the indwelling catheter to prevent dislodgement. <BR/>Review of Resident #48's Consolidated physician orders reflected an order dated 02/06/2024 Foley Catheter 18 French to be changed once monthly and PRN. Further review reflected an order dated 09/19/2023 Check foley stabilization device placement every shift. <BR/>Review of Resident #48's TAR dated February 2024 reflected an entry to check Foley stabilization device placement every shift. Further review of the TAR reflected the entry was documented as being checked every shift. <BR/>Observation on 02/06/2024 at 11:17 AM revealed LVN A in Resident #48's room to perform care. LVN A removed Resident #48's covers to reveal he had an indwelling catheter. Resident #48 had a secure catheter device taped to his right thigh. The device latch was open, and the catheter tubing was not secured into the device leaving the catheter tubing lying between Resident #48's legs. <BR/>In an interview on 02/06/2024 at 11:36 AM LVN A stated the catheter secure device was not functioning properly and they have been having issues with the devices. She stated the devices come open very easily and come open all the time causing the tubing to not be secured. She stated the catheter tubing should be secured at all times to prevent pulling on the tube or dislodgement. <BR/>In an interview on 02/06/2024 at 2:48 PM the Interim DON stated she was not aware that the catheter secure devices being used by the facility were not working properly. She stated it is the facility's policy that catheter tubing be secured to the resident at all times to prevent dislodgement or traumatic removal.<BR/>Review of the facility's policy Catheter Care, Urinary dated 04/2022 reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts reviewed for medication storage. <BR/>The facility failed to ensure the medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA E on 3/26/25 at 10:30am. <BR/>This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles.<BR/>Findings included:<BR/>Observation on 03/26/2025 at 10:30am MA E left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway over the counter medication Oscal (a calcium supplement) and Vitamin D supplement were left out on top of cart while she administered medications inside of the room. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated the medication cart should never be left unlocked or unattended. MA E stated medications should not be left out on the top of the cart while it is unattended. She stated leaving the medication cart unlocked and medications out on top of it could allow other staff to have access to the medication cart resulting in missing medications. She stated a resident could take medications that were not prescribed to them causing allergic reactions and medication errors. <BR/>In an interview on 3/27/25 at11:45am the DON stated she expects all staff who use the medication cart to have the cart locked unless they are actively using the cart. The DON stated staff were given constant reminders to lock the cart. She stated nursing staff had skills check off yearly for competency training on medication pass completed by the ADON. She stated MA's were required to participated in the skills check off. She stated the Pharmacists also completes a medication pass with the staff to ensure competency . She stated leaving the medication cart unlocked could allow other staff and resident access to medications causing missing medications or serious injuries related to drug reactions.<BR/>Review of the facility's undated policy titled Medication Storage reflected: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts reviewed for medication storage. <BR/>The facility failed to ensure the medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA E on 3/26/25 at 10:30am. <BR/>This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles.<BR/>Findings included:<BR/>Observation on 03/26/2025 at 10:30am MA E left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway over the counter medication Oscal (a calcium supplement) and Vitamin D supplement were left out on top of cart while she administered medications inside of the room. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated the medication cart should never be left unlocked or unattended. MA E stated medications should not be left out on the top of the cart while it is unattended. She stated leaving the medication cart unlocked and medications out on top of it could allow other staff to have access to the medication cart resulting in missing medications. She stated a resident could take medications that were not prescribed to them causing allergic reactions and medication errors. <BR/>In an interview on 3/27/25 at11:45am the DON stated she expects all staff who use the medication cart to have the cart locked unless they are actively using the cart. The DON stated staff were given constant reminders to lock the cart. She stated nursing staff had skills check off yearly for competency training on medication pass completed by the ADON. She stated MA's were required to participated in the skills check off. She stated the Pharmacists also completes a medication pass with the staff to ensure competency . She stated leaving the medication cart unlocked could allow other staff and resident access to medications causing missing medications or serious injuries related to drug reactions.<BR/>Review of the facility's undated policy titled Medication Storage reflected: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the residents environment remained as free of accident hazards as was possible in 14 of 50 resident room sinks (room [ROOM NUMBER], 226, 230, 303, 307, 310, 313, 317 319, 320, 325 329, 335, and 342) and 2 of 2 common shower areas (2nd and 3rd floor) reviewed for hot water.<BR/>The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident use hot water was not reliably controlled and ranged from between 118.4 F and 129.4 in reviewed locations. <BR/>This failure could place residents at risk for sustaining scalding injuries when using resident-use / resident accessible hot water. <BR/>Findings included:<BR/>Observation on 02/07/2024 at 8:16 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122 F. <BR/>Observation on 02/07/2024 at 8:46 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.1 F. <BR/>Observation on 02/07/2024 at 8:48 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 129.4 F. <BR/>Observation on 02/07/2024 at 9:51 AM, the hot water from the shower head in the 2nd floor shower room was checked with a digital thermometer and found to be 118.4 F.<BR/>Observation on 02/07/2024 at 9:55 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 125.6 F. <BR/>Observation on 02/07/2024 at 9:59 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.4 F. <BR/>Observation on 02/07/2024 at 10:10 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.8 F. <BR/>Observation on 02/07/2024 at 10:12 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.5 F. <BR/>Observation on 02/07/2024 at 10:35 AM, the hot water from the shower head in the 3rd floor shower room was checked with a digital thermometer and found to be 122.4 F.<BR/>Observation on 02/07/2024 at 10:37 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 125.4 F. <BR/>Observation on 02/07/2024 at 10:41 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 126.5 F. <BR/>Observation on 02/07/2024 at 10:44 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122.4 F. <BR/>Interview and record review on 02/07/2024 at 10:50 AM, the Maintenance Director stated that they wanted to make sure they maintained safe water temperature in the facility. The Maintenance Director stated that they perform a daily hot water temperature check of at least one room in the facility and want the temperature to be 110 F or less. The Maintenance Director stated that if the reading does show high they do not adjust the boiler immediately because the temperatures can fluctuate but will make adjustments if it becomes a pattern. The Maintenance Director stated that he knew hot water could lead to skin burns in residents but could not state to what degree and time. The Maintenance Director provided their hot water log, which indicated a desired hot water temperature of between 105 F and 110 F and indicated a recording 02/07/2024 of 117.5. The Maintenance Director stated that they did raise the boiler temperature recently due to cooler weather but could not recall a date. The Maintenance Director stated that the reading today (2/7/24) was too high.<BR/>Interview on 02/07/2024 at 11:04 AM, the Plant Operator stated that he recorded the daily room hot water temperature check 02/07/2024 and recorded it in the log. The Plant Operator stated that if he remembered correctly he checked room [ROOM NUMBER] (no residents currently on the first floor) between 9:30 AM and 10:30 AM. The Plant Operator stated that the reading was above 110 F and they would continue to monitor and if a change was needed they would lower the boiler temperature. The Plant Manager stated that elevated water temperatures could result in skin burns depending on the water temperature and time of exposure. <BR/>Interview and observation on 02/07/2024 from 11:17 AM until 11:43 AM with the Maintenance Director as he conducted hot water temperature checks in the facility. The Maintenance Director stated that in order to obtain a proper temperature reading they are to hold their digital thermometer under the water until it remains unchanged. room [ROOM NUMBER] sink hot water tested and as the temperature raised on the thermometer the Maintenance Director stated, it's going up big time and then upon the final reading of 127.6 F stated that it was too hot. room [ROOM NUMBER] sink hot water was tested and displayed 126.5 F. room [ROOM NUMBER] sink hot water was tested and displayed 118.5 F. room [ROOM NUMBER] sink hot water was tested and displayed 122.4. room [ROOM NUMBER] sink hot water was tested and displayed 121.3 F. Shower room on the 3rd floor hot water was tested and displayed 120.2 F. room [ROOM NUMBER] sink hot water was tested and displayed 128.6 F. room [ROOM NUMBER] sink hot water was tested and displayed 126.2 F. Shower room on the 2nd floor hot water was tested and displayed 118.6 F. The Maintenance Director stated that they were going to have to change their policy / procedures to test multiple rooms on all floors daily to ensure temperatures were not out of range. The Maintenance Director stated that he was going immediately to the boiler to lower it and ensure the temperatures were at or below 110 F. <BR/>Interview on 02/07/2024 at 12:15 PM, the Division [NAME] President stated that a notice was sent throughout the facility for no hot water use until temperatures were returned to proper temperature. Division [NAME] President stated that staff were currently conducting skin assessments on every resident in the facility to ensure none were negatively affected by the hot water 02/07/2024. The Division [NAME] President stated that extended exposure to elevated water temperatures could result in skin burns. <BR/>Follow-up interview on 02/07/2024 at 12:36 PM, the Division [NAME] President stated that they not only lowered the boiler temperatures, but maintenance was bleeding the hot water tanks to speed the water-cooling process.<BR/>Interview on 02/07/2024 at 12:59 PM, the DON stated that skin assessments are routinely completed at shower time and there have been no reports of skin burns due to hot water. The DON stated that she completed an in-service with all staff for no hot water usage until the water temperatures are returned to a safe temperature. The DON stated that staff were currently finishing their skin assessments of residents. The DON stated residents could be burned by hot water depending on temperature and duration. <BR/>Follow-up interview and observation on 02/07/2024 from 1:40 PM to 1:56 PM with the Maintenance Director to verify water temperatures in various areas of the facility. Shower room on the 3rd floor hot water tested and displayed 103.8. room [ROOM NUMBER] sink hot water tested and displayed 106.4 F. room [ROOM NUMBER] sink hot water tested and displayed 106.2. room [ROOM NUMBER] sink hot water tested and displayed 110.3 F. Shower room on the 2rd floor hot water tested and displayed 93.7, which the Maintenance Director stated was probably an issue with a malfunctioning mixer. room [ROOM NUMBER] sink hot water tested and displayed 107.8 F. <BR/>Interview on 02/07/2024 at 3:48 PM, the ADMINISTRATOR stated that the water temperatures in the resident rooms and shared shower rooms should be at 110 F or less. The ADMINISTRATOR stated that water temperatures above 110 F could result in skin burns. <BR/>Review of in-service conducted on 02/07/2024 by the DON for RE: No usage of hot water at present All staff is to not use the hot water until further notice. (Temp adjustments in progress), which was signed by fourteen staff members.<BR/>Review of skin monitoring sheets provided by the DON from 02/07/2024. Assessments present for Census Residents totaling 55 with documentation of negative findings for burns or blisters being found on any resident.<BR/>Review of daily round logs indicated the following recorded dates and hot water temperatures, which are to be from any patient room and between (105-110 F). Recording of temperatures from 1/21/2024 through 2/7/2024 reflect: 1/21 of 117.1, 1/22 of 110.1, 1/23 of 110.1, 1/24 of 116, 1/25 of 117.0, 1/26 of 118.0, 1/27 of 121.0, 1/28 of 118.0, 1/29 of 117.0, 1/30 no temp recorded, 1/31 of 110.1, 2/1 of 110.1, 2/2 of 110, 2/3 of 110.1, 2/4 of 116.1, 2/5 of 111.1, 2/6 of 115.1 and 2/7 of 117.5.<BR/>Review of facility's Hot Water Temperature Policy, revised on 02/2024 revealed, POLICY It is the policy of [facility] to ensure the safety of patients and associates by regulating hot water temperature, in accordance with State Health Department regulations. PROCEDURE 1. The temperature of hot water used by patients (domestic hot water) in [facility] shall be maintained in accordance with state health department regulations (DOH). Absent state regulations, the following limits shall apply: a. 95-110 degrees Fahrenheit in residential treatment buildings / spaces (e.g. Nursing Homes and Long Term Care Units). 3. The temperature of domestic hot water is tested monthly as part of environmental maintenance checks.<BR/>Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F caused third degree burns in 1 minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts reviewed for medication storage. <BR/>The facility failed to ensure the medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA E on 3/26/25 at 10:30am. <BR/>This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles.<BR/>Findings included:<BR/>Observation on 03/26/2025 at 10:30am MA E left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway over the counter medication Oscal (a calcium supplement) and Vitamin D supplement were left out on top of cart while she administered medications inside of the room. <BR/>In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated the medication cart should never be left unlocked or unattended. MA E stated medications should not be left out on the top of the cart while it is unattended. She stated leaving the medication cart unlocked and medications out on top of it could allow other staff to have access to the medication cart resulting in missing medications. She stated a resident could take medications that were not prescribed to them causing allergic reactions and medication errors. <BR/>In an interview on 3/27/25 at11:45am the DON stated she expects all staff who use the medication cart to have the cart locked unless they are actively using the cart. The DON stated staff were given constant reminders to lock the cart. She stated nursing staff had skills check off yearly for competency training on medication pass completed by the ADON. She stated MA's were required to participated in the skills check off. She stated the Pharmacists also completes a medication pass with the staff to ensure competency . She stated leaving the medication cart unlocked could allow other staff and resident access to medications causing missing medications or serious injuries related to drug reactions.<BR/>Review of the facility's undated policy titled Medication Storage reflected: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, interview and record review the facility failed to ensure nurse staffing information was posted to include: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift for, registered nurses, licensed practical nurses or licensed vocational nurses, certified nurse aides, and resident census for 1 of 1 day (07/09/25) reviewed for posted nurse staffing information. The facility failed to have daily nurse staffing posted on 07/09/25. This failure could place residents at risk of not knowing how many nursing staff should be present in the facility. Based on observation, interview and record review the facility failed to ensure nurse staffing information was posted to include: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift for, registered nurses, licensed practical nurses or licensed vocational nurses, certified nurse aides, and resident census for 1 of 1 day (07/09/25) reviewed for posted nurse staffing information. The facility failed to have daily nurse staffing posted on 07/09/25. This failure could place residents at risk of not knowing how many nursing staff should be present in the facility. Findings include: Observation on 07/09/25 at 05:10 AM revealed no posted nurse staffing in the building. There was a binder in the front lobby which contained the schedules, but this document did not include the required number of licensed nursing staff for each shift. The lobby, the 2nd floor nurse's station, the 3rd floor nurse's station, and all walls of all hallways were checked for the posted nurse staffing information, and the posting was not present. During an interview on 07/09/25 at 01:00 PM, the DON stated she thought the schedule binder in the lobby met the posted nurse staffing information requirement. She then stated she did not know there was a requirement to post nurse staffing and did not understand how to get to that report in her system. The DON denied any knowledge of who should be posting the nurse staffing. During an interview on 07/09/25 at 01:05 PM, the RNC stated she was aware of the requirement to post nurse staffing and was not aware the facility was not doing it. She stated she thought the binder in the lobby was the nurse staffing, but she had learned it was the schedule. She stated the schedule did not meet the requirement. She stated it was the DON's responsibility to ensure staffing information was posted. She stated she had shown the DON how to pull the report in their electronic system. Record review of the facility's, undated, policy titled Nurse Staffing Posting Information reflected the following: Policy: it is the policy of this facility to make sure nurse staffing information readily available in a readable format to residence, staff, and visitors at any given time.Policy explanation and compliance guidelines&gt;The nurse staffing sheet will be posted on a daily basis, and will contain the following information:-Facility name-The current date-Facility's current resident census&gt;The total number and the actual hours worked by the following categories of licensed and unlicensed, nursing staff, directly responsible for resident care per shift:-Registered nurses-Licensed practical nurses/licensed vocational nurse-Certified nurse aidesThe facility will post the nurse staffing sheet at the beginning of each shift.The information posted will be:&gt;Presented in a clear and readable format&gt;In a prominent place, readily accessible to residents, staff, and visitors.