COTTONWOOD NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #23 and Resident #26) of nineteen residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #23 and Resident #26's rooms were in a position that was accessible to the residents.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Resident #23 <BR/>Review of Resident #23's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included lack of coordination and weakness.<BR/>Review of Resident #23's Quarterly MDS Assessment, dated 05/01/2024, reflected Resident #23 had a moderate impairment in cognition with a BIMS score of 09. Resident #23 was dependent to staff for toileting, shower, dressing, and personal hygiene. <BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/07/2024, reflected Resident #23 was at risk for falls related to deconditioning due to CVA (cerebrovascular accident: stroke) with hemiparesis (weakness on one side of the body) and one of the interventions was to be sure the call light was within reach.<BR/>Observation and interview with Resident #23 on 07/09/2024 at 9:15 AM revealed Resident #23 was in her bed, awake. Resident #23's call light was observed on the floor and under the bed of the resident. Resident #23 tried to search for her call light because she said she needed to be changed. Resident #23 stated she could not even find the cord of the call light to pull it. She said the staff should put her call light where she could reach it because it was hard for her to move.<BR/>Observation and interview with CNA A on 07/09/2024 at 11:11 AM, CNA A stated it was important that the call lights were placed near the residents. CNA A said the call lights should always be with the residents because the residents used them to call the staff if they needed something. CNA A said if the call lights were not with the resident, the resident would not be able to tell the staff what they needed. CNA A said the resident might be needing to be changed and she would not know. She said the resident might be frustrated, mad, or might fall if the call light was far from her. CNA A looked for Resident #23's call light and found it on the floor under the bed. CNA A knelt down, pulled the call light from the bottom of the bed, and placed it near the resident. CNA A said she did a quick tour at the beginning of her shift but did not notice that the call light was not with Resident #23. CNA A added she did not make sure the call light was with the resident after she was done with the resident's incontinent care. <BR/>Resident #26 <BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction (blockage in the blood vessels of the brain) and anxiety disorder.<BR/>Review of Resident #26's Quarterly MDS Assessment, dated 05/27/2024, reflected Resident #26 had a moderate cognitive impairment with a BIMS score of 09. Resident #26 required maximal assistance for shower, dressing, and personal hygiene.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected Resident #26 was at risk for falls r/t to impaired mobility and one of the interventions was to be sure my call light is within reach.<BR/>Observation and interview with Resident #26 on 07/10/24 at 7:14 AM revealed the resident was lying in bed, awake. Resident #26 said he just woke up. The resident's call light was observed on the floor. Resident #26 said he was looking for his call light but could not find it. Resident #26 said it was important that he had his call light because he usually was in bed and dependent on the staff for almost everything. Resident #26 added the staff should place the call light near his functioning hand.<BR/>Observation and interview with LVN B on 07/10/2024 at 8:24 AM revealed LVN B entered Resident #26's room to check his blood pressure. LVN B stated the call light was on the floor. LVN B said she did not notice the resident's call light was on the floor when she did her shift change round. LVN B picked up the call light and placed it where the resident could reach it. LVN B said it was important for the call light to be within reach, so the residents could be helped when they needed assistance or help. LVN B said if the call lights were not with the residents, the residents might fall or the staff would not know the residents were having an emergency. She said she was responsible in ensuring the call lights were within reach for her assigned residents.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated call lights were very important for the residents. The DON said the call lights were the only way of communication between the residents and the staff. The DON said the residents were also encouraged to use the call lights to call for assistance, like if they needed to go to the bathroom or needed to be turned. He said the call lights were also used by the resident if they needed something, like pain medication, refill of water, or to turn the lights off. The DON said without the call lights, the needs of the residents would not be known and would not be addressed. He added, without the call lights the needed care would not be provided. The DON said the expectation was for the staff would be mindful that every time they leave the resident's room, the call lights were with the residents. The DON said he would conduct a whole-house in-service about the call lights because the call lights were everybody's responsibility. He said the in-service would be for the nurses, CNAs, housekeeping, therapists, and management. He said he would personally monitor that all the residents' call light were within reach.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the call lights should not be on the floor or in a place where the residents could not reach it. The ADON said the call light must be within reach of the residents at all times because they use the call light to let the staff know they needed something. The ADON said if the call lights were far from the residents, the residents would not be able to call the staff and their needs would not be addressed. The ADON said the resident might even had a fall if they try to go to the bathroom by themselves because they could not call the staff. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of all the residents. The ADON said they would do an in-service about call lights being accessible to the residents. <BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated the call lights should not be far from the residents. The Administrator said the call lights were used by the residents to call the attention of the staff if they needed something. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be sensible about call light placement. The Administrator said they would re-educate the staff regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident.<BR/>Record review of facility's policy Resident Rights Social Services Manual 2003, revealed We believe each resident has a right to a dignified existence . and communication with and access to persons and services inside and outside our facility . Each resident is treated with consideration . care for personal needs.<BR/>Record review of facility's policy Perineal Care Female Nursing Policy and Procedure Manual 2003 rev December 8. 2009, revealed K. Closing steps . e. Always replace call signal and needed items within resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for two (Resident #40 and Resident #44) of eight residents reviewed for privacy and confidentiality. 1. The facility failed to ensure the ADON closed, locked, or minimized her laptop's monitor while preparing Resident #40's medication via g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) on 08/13/2025. 2. The facility failed to ensure LVN A closed the door while performing ADL on Resident #44 on 08/12/2025. These failures could place the residents at risk of not having their personal privacy maintained during ADLs and their medical information exposed to unauthorized individuals. Findings included: 1. Review of Resident #40's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Review of Resident #40's Quarterly MDS Assessment, dated 07/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Review of Resident #40's Comprehensive Care Plan, dated 06/15/2025, reflected the resident required tube feeding and one of the interventions was to administer medications as ordered. Record review of Resident #40's Physician Order, dated 11/09/2023, reflected Dilantin Infatabs Tablet Chewable 50 MG (Phenytoin) Give 3 tablet via GTubetwo times a day related to EPILEPSY (a medical condition characterized by recurring seizures) . HOLD FEEDING 1 HOUR BEFORE AND 1 HOUR AFTER GIVING. Record review of Resident #40's Physician Order, dated 02/28/2025, reflected Fluoxetine HCl Capsule 10 MG Give 4 capsule via G-Tube one time a day for depression (persistent feeling of sadness or loss of interest). Record review of Resident #40's Physician Order, dated 08/14/2024, reflected Gemfibrozil Oral Tablet 600 MG (Gemfibrozil) Give 600 mg via peg tube (a flexible feeding tube inserted directly to the stomach) two times a day for Elevated cholesterol. Record review of Resident #40's Physician Order, dated 03/13/2024, reflected Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 2.5 ml via Gtube one time a day related to EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS. Record review of Resident #40's Physician Order, dated 02/05/2025, reflected Vitamin C Tablet (Ascorbic Acid) Give 500 mg via Gtube two times a day for Supplement. Record review of Resident #40's Physician Order, dated 07/25/2025, reflected Xarelto Oral Tablet 20 MG (Rivaroxaban) Give 1 tablet by mouth one time a dayrelated to PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS (formation of blood clots) AND EMBOLISM (blockage in the blood vessel that originated from somewhere and traveled to other parts of the body). Observation on 08/13/2025 at 8:57 AM revealed the ADON was about to administer Resident #40's medication via g-tube. She went inside the resident's room to sanitize the overbed table. She left her laptop, that was on top of her cart, open and the displayed the resident's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, that the resident was on gtube, name of the NP, and several physician orders. The screen of the computer was facing the hallway. In an interview on 08/13/2025 at 8:59 AM, the ADON stated she should have locked her computer when she went inside Resident #40's room to clean the resident's table. She said it was a HIPAA violation because the resident's personal and medical information were exposed. She said the said information should be secured and confidential. 2. Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident needed assistance rolling to left and right. Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with bed mobility. Observation and interview on 08/12/2025 at 11:11 AM, LVN A stated Resident #44 wanted to have a bowel movement. She said she would turn the resident to her side because the resident preferred to be on her side every time she had a bowel movement. She turned the resident without pulling the privacy curtain or closing the door and the assistance being given to the resident could be seen from the hallway. In an interview on 08/12/2025 at 11:38 AM, LVN A stated she was not aware that the door was open when she repositioned Resident #44. She said she should have pulled the privacy curtain and closed the door to make sure privacy was provided when giving assistance to the resident. She said the resident might be embarrassed that people would see her condition that she needed assistance to turn to her side. In an interview on 08/12/2025 at 11:58 AM, Resident #44 stated it would be nice if her door was closed so nobody would see if staff was helping her with her limitation. In an interview on 08/13/2025 at 7:38 AM, SNA F she was engrossed with what she could learn and did not notice that the door was open when Resident #44 was turned. She said the door should be close to provide privacy. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent awkwardness and that the medical information of the residents were secured and protected to prevent improper use of their information. She said the expectation was for the staff to be mindful about privacy when providing care and confidentiality of the residents' medical records. She said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality. In an interview on 08/14/2025 at 10:13 AM, the DON stated the door should be closed when repositioning the residents to provide privacy. She said ADLs, such as repositioning the residents, should be done with the door closed or the privacy curtain pulled. She said privacy should be provided during care to avoid embarrassment. She said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. The DON stated all the medical information of all the residents should be protected and not be visible for everybody to see because those were confidential information. She said it was a HIPAA violation when unauthorized individuals would see the medical information of the residents. She said all the staff, including her, were expected to provide full privacy during care and to secure all confidential information of the residents. The DON said she would start an in-service about privacy during care and confidentiality of the residents' information. Record review of the facility's policy, Resident Rights Social Services Manual 2003, no revision date revealed, 8. Each resident is treated with . including privacy in treatment and in care . 22. Each resident is ensured confidential treatment of all information .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for six (Residents #2 #9, #10, #12, #29, and #44) of eight residents reviewed for care plan revision. The facility failed to complete a quarterly care plan for Residents #2, #9, #10, 312, #29, and #44. This failure could place the residents at risk of care and needs not being met. Findings included: Resident #2 Record review of Resident #2's Face Sheet, dated 08/12/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's Comprehensive Care Plan on 08/12/2025 reflected the quarterly care plan completed after 12/11/2024 was dated 06/15/2025. There should have been care plan dated 03/2025. Resident #9 Record review of Resident #9's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #9's Comprehensive Care Plan on 08/12/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/15/2025. There should have been a care plan dated 02/2025. Resident #10 Record review of Resident #10's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #10's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/10/2025. There should have been a care plan dated 02/2025. Resident #12 Record review of Resident #12's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #12's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/15/2025. There should have been a care plan dated 02/2025. Resident #29 Record review of Resident #29's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #29's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 12/11/2024 was dated 06/15/2025. There should have been a care plan dated 03/2025. Resident #44 Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #44's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 01/23/2024 was dated 06/15/2025. There should have been a care plan dated 04/2025. Observation and interview on 08/13/2025 at 12:02 PM, the MDS Coordinator stated it was her responsibility to update the care plans. She said the care plans should be updated if there was a change in condition, the resident came back from the hospital, or if the resident had a fall. She said care plans were done upon admission and quarterly afterwards. She logged on to her computer and saw that Residents #2 #9, #10, #12, #29, and #44's care plans were updated but had gaps and missing some quarterly care plans. She said it was an oversight on her part that some of the resident's care plans had a gap. She said the care plans should be updated to reflect the current conditions of the residents so applicable interventions could be applied. She said she would audit all the care plans to make sure they were updated. In an interview on 08/14/2025 at 7:02 AM, the ADON stated she was familiar with the care plans. She said the care plans were done during admission and were being updated quarterly. She said the care plans should be update if there was an acute change, new wound, resident now needed a blood thinner. She said the care needed to be in place so the staff would know if there were new interventions that needed to be done and to monitor the resident's response to the new interventions. She said if the care plans were not updated, it could mess up the monitoring side of the interventions. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated all the residents should be care planned accordingly and timely to make sure all the current care and needs of the residents were provided. She said the MDS Nurse was the primary responsible for making and updating the care plans, but she and the nurse managers were equally responsible in making sure that the care plans were up to date. She said without the care plan, there would not be continuity of care and the residents' health issues would not be addressed. She also said she would coordinate with the DON and the MDS Nurse to make sure the care plans were current. In an interview on 08/14/2025 at 10:13 AM, the DON stated every resident needed a thorough and updated care plan to ensure the residents receive proper care and in accordance with their current needs. She said the care plans should be reviewed because the needs of the resident's change, and they need to be congruent with these needs to provide quality care. She said, aside from acute changes, the care plans should be done quarterly to monitor if there were new interventions or to assess if the goals were not being met. She said if the care plans were not updated, the current needs of the residents might not be met. She said she would coordinate with the MDS to audit the care plans of the residents and to make sure, moving forward, that there the care plans would not have gaps on their quarterly. Record review of the facility's policy, Comprehensive Care Planning Nursing Policy & Procedure Manual, no revision date, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident . Comprehensive Care Plans . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for quality of care.<BR/>The facility failed to sufficiently monitor Resident #32's blood pressure while she was taking anti-hypertensive medication Amlodipine and failed to implement Resident #32's comprehensive care plan intervention to take her blood pressures daily. <BR/>This failure could place residents at risk for adverse effects of an anti-hypertensive medicine regimen. <BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. <BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. <BR/>Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily.<BR/>Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed:<BR/>3/24/2023 12:38 PM- 148 / 78 mmHg<BR/> 2/17/2023 05:02 PM- 156 / 83 mmHg <BR/>2/3/2023 12:01 AM- 88 / 42 mmHg<BR/>2/1/2023 10:00 PM- 115 / 78 mmHg <BR/>1/30/2023 09:26 PM- 112 / 68 mmHg <BR/>1/18/2023 06:19 AM- 123 / 74 mmHg<BR/>1/11/2023 09:19 AM- 100 / 60 mmHg<BR/>Record review of Resident #32's physician orders revealed there was not a physician's order related to the frequency of blood pressure monitoring nor parameters for blood pressure notification. Further review revealed an order: Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023.<BR/>In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency.<BR/>In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that she (Resident #32) was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medications and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to write an order because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings outside of normal limits. <BR/>In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday, 05/16/23, and the morning of 05/17/23. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer Resident #32's anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She then declined to answer any further questions. <BR/>In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. <BR/>In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. <BR/>In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. <BR/>In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. <BR/>In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. <BR/>Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. &lt;https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91&gt;<BR/>Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #44) two residents reviewed for catheter care. The facility failed to ensure that LVN A placed Resident #44's catheter bag (collects urine from the urinary bladder) below the bladder on 08/12/2025. This failure could place residents with catheter at risk for urinary tract infection. Findings included: Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had a Foley catheter and one of the interventions was to position the catheter bag and tubing below the level of the bladder. Observation and interview on 08/12/2025 at 11:11 AM, LVN A stated Resident #44 wanted to have a bowel movement. She said she would turn the resident to her side because the resident preferred to be on her side every time she had a bowel movement. It was observed that the resident had an indwelling catheter. LVN A turned the resident but before she turned the resident, she unhooked the resident's catheter and placed it on top of the resident's bed. It was observed that the catheter bag was at the same level of the resident's bladder and urine from the catheter bag travelled back to the catheter's tubing. Observation on 08/12/2025 at 11:22 AM revealed LVN A proceeded with wound care after Resident #44 tried to have a bowel movement since the resident was already on her side. It was observed that the catheter bag was still on top of the bed, at the same level of the bladder and urine was still observed on the tubing. In an interview on 08/12/2025 at 11:38 AM, LVN A stated she placed Resident #44's catheter bag on top of the bed so it would not be pulled that could cause injury to the resident. She said she should have pulled the bed and hang the catheter on the other side to prevent backflow of the urine that could cause urinary retention and UTI. In an interview on 08/12/2025 at 11:58 AM, Resident #44 stated some staff would pull her bed to transfer her catheter when she needed to be turned. She said some staff did not and would just put the catheter bag on top of her bed. In an interview on 08/14/2025 at 7:02 AM, the ADON stated the catheter bag should always be below the bladder to prevent backflow of the urine to the bladder. She said what should have done was to pull the bed to transfer the catheter bag or turn the resident to where the catheter bag was hooked. She said the expectation was for the catheter bag be below the bladder to allow the urine to drain by gravity and prevent backflow that could potentially introduce bacteria to the bladder that could lead to infection. She said she would coordinate with the DON to do an in-service about catheter care. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the expectation was for the catheter bag be below the bladder to prevent infection. She said she would collaborate with the ADON and the DON to make sure the said issue would be addressed. In an interview on 08/14/2025 at 10:13 AM, the DON stated the catheter bag should always be below the bladder to prevent backflow of the urine to the bladder that could result to urinary retention or infection. She said the Resident #44's bed should have been pulled to place the catheter on the other side. She said the expectation was for the staff would make sure that the catheter bag was below the bladder and make adjustments if needed, like pull the bed or turn the resident to where the catheter was hooked. She said she would initiate an in-service about catheter care and would do a one-on-one with LVN A. Record review of the facility's policy Catheter Care Nursing Policy and Procedure Manual 2003 revised February 13, 2007, revealed, 15. Keep drainage bag below level of bladder when cleaning the urethral area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #20) three residents reviewed for gastrostomy tube management.<BR/>The facility failed to ensure that LVN B checked Resident #20's G-tube (Gastrostomy tube: A tube directly inserted through the skin to the stomach to deliver nutrition) placement prior to medication administration.<BR/>The facility failed to ensure that LVN B checked Resident #20's residual (amount of liquid remaining in the stomach) before administering medications via gastrostomy tube. <BR/>These failures could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Review of Resident #20's Face Sheet, dated 07/09/24, reflected resident was a 77- year-old female admitted on [DATE]. Relevant diagnosis included cognitive communication deficit and dysphagia (difficulty in swallowing).<BR/>Review of Resident 20's Comprehensive MDS Assessment, dated 05/29/2024, reflected resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated resident was on tube feeding while a resident of the facility. <BR/>Review of Resident #20's Care Plan on 07/09/2024 revealed that the resident did not have a care plan for tube feeding.<BR/>Review of Resident #20's Physician's Order, dated 05/23/2024, reflected Every shift Check placement prior to feeding and medication administration.<BR/>Review of Resident #20's Physician's Order, dated 05/23/2024, reflected every shift Check residual before medications and feedings; return contents after each check.<BR/>Observation on 07/11/2024 at 7:40 AM revealed Resident #20 was in bed, awake. Resident #20 had a feeding formula hanging from an IV pole. The feeding formula was not connected to the resident. LVN B prepared the resident's medication. LVN B prepared three medications and put them in three separate plastic cups. LVN B then crushed the medications one-by-one and put them back in three small plastic cups. LVN B donned (put on) a gown and a pair of gloves. LVN B went inside the room, set the medications on the side table, and told the resident what she was going to do. LVN B went to the bathroom to get some water for flushing. LVN B put some water in the medications. LVN B started to stir the medications with the tip of the syringe. After mixing the medications, LVN B pulled the plunger of the syringe, attached the tip of the syringe to the g-tube, flushed the g-tube with 60 ml of water, and poured the dissolved medication into the syringe attached to the g-tube one at a time. LVN B flushed the g-tube with 5 ml of water after every medication administration. After giving the medication, LVN B flushed the g-tube and then connected the g-tube to the formula and turned it on. LVN B did not check for placement of the g-tube before administering the medication. LVN B did not check for the residual before administering the medications.<BR/>In an interview with LVN B on 07/11/2024 at 8:05 AM, LVN B stated it was important to check the placement of the g-tube before feeding or medication administration to ensure the g-tube was in the correct position. LVN B said it was also important to check the gastric residual to make sure the stomach was emptying effectively. She said she was not able to check for the placement and for the residual when she gave Resident #20's medication. She said she sometimes checked for both when she disconnected the g-tube. She said she should always check for both before giving the medications. She said she did a competency check-off for enteral feeding but forgot to do both. She said if the placement was not checked, it could cause harm to the resident. She added that if the residual was not checked, the resident could suffer from aspiration pneumonia.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated it was important to check for the placement of the g-tube to ensure the g-tube was in the proper place. He said placement was checked before feeding or medication administration to be sure it was not clogged or displaced. He said the residual was checked also to see if the stomach was not having any intolerance to feeding. He said not checking the placement of the g-tube and the gastric residual could result to vomiting and aspiration pneumonia. He said the expectation was for the staff to check the placement of the g-tube and gastric residual before every feeding, before every medication administration, and every shift. He said he would re-educate LVN B about the proper procedure of enteral feeding. He said he would also do an in-service to all the staff doing enteral feeding.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the g-tube placement was always checked to make sure it was in the right place. She said even though it was checked in the morning, it should still be checked at noon. She said checking for placement could be done by using a stethoscope or by checking the residual. She said the gastric residual was also checked to make sure the stomach was not full. She said not checking the residual could result to vomiting and aspiration. She said she would coordinate with the DON on what to do about the issue.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM stated the staff should follow the g-tube orders. She said if the orders said to check for placement and residual before giving medications, the staff should check for placement and residual before giving the medications. She said both were included in the procedure to provide safety for residents with a g-tube. She said she would collaborate with the clinicians to do in-service about g-tubes.<BR/>Record review of facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual 2003 rev. March 02, 2021 revealed Goals . 1. The resident will maintain nutritional status ,,, Procedure . 7. Perform intermittent feeding . a. check for placement by aspiration or injecting air and listening to the stomach for sounds . b. Aspirate for gastric contents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #26, #30, and Resident #189) of eight residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure an Oxygen In Use sign was placed outside of Resident #26's room. <BR/>2. <BR/>The facility failed to ensure Resident #189's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored.<BR/>3. <BR/>The facility failed to ensure Resident #30's oxygen mask was properly stored.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #26's Comprehensive MDS Assessment, dated 05/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated Resident #26 was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected the resident had oxygen therapy due to ineffective gas exchange and one of the interventions was oxygen at 2 lpm per nasal canula.<BR/>Review of Resident 26's Physician's Order, dated 05/29/2024, reflected, OXYGEN 3-4L/MIN VIA NASAL CANNULA every shift for SOB/wheezing/LOW OXYGEN SAT LESS THAN 92% and prn.<BR/>Observation on 07/09/2024 at 9:37 AM revealed Resident #26 was on oxygen therapy at 3 liters per minute via nasal cannula. It was observed that there was no Oxygen In Use sign outside the door of the resident. <BR/>Observation and interview with LVN B on 07/10/2024 at 10:46 AM, LVN B said there should be a sign outside the room of the residents that use oxygen. LVN B said the sign was to remind the staff and the visitors that oxygen was being used inside the facility. She said oxygen could be a dangerous fire hazard. She said adequate precautions should be in place. LVN B said she would look for a Oxygen In Use sign. LVN B came back to the room and placed the Oxygen In Use sign outside Resident #26's room.<BR/>2. <BR/>Record review of Resident #30's Face Sheet, dated 07/11/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included COPD and obstructive sleep disorder. <BR/>Record review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 07 (severe cognitive impairment) and an active diagnosis of COPD.<BR/>Record review of Resident #30's physician's orders dated 07/11/24 revealed the resident had active orders for may use oxygen @ 4 L/M (liters per minute) via nasal cannula every shift.<BR/>An observation on 07/09/24 at 11:01 AM revealed Resident #30 not being in his room and his oxygen mask was observed sitting on a stand exposed, and not in a sealed bag.<BR/>In an interview and observation on 07/10/24 at 01:55 AM with RN M, she stated she was the floor nurse for the North Hall and she acknowledged that Resident #30 did use an oxygen concentrator. She stated that when the resident's mask was not in use, it had to be placed in a sealed bag. She was shown a picture of Resident #30's mask sitting exposed and uncovered. She stated she had observed that today and had made sure that it was bagged. She stated the CNAs were supposed to remind the nurses if they observed masks not stored in a bag. She stated the risk of not placing the resident's mask in a sanitized bag could result in the resident having respiratory concerns.<BR/>3. <BR/>Review of Resident #189's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Resident #189 had a diagnosis of obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep).<BR/>Review of Resident #189's Comprehensive Care Plan, dated 07/05/2024, reflected resident required the use of CPAP related to sleep apnea and one of the interventions was the resident will use device as ordered.<BR/>Review of Resident #189's Physician's Order, dated 07/05/2024, reflected, CPAP AT HS AND AS NEEDED FOR NAP IN DAY TIME. at bedtime for SLEEP APNEA.<BR/>Observation and interview on 07/09/2024 at 9:08 AM revealed Resident #189 was in his wheelchair inside his room. Resident #189 had a CPAP machine on his bed side table and a CPAP mask was connected to the machine. The CPAP mask was noted on top of the CPAP machine. The CPAP mask was not bagged. Resident #189 stated he used the CPAP machine at night. The resident said staff would put the CPAP on him at night and would take it off in the morning. He said he never saw a plastic bag for the CPAP mask and nobody told him to put the mask one if ever he would take it off.<BR/>Observation and interview with LVN B on 07/09/2024 at 9:53 AM, LVN B stated the CPAP mask should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN B said the CPAP mask should be bagged when not in use. LVN B said she did not notice the CPAP mask was not bagged and that there was no bag for the CPAP mask. LVN B said the resident would sometimes take the CPAP mask off but said she should have monitored if it was in a plastic bag. LVN B saw the CPAP mask on top of the CPAP machine and said she would get a plastic bag for the mask, clean the mask, and place it inside the plastic bag.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated the CPAP mask should be bagged when not in use. He said if the CPAP mask was not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to cross contamination and respiratory infections. He said the expectation was for the CPAP mask would be stored properly. He added the nasal cannula and the breathing mask for nebulization should also be bagged for the same reason. With regards to signage for oxygen, the DON said there should be a Oxygen In Use sign outside the door of the resident using oxygen. The sign was for safety purposes. He continued that oxygen was a flammable substance and could cause an explosion if somebody lit a cigarette near the room. He said the facility was a non-smoking facility but it would be prudent to remind the residents, staff, and visitors. He said he was responsible in putting the sign on the door of the resident and he must have overlooked it. He said the expectation was there would be an Oxygen In Use sign on every door of the residents using oxygen. The DON concluded that moving forward, he would do an in-service about bagging the CPAP mask and would continually remind them to be diligent in making sure the procedures for respiratory care were followed. He said he would also do a round to make sure all the residents using oxygen has a sign outside their door.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the CPAP mask should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who take off the mask should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. She said the expectation was for the staff to bag the CPAP mask. She said, not just the CPAP mask but also the nasal cannula and the mask used for nebulizer should also be bagged. She said it was important that there was an Oxygen In Use sign outside the door of a resident using oxygen. She said the sign was for safety precaution so everybody in the building would know oxygen was being used in the building. She said she would coordinate with the DON to do an in-service pertaining to bagging the CPAP mask, nasal cannula, and breathing mask when the residents were not using them and making sure there was a sign outside the doors of the resident in oxygen administration whether continuously or as needed.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated that in general, the CPAP masks should be stored properly to prevent respiratory issues or exacerbation of whatever respiratory issues the residents already had. The Administrator said the expectation was for the staff to be mindful during their rounds and make sure the CPAP masks were bagged. The Administrator said it was important that there was sign outside the door of the residents using oxygen for safety purposes. She said oxygen was a flammable substance. The Administrator said she would check if the clinicians already did correct the issue.<BR/>Record review of facility's policy, Oxygen Administration Nursing Policy & Procedure Manual 2003 revised February 13, 2007 revealed Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat . O2 therapy is also prescribed to ensure oxygenation of all body organs and systems . 11. Place . signs in area when oxygen is administered.<BR/>A policy for masks being bagged was requested on 07/10/2024 at 1:45 PM and followed-up on 07/11/2024 at 9:40 AM. The Corporate Nurse said the facility did not have a policy specific for masks being bagged.

**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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eight residents (Resident #30) reviewed for pharmaceutical services. The facility failed to ensure vials of solutions used for breathing treatment were not left inside Resident #30's room for the resident to administer by himself on 08/12/2025. This failure could place residents at risk of not receiving medications as ordered by the physician, potential overdose, and adverse effects. Findings include: Record review of Resident #30's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #30's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had a moderated impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #30's Comprehensive Care Plan, dated 05/28/2025, reflected the resident had shortness of breath and one of the interventions was to administer medications as ordered. Record review of Resident #30's Physician's Order, dated 04/26/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours for SOB or Wheezing via nebulizer **While awake, do not administer if res sleeping. Record review of Resident #30's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. Observation and interview on 08/12/2025 at 12:18 AM revealed Resident #30 was in his wheelchair, awake. A nebulizer machine was observed on top of the resident's side table and beside the nebulize machine were four plastic vials of solutions used for breathing treatment. The plastic vials were not opened and still had the solutions inside. Resident #30 said he was the one administering his breathing treatment. He said the nurse would leave several vials with him so he could do the breathing treatment if he needed to. He said he did not call or tell the nurse he did a breathing treatment. In an interview on 08/12/2025 at 12:28 PM, LVN B stated she was the one administering Resident #30's breathing treatment. She said she was not aware the resident was doing it by himself. She said she saw the solutions for breathing treatment when he gave the resident's morning medications but forgot to grab them on her way out. She said the solutions should not be left inside the room because they were medications. she said the resident might use them every hour and no one would know until adverse reactions such as palpitations, chest pain, or headache. In an interview on 08/13/2025 at 7:16 AM, Resident #30 said the nurses gave his breathing treatment on evening of 08/12/2025. He said but before that date, he would usually do his breathing treatment. In an interview on 08/14/2025 at 7:02 AM, the ADON stated medications should not be left with a resident to administer unsupervised. She said the staff administering the breathing treatment should stay with the resident until the resident was done with it. She said the resident might not take them, someone else might, or the resident might administer it not as ordered. She said if the resident did not have an assessment that he could administer the medications by himself, the staff should do it, and medications should not be left inside the room. She said the medication should be in the cart because the nurses were the one who was supposed to administer it. She said she would coordinate with the DON to do an in-service about not leaving the medications with the residents. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated no medications should be left inside the room because the resident might overmedicate. She said the expectation was for the staff not to leave any medication inside the room for the resident to administer by himself. She said she would coordinate with the DON and the ADON to do an in-service about not leaving the medications with the resident. In an interview on 08/14/2025 at 10:13 AM, the DON stated staff should never leave the solutions at the bedside for the resident to administer unsupervised. She said the staff must ensure the resident had the breathing treatment as scheduled. She said the residents could overdose as manifested by increased heart rate and chest pain. She said if the resident was the one administering the breathing treatment, there should be proper assessment that the resident was capable to do so. If the resident was capable, the solutions should still not be on top of the side table were other confused residents could assess it and consume it. The DON said she would do an in-service not leaving any medication inside the residents' room. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17. reflected, 1. All medications are administered by licensed medical or nursing personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of sixteen residents (Resident #2, #11, #30, and #42) reviewed for medication storage. 1. The facility failed to ensure Resident #2's zinc oxide (medicated cream used to prevent skin irritation) was not left inside the resident's room on 08/12/2025. 2. The facility failed to ensure Resident #11's zinc oxide was not left inside the resident's room on 08/12/2025. 3. The facility failed to ensure Resident #42's zinc oxide was not left inside the resident's room on 08/12/2025. 4. The facility failed to ensure Resident #30's vials of solutions used for breathing treatment were not left inside the resident's room on 08/12/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing. Findings include: 1. Record review of Resident #2's face sheet, dated 08/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #2's Comprehensive MDS Assessment, dated 06/26/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had dementia and was at risk of developing pressure ulcers/injuries. Record review of Resident #2's Comprehensive Care Plan, dated 06/28/2025, reflected the resident had incontinence and one of the interventions was to apply barrier cream after each episode. Record review of Resident #2' Physician Order, dated 05/30/2024, reflected May apply barrier cream as needed every shift. 2. Record review of Resident #11's Face Sheet, dated 08/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a disorder that primarily affects memory). Record review of Resident #11's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident had Alzheimer's Disease and was at risk of developing pressure ulcers/injuries. Record review of Resident #11's Care Plan, dated 06/15/2025, reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per physician order. Record review of Resident #11's Physician Order, dated 12/01/2020, reflected May apply barrier cream as needed. Observation on 08/12/2025 at 8:57 AM revealed there were two tubes of zinc oxide inside Resident #2 and Resident #11's room. The zinc oxide was located beside the sink inside the room. Observation and interview on 08/13/2025 at 7:01 AM revealed the tubes of zinc oxide were still inside Resident #2 and Resident #11's room. The ADON went inside the rooms after being notified that there were zinc oxides on the said rooms and took the tubes of zinc oxide and said it should be inside the room, or it should be placed where the residents could not access them. She said it should be inside the cart. She said confused residents might could mistake it as toothpaste and place it in their mouth. She said the expectation was for the staff to make sure no zinc oxide was placed where the residents could access them. She said she would coordinate with the DON to do an in-service about medication storage. 3. Record review of Resident #42's face sheet, dated 08/13/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #42's Quarterly MDS Assessment, dated 06/27/2025, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident had dementia and was at risk of developing pressure ulcers/injuries. Record review of Resident #42's Care Plan, dated 06/01/2025, reflected the resident reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per the physician order. Record review of Resident #42's Physician Order, dated 12/08/2024, reflected May apply barrier cream as needed every shift. Observation on 08/12/2025 at 9:00 AM revealed Resident #42 was in his bed with eyes closed. It was observed that a tube of zinc oxide was on top of his side table. Observation and interview on 08/12/2025 at 9:16 AM, LVN A stated zinc oxide was a form of medication because to was used to prevent any pressure injury to the skin. She said it should not be inside the room, as confused residents might consume it. She said the cream should be stored in the cart and just put some in a cup for use or place it somewhere not accessible. She said she would go to Resident #42's room to get the zinc oxide. She said she would also check the other rooms. 4. Record review of Resident #30's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #30's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had a moderated impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #30's Comprehensive Care Plan, dated 05/28/2025, reflected the resident had shortness of breath and one of the interventions was to administer medications as ordered. Record review of Resident #30's Physician's Order, dated 04/26/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours for SOB or Wheezing via nebulizer **While awake, do not administer if res sleeping. In an interview on 08/12/2025 at 12:28 PM, LVN B stated she was the one administering Resident #30's breathing treatment. She said she saw the solutions for breathing treatment when he gave the resident's morning medications but forgot to grab them on her way out. She said the solutions should not be left inside the room because they were medications. she said the resident might use them every hour and no one would know until adverse reactions such as palpitations, chest pain, or headache. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the expectation was for the staff to be mindful with all the tubes of zinc oxide were not inside the residents' rooms where they could assess them and consume them. She said she would coordinate with the DON and the ADON about storing the tubes of zinc oxide. In an interview on 08/14/2025 at 10:13 AM, the DON stated medications should not be stored inside the resident's room. She said zinc oxide was a form of medications that could be harmful when ingested. She said some residents might be allergic to it and was able to get hold of the zinc oxide because the tubes were in plain view. She said the expectations were for the staff to always scan the residents' rooms to make sure they were not leaving the tubes of zinc oxide inside the room, putting them where the resident could not access them, or just put them in the cart. She said she would do an in-service about storing the zinc oxide accordingly. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17, revealed, 8. After the medication administration process is completed, the medication cart must be completely locked and stored in a locked medication room or otherwise secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, Resident #19, Resident #9, Resident #28, Resident #1, and Resident #26) of twelve residents observed for infection control. <BR/>1. <BR/>The facility failed to ensure that CNA A changed his gloves and perform hand hygiene while providing incontinent care to Resident #23.<BR/>2. <BR/>The facility failed to ensure that LVN B sanitized the blood pressure cuff between Resident #19, Resident #9, Resident #28, and Resident #26.<BR/>These failures could place the residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #23's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body), and weakness.<BR/>Review of Resident #23's Comprehensive MDS Assessment, dated 05/01/2024, reflected Resident #23 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated Resident #23 was always incontinent for bowel and bladder.<BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/07/2024, reflected resident had potential for pressure ulcer development related to incontinence of bladder and bowel one of the interventions was to wash, rinse, and dry perineum (the space between the anus and the genitals).<BR/>Observation and interview on 07/09/2024 at 10:42 AM, CNA A said she would check if Resident #23 needed to be changed then said she would just go ahead and change the resident. CNA A prepared the brief and wipes. CNA A washed her hands, put on the PPE, and then lowered the head of the bed. After lowering the head of the bed, CNA A pulled the trash can beside her with her gloved hands. CNA A then grabbed the new brief from the overbed table, opened it, and put it parallel to the resident's legs. CNA A did not change her gloves nor sanitize her hands after touching the waste can. CNA A unfastened the brief on both sides and pushed the front part of the brief between the legs of the resident. CNA A pulled some wipes and started to clean the front of the resident from front to back. She did it five times. CNA A rolled the resident towards the wall and cleaned the bottom of the resident. After cleaning the resident's bottom, CNA A pulled the soiled brief and threw it in the trash can. CNA A took the new brief placed it at the side of the resident, put it at the bottom of the resident, and fixed it. CNA A did not change her gloves nor sanitize before touching the new brief. CNA A rolled the resident back. CNA A cleaned the front part again and then closed the brief and fastened it to both sides. CNA A did not change her gloves all throughout the process of incontinent care. CNA A did not wash her hands after doing incontinent care.<BR/>In an interview with CNA A on 07/09/2024 at 11:11 AM, CNA A stated she was able to wash her hands before doing incontinent care but was not able to wash her hands after incontinent care. She said she forgot to do so because she went out of the room to get some linens. CNA A said it was also important to change the gloves after touching the trash can and after pulling the soiled brief to prevent cross contamination. She said cross contamination could eventually cause infection.<BR/>2. <BR/>Review of Resident 19's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #19 was diagnosed with hypertension.<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 05/17/2024, reflected resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated hypertension as one of Resident #19's primary medical condition.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 07/09/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #19's Physician's Order for amlodipine, dated 06/28/2024, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #19's Physician's Order for lisinopril, dated 01/10/2023, reflected Lisinopril Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IS SBP IS &lt;110 OR HR IS &lt;60.<BR/>Observation on 07/10/2024 at 7:10 AM revealed LVN B was preparing Resident #19's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #19's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #19. She did not sanitize the blood pressure cuff.<BR/>Review of Resident 9's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #9 was diagnosed with hypertension.<BR/>Review of Resident #9's Quarterly MDS Assessment, dated 04/30/2024, reflected resident had severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated hypertension as one of Resident #9's primary medical condition.<BR/>Review of Resident #9's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #9's Physician's Order for amlodipine, dated 05/09/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #9's Physician's Order for lisinopril, dated 05/20/2024, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION.<BR/>Observation on 07/10/2024 at 7:55 AM revealed LVN B was preparing Resident #9's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #9's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #9. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #28's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #28 had a diagnosis of hypertension.<BR/>Review of Resident #28's Quarterly MDS Assessment, dated 05/10/2024, reflected resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated hypertension as one of Resident #28's primary medical condition.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #28's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #28's Physician's Order for lisinopril, dated 05/17/2023, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP IS &lt;100/60 OR HR &lt;60.<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #28's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #28's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #28. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #26 had a diagnosis of hypertension.<BR/>Review of Resident #26's Quarterly MDS Assessment, dated 05/10/2024, reflected resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated hypertension as one of Resident #26's primary medical condition.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #26's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #26's Physician's Order for lisinopril, dated 03/29/2024, reflected Lisinopril Oral Tablet 20 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION (I10).<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #26's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #26's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart and then prepared and gave the medications to Residents #26. She did not sanitize the blood pressure cuff.<BR/>In an interview with LVN B on 07/10/2024 at 9:48 AM, LVN B stated she obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. LVN B said the proper thing to do was to wash or sanitize her hands before and after giving medications. LVN B said the blood pressure cuff should be sanitized as well after using it and before using it on another resident. LVN B then acknowledged she forgot to sanitize the blood pressure cuff in between residents when she passed the medications. LVN B stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. LVN B added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated that the blood pressure cuff should be sanitized every after use. He said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. The DON added that was also true for the glucometer and the pulse oximeter. The DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said he just did a check-off about incontinent care. He said he showed the staff how to do incontinent care and then let the staff returned the demonstration. He said he used a mannequin during his demonstration. He said the CNA involved was present during the time of the check-off so he did not know what happened. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks. He said the gloves should have been changed when the trash can was touched. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON said the expectation was for the staff to wash their hands before and after every care, change their gloves when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and sanitizing the blood pressure cuff after every use. The DON said he would do a one-on-one in-service with CNA A about washing of hands and changing of gloves and then talk to LVN B about sanitizing the blood pressure cuff. He added he would do an in-service about infection control for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the blood pressures were checked first before administering medications for hypertensions. The ADON said since the nurses were only using one blood pressure cuff for all the residents, the blood pressure cuff should be sanitized every after use to prevent cross contamination. The ADON said, during incontinent care, the staff must always change their gloves and sanitize the hands before touching the new brief. She said the expectation was for the blood pressure cuff to be sanitized in between residents and staff would wash their hands, and change their gloves to prevent infection among the residents. She said she would coordinate with the DON on how to go forward.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated not washing the hands nor sanitizing them could contribute to cross contamination. She said not sanitizing the blood pressure cuff would do the same. The Administrator said the expectation was for the staff to make sure all items and equipment used by the residents were sanitized and the gloves were changed during incontinent care for the basic reason of infection control. She said she would collaborate with the clinicians to in-service the staff about infection control.<BR/>Review of facility policy, Perineal Care Female (With or without catheter) Nursing Policy and Procedure Manual 2003 rev. December 8.2009 revealed Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area . Procedural Guidelines . A. Beginning Steps . a. Wash hands . H. Wash hands and put on clean gloves for perineal care . I. Gently wash . d. Change gloves . g. pat dry . h. Change gloves . J. Cleaning the rectal and buttocks area . c. Change gloves . K. Closing steps . a. if gloved, remove and discard gloves. Wash hands.<BR/>Record review of facility's policy Infection Control Plan: Overview updated 03/2023 revealed The facility will establish and maintain an Infection Control Program designed . to help prevent the development and transmission of disease and infection . Environmental Infection Control . All non-dedicated, non-disposable medical equipment used for the patient should be cleaned and disinfected . before use on another patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, Resident #19, Resident #9, Resident #28, Resident #1, and Resident #26) of twelve residents observed for infection control. <BR/>1. <BR/>The facility failed to ensure that CNA A changed his gloves and perform hand hygiene while providing incontinent care to Resident #23.<BR/>2. <BR/>The facility failed to ensure that LVN B sanitized the blood pressure cuff between Resident #19, Resident #9, Resident #28, and Resident #26.<BR/>These failures could place the residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #23's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body), and weakness.<BR/>Review of Resident #23's Comprehensive MDS Assessment, dated 05/01/2024, reflected Resident #23 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated Resident #23 was always incontinent for bowel and bladder.<BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/07/2024, reflected resident had potential for pressure ulcer development related to incontinence of bladder and bowel one of the interventions was to wash, rinse, and dry perineum (the space between the anus and the genitals).<BR/>Observation and interview on 07/09/2024 at 10:42 AM, CNA A said she would check if Resident #23 needed to be changed then said she would just go ahead and change the resident. CNA A prepared the brief and wipes. CNA A washed her hands, put on the PPE, and then lowered the head of the bed. After lowering the head of the bed, CNA A pulled the trash can beside her with her gloved hands. CNA A then grabbed the new brief from the overbed table, opened it, and put it parallel to the resident's legs. CNA A did not change her gloves nor sanitize her hands after touching the waste can. CNA A unfastened the brief on both sides and pushed the front part of the brief between the legs of the resident. CNA A pulled some wipes and started to clean the front of the resident from front to back. She did it five times. CNA A rolled the resident towards the wall and cleaned the bottom of the resident. After cleaning the resident's bottom, CNA A pulled the soiled brief and threw it in the trash can. CNA A took the new brief placed it at the side of the resident, put it at the bottom of the resident, and fixed it. CNA A did not change her gloves nor sanitize before touching the new brief. CNA A rolled the resident back. CNA A cleaned the front part again and then closed the brief and fastened it to both sides. CNA A did not change her gloves all throughout the process of incontinent care. CNA A did not wash her hands after doing incontinent care.<BR/>In an interview with CNA A on 07/09/2024 at 11:11 AM, CNA A stated she was able to wash her hands before doing incontinent care but was not able to wash her hands after incontinent care. She said she forgot to do so because she went out of the room to get some linens. CNA A said it was also important to change the gloves after touching the trash can and after pulling the soiled brief to prevent cross contamination. She said cross contamination could eventually cause infection.<BR/>2. <BR/>Review of Resident 19's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #19 was diagnosed with hypertension.<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 05/17/2024, reflected resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated hypertension as one of Resident #19's primary medical condition.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 07/09/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #19's Physician's Order for amlodipine, dated 06/28/2024, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #19's Physician's Order for lisinopril, dated 01/10/2023, reflected Lisinopril Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IS SBP IS &lt;110 OR HR IS &lt;60.<BR/>Observation on 07/10/2024 at 7:10 AM revealed LVN B was preparing Resident #19's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #19's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #19. She did not sanitize the blood pressure cuff.<BR/>Review of Resident 9's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #9 was diagnosed with hypertension.<BR/>Review of Resident #9's Quarterly MDS Assessment, dated 04/30/2024, reflected resident had severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated hypertension as one of Resident #9's primary medical condition.<BR/>Review of Resident #9's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #9's Physician's Order for amlodipine, dated 05/09/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #9's Physician's Order for lisinopril, dated 05/20/2024, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION.<BR/>Observation on 07/10/2024 at 7:55 AM revealed LVN B was preparing Resident #9's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #9's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #9. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #28's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #28 had a diagnosis of hypertension.<BR/>Review of Resident #28's Quarterly MDS Assessment, dated 05/10/2024, reflected resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated hypertension as one of Resident #28's primary medical condition.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #28's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #28's Physician's Order for lisinopril, dated 05/17/2023, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP IS &lt;100/60 OR HR &lt;60.<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #28's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #28's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #28. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #26 had a diagnosis of hypertension.<BR/>Review of Resident #26's Quarterly MDS Assessment, dated 05/10/2024, reflected resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated hypertension as one of Resident #26's primary medical condition.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #26's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #26's Physician's Order for lisinopril, dated 03/29/2024, reflected Lisinopril Oral Tablet 20 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION (I10).<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #26's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #26's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart and then prepared and gave the medications to Residents #26. She did not sanitize the blood pressure cuff.<BR/>In an interview with LVN B on 07/10/2024 at 9:48 AM, LVN B stated she obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. LVN B said the proper thing to do was to wash or sanitize her hands before and after giving medications. LVN B said the blood pressure cuff should be sanitized as well after using it and before using it on another resident. LVN B then acknowledged she forgot to sanitize the blood pressure cuff in between residents when she passed the medications. LVN B stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. LVN B added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated that the blood pressure cuff should be sanitized every after use. He said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. The DON added that was also true for the glucometer and the pulse oximeter. The DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said he just did a check-off about incontinent care. He said he showed the staff how to do incontinent care and then let the staff returned the demonstration. He said he used a mannequin during his demonstration. He said the CNA involved was present during the time of the check-off so he did not know what happened. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks. He said the gloves should have been changed when the trash can was touched. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON said the expectation was for the staff to wash their hands before and after every care, change their gloves when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and sanitizing the blood pressure cuff after every use. The DON said he would do a one-on-one in-service with CNA A about washing of hands and changing of gloves and then talk to LVN B about sanitizing the blood pressure cuff. He added he would do an in-service about infection control for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the blood pressures were checked first before administering medications for hypertensions. The ADON said since the nurses were only using one blood pressure cuff for all the residents, the blood pressure cuff should be sanitized every after use to prevent cross contamination. The ADON said, during incontinent care, the staff must always change their gloves and sanitize the hands before touching the new brief. She said the expectation was for the blood pressure cuff to be sanitized in between residents and staff would wash their hands, and change their gloves to prevent infection among the residents. She said she would coordinate with the DON on how to go forward.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated not washing the hands nor sanitizing them could contribute to cross contamination. She said not sanitizing the blood pressure cuff would do the same. The Administrator said the expectation was for the staff to make sure all items and equipment used by the residents were sanitized and the gloves were changed during incontinent care for the basic reason of infection control. She said she would collaborate with the clinicians to in-service the staff about infection control.<BR/>Review of facility policy, Perineal Care Female (With or without catheter) Nursing Policy and Procedure Manual 2003 rev. December 8.2009 revealed Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area . Procedural Guidelines . A. Beginning Steps . a. Wash hands . H. Wash hands and put on clean gloves for perineal care . I. Gently wash . d. Change gloves . g. pat dry . h. Change gloves . J. Cleaning the rectal and buttocks area . c. Change gloves . K. Closing steps . a. if gloved, remove and discard gloves. Wash hands.<BR/>Record review of facility's policy Infection Control Plan: Overview updated 03/2023 revealed The facility will establish and maintain an Infection Control Program designed . to help prevent the development and transmission of disease and infection . Environmental Infection Control . All non-dedicated, non-disposable medical equipment used for the patient should be cleaned and disinfected . before use on another patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for quality of care.<BR/>The facility failed to sufficiently monitor Resident #32's blood pressure while she was taking anti-hypertensive medication Amlodipine and failed to implement Resident #32's comprehensive care plan intervention to take her blood pressures daily. <BR/>This failure could place residents at risk for adverse effects of an anti-hypertensive medicine regimen. <BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. <BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. <BR/>Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily.<BR/>Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed:<BR/>3/24/2023 12:38 PM- 148 / 78 mmHg<BR/> 2/17/2023 05:02 PM- 156 / 83 mmHg <BR/>2/3/2023 12:01 AM- 88 / 42 mmHg<BR/>2/1/2023 10:00 PM- 115 / 78 mmHg <BR/>1/30/2023 09:26 PM- 112 / 68 mmHg <BR/>1/18/2023 06:19 AM- 123 / 74 mmHg<BR/>1/11/2023 09:19 AM- 100 / 60 mmHg<BR/>Record review of Resident #32's physician orders revealed there was not a physician's order related to the frequency of blood pressure monitoring nor parameters for blood pressure notification. Further review revealed an order: Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023.<BR/>In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency.<BR/>In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that she (Resident #32) was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medications and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to write an order because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings outside of normal limits. <BR/>In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday, 05/16/23, and the morning of 05/17/23. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer Resident #32's anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She then declined to answer any further questions. <BR/>In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. <BR/>In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. <BR/>In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. <BR/>In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. <BR/>In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. <BR/>Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. &lt;https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91&gt;<BR/>Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #23 and Resident #26) of nineteen residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #23 and Resident #26's rooms were in a position that was accessible to the residents.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Resident #23 <BR/>Review of Resident #23's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included lack of coordination and weakness.<BR/>Review of Resident #23's Quarterly MDS Assessment, dated 05/01/2024, reflected Resident #23 had a moderate impairment in cognition with a BIMS score of 09. Resident #23 was dependent to staff for toileting, shower, dressing, and personal hygiene. <BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/07/2024, reflected Resident #23 was at risk for falls related to deconditioning due to CVA (cerebrovascular accident: stroke) with hemiparesis (weakness on one side of the body) and one of the interventions was to be sure the call light was within reach.<BR/>Observation and interview with Resident #23 on 07/09/2024 at 9:15 AM revealed Resident #23 was in her bed, awake. Resident #23's call light was observed on the floor and under the bed of the resident. Resident #23 tried to search for her call light because she said she needed to be changed. Resident #23 stated she could not even find the cord of the call light to pull it. She said the staff should put her call light where she could reach it because it was hard for her to move.<BR/>Observation and interview with CNA A on 07/09/2024 at 11:11 AM, CNA A stated it was important that the call lights were placed near the residents. CNA A said the call lights should always be with the residents because the residents used them to call the staff if they needed something. CNA A said if the call lights were not with the resident, the resident would not be able to tell the staff what they needed. CNA A said the resident might be needing to be changed and she would not know. She said the resident might be frustrated, mad, or might fall if the call light was far from her. CNA A looked for Resident #23's call light and found it on the floor under the bed. CNA A knelt down, pulled the call light from the bottom of the bed, and placed it near the resident. CNA A said she did a quick tour at the beginning of her shift but did not notice that the call light was not with Resident #23. CNA A added she did not make sure the call light was with the resident after she was done with the resident's incontinent care. <BR/>Resident #26 <BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction (blockage in the blood vessels of the brain) and anxiety disorder.<BR/>Review of Resident #26's Quarterly MDS Assessment, dated 05/27/2024, reflected Resident #26 had a moderate cognitive impairment with a BIMS score of 09. Resident #26 required maximal assistance for shower, dressing, and personal hygiene.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected Resident #26 was at risk for falls r/t to impaired mobility and one of the interventions was to be sure my call light is within reach.<BR/>Observation and interview with Resident #26 on 07/10/24 at 7:14 AM revealed the resident was lying in bed, awake. Resident #26 said he just woke up. The resident's call light was observed on the floor. Resident #26 said he was looking for his call light but could not find it. Resident #26 said it was important that he had his call light because he usually was in bed and dependent on the staff for almost everything. Resident #26 added the staff should place the call light near his functioning hand.<BR/>Observation and interview with LVN B on 07/10/2024 at 8:24 AM revealed LVN B entered Resident #26's room to check his blood pressure. LVN B stated the call light was on the floor. LVN B said she did not notice the resident's call light was on the floor when she did her shift change round. LVN B picked up the call light and placed it where the resident could reach it. LVN B said it was important for the call light to be within reach, so the residents could be helped when they needed assistance or help. LVN B said if the call lights were not with the residents, the residents might fall or the staff would not know the residents were having an emergency. She said she was responsible in ensuring the call lights were within reach for her assigned residents.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated call lights were very important for the residents. The DON said the call lights were the only way of communication between the residents and the staff. The DON said the residents were also encouraged to use the call lights to call for assistance, like if they needed to go to the bathroom or needed to be turned. He said the call lights were also used by the resident if they needed something, like pain medication, refill of water, or to turn the lights off. The DON said without the call lights, the needs of the residents would not be known and would not be addressed. He added, without the call lights the needed care would not be provided. The DON said the expectation was for the staff would be mindful that every time they leave the resident's room, the call lights were with the residents. The DON said he would conduct a whole-house in-service about the call lights because the call lights were everybody's responsibility. He said the in-service would be for the nurses, CNAs, housekeeping, therapists, and management. He said he would personally monitor that all the residents' call light were within reach.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the call lights should not be on the floor or in a place where the residents could not reach it. The ADON said the call light must be within reach of the residents at all times because they use the call light to let the staff know they needed something. The ADON said if the call lights were far from the residents, the residents would not be able to call the staff and their needs would not be addressed. The ADON said the resident might even had a fall if they try to go to the bathroom by themselves because they could not call the staff. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of all the residents. The ADON said they would do an in-service about call lights being accessible to the residents. <BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated the call lights should not be far from the residents. The Administrator said the call lights were used by the residents to call the attention of the staff if they needed something. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be sensible about call light placement. The Administrator said they would re-educate the staff regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident.<BR/>Record review of facility's policy Resident Rights Social Services Manual 2003, revealed We believe each resident has a right to a dignified existence . and communication with and access to persons and services inside and outside our facility . Each resident is treated with consideration . care for personal needs.<BR/>Record review of facility's policy Perineal Care Female Nursing Policy and Procedure Manual 2003 rev December 8. 2009, revealed K. Closing steps . e. Always replace call signal and needed items within resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #20) three residents reviewed for gastrostomy tube management.<BR/>The facility failed to ensure that LVN B checked Resident #20's G-tube (Gastrostomy tube: A tube directly inserted through the skin to the stomach to deliver nutrition) placement prior to medication administration.<BR/>The facility failed to ensure that LVN B checked Resident #20's residual (amount of liquid remaining in the stomach) before administering medications via gastrostomy tube. <BR/>These failures could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Review of Resident #20's Face Sheet, dated 07/09/24, reflected resident was a 77- year-old female admitted on [DATE]. Relevant diagnosis included cognitive communication deficit and dysphagia (difficulty in swallowing).<BR/>Review of Resident 20's Comprehensive MDS Assessment, dated 05/29/2024, reflected resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated resident was on tube feeding while a resident of the facility. <BR/>Review of Resident #20's Care Plan on 07/09/2024 revealed that the resident did not have a care plan for tube feeding.<BR/>Review of Resident #20's Physician's Order, dated 05/23/2024, reflected Every shift Check placement prior to feeding and medication administration.<BR/>Review of Resident #20's Physician's Order, dated 05/23/2024, reflected every shift Check residual before medications and feedings; return contents after each check.<BR/>Observation on 07/11/2024 at 7:40 AM revealed Resident #20 was in bed, awake. Resident #20 had a feeding formula hanging from an IV pole. The feeding formula was not connected to the resident. LVN B prepared the resident's medication. LVN B prepared three medications and put them in three separate plastic cups. LVN B then crushed the medications one-by-one and put them back in three small plastic cups. LVN B donned (put on) a gown and a pair of gloves. LVN B went inside the room, set the medications on the side table, and told the resident what she was going to do. LVN B went to the bathroom to get some water for flushing. LVN B put some water in the medications. LVN B started to stir the medications with the tip of the syringe. After mixing the medications, LVN B pulled the plunger of the syringe, attached the tip of the syringe to the g-tube, flushed the g-tube with 60 ml of water, and poured the dissolved medication into the syringe attached to the g-tube one at a time. LVN B flushed the g-tube with 5 ml of water after every medication administration. After giving the medication, LVN B flushed the g-tube and then connected the g-tube to the formula and turned it on. LVN B did not check for placement of the g-tube before administering the medication. LVN B did not check for the residual before administering the medications.<BR/>In an interview with LVN B on 07/11/2024 at 8:05 AM, LVN B stated it was important to check the placement of the g-tube before feeding or medication administration to ensure the g-tube was in the correct position. LVN B said it was also important to check the gastric residual to make sure the stomach was emptying effectively. She said she was not able to check for the placement and for the residual when she gave Resident #20's medication. She said she sometimes checked for both when she disconnected the g-tube. She said she should always check for both before giving the medications. She said she did a competency check-off for enteral feeding but forgot to do both. She said if the placement was not checked, it could cause harm to the resident. She added that if the residual was not checked, the resident could suffer from aspiration pneumonia.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated it was important to check for the placement of the g-tube to ensure the g-tube was in the proper place. He said placement was checked before feeding or medication administration to be sure it was not clogged or displaced. He said the residual was checked also to see if the stomach was not having any intolerance to feeding. He said not checking the placement of the g-tube and the gastric residual could result to vomiting and aspiration pneumonia. He said the expectation was for the staff to check the placement of the g-tube and gastric residual before every feeding, before every medication administration, and every shift. He said he would re-educate LVN B about the proper procedure of enteral feeding. He said he would also do an in-service to all the staff doing enteral feeding.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the g-tube placement was always checked to make sure it was in the right place. She said even though it was checked in the morning, it should still be checked at noon. She said checking for placement could be done by using a stethoscope or by checking the residual. She said the gastric residual was also checked to make sure the stomach was not full. She said not checking the residual could result to vomiting and aspiration. She said she would coordinate with the DON on what to do about the issue.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM stated the staff should follow the g-tube orders. She said if the orders said to check for placement and residual before giving medications, the staff should check for placement and residual before giving the medications. She said both were included in the procedure to provide safety for residents with a g-tube. She said she would collaborate with the clinicians to do in-service about g-tubes.<BR/>Record review of facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual 2003 rev. March 02, 2021 revealed Goals . 1. The resident will maintain nutritional status ,,, Procedure . 7. Perform intermittent feeding . a. check for placement by aspiration or injecting air and listening to the stomach for sounds . b. Aspirate for gastric contents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #26, #30, and Resident #189) of eight residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure an Oxygen In Use sign was placed outside of Resident #26's room. <BR/>2. <BR/>The facility failed to ensure Resident #189's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored.<BR/>3. <BR/>The facility failed to ensure Resident #30's oxygen mask was properly stored.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #26's Comprehensive MDS Assessment, dated 05/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated Resident #26 was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected the resident had oxygen therapy due to ineffective gas exchange and one of the interventions was oxygen at 2 lpm per nasal canula.<BR/>Review of Resident 26's Physician's Order, dated 05/29/2024, reflected, OXYGEN 3-4L/MIN VIA NASAL CANNULA every shift for SOB/wheezing/LOW OXYGEN SAT LESS THAN 92% and prn.<BR/>Observation on 07/09/2024 at 9:37 AM revealed Resident #26 was on oxygen therapy at 3 liters per minute via nasal cannula. It was observed that there was no Oxygen In Use sign outside the door of the resident. <BR/>Observation and interview with LVN B on 07/10/2024 at 10:46 AM, LVN B said there should be a sign outside the room of the residents that use oxygen. LVN B said the sign was to remind the staff and the visitors that oxygen was being used inside the facility. She said oxygen could be a dangerous fire hazard. She said adequate precautions should be in place. LVN B said she would look for a Oxygen In Use sign. LVN B came back to the room and placed the Oxygen In Use sign outside Resident #26's room.<BR/>2. <BR/>Record review of Resident #30's Face Sheet, dated 07/11/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included COPD and obstructive sleep disorder. <BR/>Record review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 07 (severe cognitive impairment) and an active diagnosis of COPD.<BR/>Record review of Resident #30's physician's orders dated 07/11/24 revealed the resident had active orders for may use oxygen @ 4 L/M (liters per minute) via nasal cannula every shift.<BR/>An observation on 07/09/24 at 11:01 AM revealed Resident #30 not being in his room and his oxygen mask was observed sitting on a stand exposed, and not in a sealed bag.<BR/>In an interview and observation on 07/10/24 at 01:55 AM with RN M, she stated she was the floor nurse for the North Hall and she acknowledged that Resident #30 did use an oxygen concentrator. She stated that when the resident's mask was not in use, it had to be placed in a sealed bag. She was shown a picture of Resident #30's mask sitting exposed and uncovered. She stated she had observed that today and had made sure that it was bagged. She stated the CNAs were supposed to remind the nurses if they observed masks not stored in a bag. She stated the risk of not placing the resident's mask in a sanitized bag could result in the resident having respiratory concerns.<BR/>3. <BR/>Review of Resident #189's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Resident #189 had a diagnosis of obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep).<BR/>Review of Resident #189's Comprehensive Care Plan, dated 07/05/2024, reflected resident required the use of CPAP related to sleep apnea and one of the interventions was the resident will use device as ordered.<BR/>Review of Resident #189's Physician's Order, dated 07/05/2024, reflected, CPAP AT HS AND AS NEEDED FOR NAP IN DAY TIME. at bedtime for SLEEP APNEA.<BR/>Observation and interview on 07/09/2024 at 9:08 AM revealed Resident #189 was in his wheelchair inside his room. Resident #189 had a CPAP machine on his bed side table and a CPAP mask was connected to the machine. The CPAP mask was noted on top of the CPAP machine. The CPAP mask was not bagged. Resident #189 stated he used the CPAP machine at night. The resident said staff would put the CPAP on him at night and would take it off in the morning. He said he never saw a plastic bag for the CPAP mask and nobody told him to put the mask one if ever he would take it off.<BR/>Observation and interview with LVN B on 07/09/2024 at 9:53 AM, LVN B stated the CPAP mask should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN B said the CPAP mask should be bagged when not in use. LVN B said she did not notice the CPAP mask was not bagged and that there was no bag for the CPAP mask. LVN B said the resident would sometimes take the CPAP mask off but said she should have monitored if it was in a plastic bag. LVN B saw the CPAP mask on top of the CPAP machine and said she would get a plastic bag for the mask, clean the mask, and place it inside the plastic bag.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated the CPAP mask should be bagged when not in use. He said if the CPAP mask was not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to cross contamination and respiratory infections. He said the expectation was for the CPAP mask would be stored properly. He added the nasal cannula and the breathing mask for nebulization should also be bagged for the same reason. With regards to signage for oxygen, the DON said there should be a Oxygen In Use sign outside the door of the resident using oxygen. The sign was for safety purposes. He continued that oxygen was a flammable substance and could cause an explosion if somebody lit a cigarette near the room. He said the facility was a non-smoking facility but it would be prudent to remind the residents, staff, and visitors. He said he was responsible in putting the sign on the door of the resident and he must have overlooked it. He said the expectation was there would be an Oxygen In Use sign on every door of the residents using oxygen. The DON concluded that moving forward, he would do an in-service about bagging the CPAP mask and would continually remind them to be diligent in making sure the procedures for respiratory care were followed. He said he would also do a round to make sure all the residents using oxygen has a sign outside their door.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the CPAP mask should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who take off the mask should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. She said the expectation was for the staff to bag the CPAP mask. She said, not just the CPAP mask but also the nasal cannula and the mask used for nebulizer should also be bagged. She said it was important that there was an Oxygen In Use sign outside the door of a resident using oxygen. She said the sign was for safety precaution so everybody in the building would know oxygen was being used in the building. She said she would coordinate with the DON to do an in-service pertaining to bagging the CPAP mask, nasal cannula, and breathing mask when the residents were not using them and making sure there was a sign outside the doors of the resident in oxygen administration whether continuously or as needed.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated that in general, the CPAP masks should be stored properly to prevent respiratory issues or exacerbation of whatever respiratory issues the residents already had. The Administrator said the expectation was for the staff to be mindful during their rounds and make sure the CPAP masks were bagged. The Administrator said it was important that there was sign outside the door of the residents using oxygen for safety purposes. She said oxygen was a flammable substance. The Administrator said she would check if the clinicians already did correct the issue.<BR/>Record review of facility's policy, Oxygen Administration Nursing Policy & Procedure Manual 2003 revised February 13, 2007 revealed Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat . O2 therapy is also prescribed to ensure oxygenation of all body organs and systems . 11. Place . signs in area when oxygen is administered.<BR/>A policy for masks being bagged was requested on 07/10/2024 at 1:45 PM and followed-up on 07/11/2024 at 9:40 AM. The Corporate Nurse said the facility did not have a policy specific for masks being bagged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, Resident #19, Resident #9, Resident #28, Resident #1, and Resident #26) of twelve residents observed for infection control. <BR/>1. <BR/>The facility failed to ensure that CNA A changed his gloves and perform hand hygiene while providing incontinent care to Resident #23.<BR/>2. <BR/>The facility failed to ensure that LVN B sanitized the blood pressure cuff between Resident #19, Resident #9, Resident #28, and Resident #26.<BR/>These failures could place the residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #23's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body), and weakness.<BR/>Review of Resident #23's Comprehensive MDS Assessment, dated 05/01/2024, reflected Resident #23 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated Resident #23 was always incontinent for bowel and bladder.<BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/07/2024, reflected resident had potential for pressure ulcer development related to incontinence of bladder and bowel one of the interventions was to wash, rinse, and dry perineum (the space between the anus and the genitals).<BR/>Observation and interview on 07/09/2024 at 10:42 AM, CNA A said she would check if Resident #23 needed to be changed then said she would just go ahead and change the resident. CNA A prepared the brief and wipes. CNA A washed her hands, put on the PPE, and then lowered the head of the bed. After lowering the head of the bed, CNA A pulled the trash can beside her with her gloved hands. CNA A then grabbed the new brief from the overbed table, opened it, and put it parallel to the resident's legs. CNA A did not change her gloves nor sanitize her hands after touching the waste can. CNA A unfastened the brief on both sides and pushed the front part of the brief between the legs of the resident. CNA A pulled some wipes and started to clean the front of the resident from front to back. She did it five times. CNA A rolled the resident towards the wall and cleaned the bottom of the resident. After cleaning the resident's bottom, CNA A pulled the soiled brief and threw it in the trash can. CNA A took the new brief placed it at the side of the resident, put it at the bottom of the resident, and fixed it. CNA A did not change her gloves nor sanitize before touching the new brief. CNA A rolled the resident back. CNA A cleaned the front part again and then closed the brief and fastened it to both sides. CNA A did not change her gloves all throughout the process of incontinent care. CNA A did not wash her hands after doing incontinent care.<BR/>In an interview with CNA A on 07/09/2024 at 11:11 AM, CNA A stated she was able to wash her hands before doing incontinent care but was not able to wash her hands after incontinent care. She said she forgot to do so because she went out of the room to get some linens. CNA A said it was also important to change the gloves after touching the trash can and after pulling the soiled brief to prevent cross contamination. She said cross contamination could eventually cause infection.<BR/>2. <BR/>Review of Resident 19's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #19 was diagnosed with hypertension.<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 05/17/2024, reflected resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated hypertension as one of Resident #19's primary medical condition.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 07/09/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #19's Physician's Order for amlodipine, dated 06/28/2024, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #19's Physician's Order for lisinopril, dated 01/10/2023, reflected Lisinopril Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IS SBP IS &lt;110 OR HR IS &lt;60.<BR/>Observation on 07/10/2024 at 7:10 AM revealed LVN B was preparing Resident #19's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #19's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #19. She did not sanitize the blood pressure cuff.<BR/>Review of Resident 9's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #9 was diagnosed with hypertension.<BR/>Review of Resident #9's Quarterly MDS Assessment, dated 04/30/2024, reflected resident had severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated hypertension as one of Resident #9's primary medical condition.<BR/>Review of Resident #9's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #9's Physician's Order for amlodipine, dated 05/09/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #9's Physician's Order for lisinopril, dated 05/20/2024, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION.<BR/>Observation on 07/10/2024 at 7:55 AM revealed LVN B was preparing Resident #9's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #9's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #9. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #28's Face Sheet, dated 07/10/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #28 had a diagnosis of hypertension.<BR/>Review of Resident #28's Quarterly MDS Assessment, dated 05/10/2024, reflected resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated hypertension as one of Resident #28's primary medical condition.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 07/07/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #28's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #28's Physician's Order for lisinopril, dated 05/17/2023, reflected Lisinopril Oral Tablet 40 MG (Lisinopril). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP IS &lt;100/60 OR HR &lt;60.<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #28's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #28's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #28. She did not sanitize the blood pressure cuff.<BR/>Review of Resident #26's Face Sheet, dated 07/09/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #26 had a diagnosis of hypertension.<BR/>Review of Resident #26's Quarterly MDS Assessment, dated 05/10/2024, reflected resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated hypertension as one of Resident #26's primary medical condition.<BR/>Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. <BR/>Review of Resident #26's Physician's Order for amlodipine, dated 05/04/2023, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF BP &lt;100/60 OR HR&lt;60.<BR/>Review of Resident #26's Physician's Order for lisinopril, dated 03/29/2024, reflected Lisinopril Oral Tablet 20 MG (Lisinopril). Give 1 tablet by mouth one time a day for hold for sbp&lt;110, dbp&lt;60 hr&lt;60 related to ESSENTIAL (PRIMARY) HYPERTENSION (I10).<BR/>Observation on 07/10/2024 at 8:12 AM revealed LVN B was preparing Resident #26's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #26's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart and then prepared and gave the medications to Residents #26. She did not sanitize the blood pressure cuff.<BR/>In an interview with LVN B on 07/10/2024 at 9:48 AM, LVN B stated she obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. LVN B said the proper thing to do was to wash or sanitize her hands before and after giving medications. LVN B said the blood pressure cuff should be sanitized as well after using it and before using it on another resident. LVN B then acknowledged she forgot to sanitize the blood pressure cuff in between residents when she passed the medications. LVN B stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. LVN B added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized.<BR/>In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated that the blood pressure cuff should be sanitized every after use. He said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. The DON added that was also true for the glucometer and the pulse oximeter. The DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said he just did a check-off about incontinent care. He said he showed the staff how to do incontinent care and then let the staff returned the demonstration. He said he used a mannequin during his demonstration. He said the CNA involved was present during the time of the check-off so he did not know what happened. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks. He said the gloves should have been changed when the trash can was touched. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON said the expectation was for the staff to wash their hands before and after every care, change their gloves when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and sanitizing the blood pressure cuff after every use. The DON said he would do a one-on-one in-service with CNA A about washing of hands and changing of gloves and then talk to LVN B about sanitizing the blood pressure cuff. He added he would do an in-service about infection control for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control.<BR/>In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the blood pressures were checked first before administering medications for hypertensions. The ADON said since the nurses were only using one blood pressure cuff for all the residents, the blood pressure cuff should be sanitized every after use to prevent cross contamination. The ADON said, during incontinent care, the staff must always change their gloves and sanitize the hands before touching the new brief. She said the expectation was for the blood pressure cuff to be sanitized in between residents and staff would wash their hands, and change their gloves to prevent infection among the residents. She said she would coordinate with the DON on how to go forward.<BR/>In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated not washing the hands nor sanitizing them could contribute to cross contamination. She said not sanitizing the blood pressure cuff would do the same. The Administrator said the expectation was for the staff to make sure all items and equipment used by the residents were sanitized and the gloves were changed during incontinent care for the basic reason of infection control. She said she would collaborate with the clinicians to in-service the staff about infection control.<BR/>Review of facility policy, Perineal Care Female (With or without catheter) Nursing Policy and Procedure Manual 2003 rev. December 8.2009 revealed Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area . Procedural Guidelines . A. Beginning Steps . a. Wash hands . H. Wash hands and put on clean gloves for perineal care . I. Gently wash . d. Change gloves . g. pat dry . h. Change gloves . J. Cleaning the rectal and buttocks area . c. Change gloves . K. Closing steps . a. if gloved, remove and discard gloves. Wash hands.<BR/>Record review of facility's policy Infection Control Plan: Overview updated 03/2023 revealed The facility will establish and maintain an Infection Control Program designed . to help prevent the development and transmission of disease and infection . Environmental Infection Control . All non-dedicated, non-disposable medical equipment used for the patient should be cleaned and disinfected . before use on another patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for care plans.<BR/>The facility failed to ensure for accuracy and effectively implement Resident #32's comprehensive care plan. <BR/>This failure can result in the facility not meeting Resident #32's specific care needs related to her anti-hypertensive medication regimen. <BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. <BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. <BR/>Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily.<BR/>Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed:<BR/>3/24/2023 12:38 PM <BR/>148 / 78 mmHg<BR/> 2/17/2023 05:02 PM <BR/>156 / 83 mmHg <BR/>2/3/2023 12:01 AM <BR/>88 / 42 mmHg<BR/>2/1/2023 10:00 PM <BR/>115 / 78 mmHg <BR/>1/30/2023 09:26 PM <BR/>112 / 68 mmHg <BR/>1/18/2023 06:19 AM 123 / 74 mmHg<BR/>1/11/2023 09:19 AM 100 / 60 mmHg<BR/>Record review of Resident #32's physician orders reveale no evidence of physician orders related to frequency of blood pressure monitoring or parameters for notification related information were observed. Further review revealed:<BR/>Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023.<BR/>In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency.<BR/>In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that [Resident #32] was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medication and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings out of normal limits. <BR/>In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday and this morning. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer her anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She declined to answer any further questions. <BR/>In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring and/or frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. <BR/>In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. <BR/>In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. <BR/>In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. <BR/>In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. <BR/>Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. &lt;https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91&gt;<BR/>Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs (Resident #32). <BR/>The facility did not shower Resident #32 regularly.<BR/>This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health.<BR/>The findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a full code [AGE] year-old female originally admitted to the facility on [DATE]. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression.<BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, toileting, and bathing. <BR/>Record review of Resident #32's most recent Care Plan, dated 02/16/23, revealed the resident had an ADL Self Care Performance Deficit. The goals were to ensure the resident maintain or improve current level of function in personal hygiene. Also, to ensure the resident improve current level of function in personal hygiene through the review date. The care plan reflected Resident #32 required assitance from 1 staff for bathing. <BR/>Record review of ADL care provided for Resident #32, dated March 2023, revealed the resident did not receive showers from 03/04/23-03/09/23.<BR/>Record review of ADL care provided for Resident #32, dated May 2023, revealed the resident did not receive showers from 05/04/23-05/07/23. <BR/>During an interview on 05/18/23 at 12:14 PM, Resident #32 stated she gets tired of being put off for showers. She stated showers are important to her. She stated she would like to have showers especially before her doctors' appointments and she rarely gets them. She stated if she did not get them on the scheduled day, it was ok, if she was to get it on another day. However, when she did not get her showers on the day of her appointments then that really bothered her. She stated she was supposed to get a shower on 05/17/23 and she did not get it. She stated she had not gotten a shower at the time of this interview. She stated she was upset because she had a doctor's appointment at 4:00 PM on this day and still had not had a shower.<BR/>During an interview on 05/18/23 at 12:19 PM Resident #21 stated the aides said they were instructed to stick to the schedule and not deviate. She stated if they did not get a shower on their scheduled day and shift, then they would have to wait until the next scheduled shower day. <BR/>During an interview on 05/18/23 at 9:27 AM, C.N.A. A stated on certain days of the week, they had more staff on shift and they were able to shower the residents on schedule. However, when it was just a couple of aides on shift, it was hard to get to everyone, because call lights took priority and they had other duties that had to be done. <BR/>During an interview on 05/18/23 at 12:49 PM, the Director of Nursing she stated she had begun an audit on showers. She stated the aides were prompted on the days of the residents' showers to be showered. She stated it was important to get soap and water on their skin. She stated the nurses received a report every morning and she could not verify that everyone was documenting. She stated lack of showers could affect their skin health and comfort.<BR/>During an interview on 05/18/23 at 1:00 PM, the Administrator stated his expectation was that residents get their showers on their scheduled days. He stated some days they did have more staff on shift than others. He stated residents could feel frustrated and feel not cared for if they did not receive regular showers.<BR/>Record review of facility policy on Resident Rights, revised 11/28/16, revealed The Resident has the right to be treated with dignity and respect , including the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences, except when to do so would endanger the health or safety of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for quality of care.<BR/>The facility failed to sufficiently monitor Resident #32's blood pressure while she was taking anti-hypertensive medication Amlodipine and failed to implement Resident #32's comprehensive care plan intervention to take her blood pressures daily. <BR/>This failure could place residents at risk for adverse effects of an anti-hypertensive medicine regimen. <BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. <BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. <BR/>Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily.<BR/>Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed:<BR/>3/24/2023 12:38 PM- 148 / 78 mmHg<BR/> 2/17/2023 05:02 PM- 156 / 83 mmHg <BR/>2/3/2023 12:01 AM- 88 / 42 mmHg<BR/>2/1/2023 10:00 PM- 115 / 78 mmHg <BR/>1/30/2023 09:26 PM- 112 / 68 mmHg <BR/>1/18/2023 06:19 AM- 123 / 74 mmHg<BR/>1/11/2023 09:19 AM- 100 / 60 mmHg<BR/>Record review of Resident #32's physician orders revealed there was not a physician's order related to the frequency of blood pressure monitoring nor parameters for blood pressure notification. Further review revealed an order: Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023.<BR/>In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency.<BR/>In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that she (Resident #32) was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medications and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to write an order because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings outside of normal limits. <BR/>In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday, 05/16/23, and the morning of 05/17/23. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer Resident #32's anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She then declined to answer any further questions. <BR/>In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. <BR/>In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. <BR/>In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. <BR/>In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. <BR/>In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. <BR/>Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. &lt;https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91&gt;<BR/>Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for care plans.<BR/>The facility failed to ensure for accuracy and effectively implement Resident #32's comprehensive care plan. <BR/>This failure can result in the facility not meeting Resident #32's specific care needs related to her anti-hypertensive medication regimen. <BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. <BR/>Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. <BR/>Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily.<BR/>Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed:<BR/>3/24/2023 12:38 PM <BR/>148 / 78 mmHg<BR/> 2/17/2023 05:02 PM <BR/>156 / 83 mmHg <BR/>2/3/2023 12:01 AM <BR/>88 / 42 mmHg<BR/>2/1/2023 10:00 PM <BR/>115 / 78 mmHg <BR/>1/30/2023 09:26 PM <BR/>112 / 68 mmHg <BR/>1/18/2023 06:19 AM 123 / 74 mmHg<BR/>1/11/2023 09:19 AM 100 / 60 mmHg<BR/>Record review of Resident #32's physician orders reveale no evidence of physician orders related to frequency of blood pressure monitoring or parameters for notification related information were observed. Further review revealed:<BR/>Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023.<BR/>In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency.<BR/>In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that [Resident #32] was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medication and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings out of normal limits. <BR/>In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday and this morning. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer her anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She declined to answer any further questions. <BR/>In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring and/or frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. <BR/>In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. <BR/>In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. <BR/>In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. <BR/>In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. <BR/>Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. &lt;https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91&gt;<BR/>Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food storage. <BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>This failure could place residents at risk for food-borne illnesses.<BR/>Findings include:<BR/>Observation on 05/16/23 at 9:00 AM in the walk-in refrigerator, revealed the following:<BR/>One opened &frac12; gallon Jar of Maraschino Cherries Halves dated 11/03/22, and no expiration date was observed on the container. <BR/>One 1-gallon container of Nacho sliced jalapeno peppers dated 04/07/21 and expired 09/16/22.<BR/>One 64-ounce container of Enchilada Sauce dated 07/14/22, and expired 05/12/23<BR/>Two 1-gallon jars of Balsamic Vinaigrette Dressing dated 12/12/ (No year), and no expiration was observed on the container <BR/>Interview with Dietary Manager on 05/17/2023 at 1:00 PM revealed she was responsible for the dating and storage of foods as they are delivered to the facility. She was shown the photos of the expired foods and she stated the items should have been discarded and she will discard them. The Dietary Manager stated the risk of not discarding expired foods could result in food-borne illnesses. <BR/>Interview with Administrator on 05/18/2023 at 11:50 AM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they are following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Dietary Services Policy & Procedure Manual 2012 (undated), revealed Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or bet by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality deteriorated. <BR/>Review of FDA Food Code 2022 under Disposition revealed, A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under &sect; 3-101.11 shall be discarded or reconditioned according to an APPROVED procedure.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food storage. <BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>This failure could place residents at risk for food-borne illnesses.<BR/>Findings include:<BR/>Observation on 05/16/23 at 9:00 AM in the walk-in refrigerator, revealed the following:<BR/>One opened &frac12; gallon Jar of Maraschino Cherries Halves dated 11/03/22, and no expiration date was observed on the container. <BR/>One 1-gallon container of Nacho sliced jalapeno peppers dated 04/07/21 and expired 09/16/22.<BR/>One 64-ounce container of Enchilada Sauce dated 07/14/22, and expired 05/12/23<BR/>Two 1-gallon jars of Balsamic Vinaigrette Dressing dated 12/12/ (No year), and no expiration was observed on the container <BR/>Interview with Dietary Manager on 05/17/2023 at 1:00 PM revealed she was responsible for the dating and storage of foods as they are delivered to the facility. She was shown the photos of the expired foods and she stated the items should have been discarded and she will discard them. The Dietary Manager stated the risk of not discarding expired foods could result in food-borne illnesses. <BR/>Interview with Administrator on 05/18/2023 at 11:50 AM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they are following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Dietary Services Policy & Procedure Manual 2012 (undated), revealed Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or bet by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality deteriorated. <BR/>Review of FDA Food Code 2022 under Disposition revealed, A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under &sect; 3-101.11 shall be discarded or reconditioned according to an APPROVED procedure.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food storage. <BR/>The facility failed to ensure expired foods were discarded upon expiration date.<BR/>This failure could place residents at risk for food-borne illnesses.<BR/>Findings include:<BR/>Observation on 05/16/23 at 9:00 AM in the walk-in refrigerator, revealed the following:<BR/>One opened &frac12; gallon Jar of Maraschino Cherries Halves dated 11/03/22, and no expiration date was observed on the container. <BR/>One 1-gallon container of Nacho sliced jalapeno peppers dated 04/07/21 and expired 09/16/22.<BR/>One 64-ounce container of Enchilada Sauce dated 07/14/22, and expired 05/12/23<BR/>Two 1-gallon jars of Balsamic Vinaigrette Dressing dated 12/12/ (No year), and no expiration was observed on the container <BR/>Interview with Dietary Manager on 05/17/2023 at 1:00 PM revealed she was responsible for the dating and storage of foods as they are delivered to the facility. She was shown the photos of the expired foods and she stated the items should have been discarded and she will discard them. The Dietary Manager stated the risk of not discarding expired foods could result in food-borne illnesses. <BR/>Interview with Administrator on 05/18/2023 at 11:50 AM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they are following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. <BR/>Record Review of facility's policy and procedures for Dietary Services Policy & Procedure Manual 2012 (undated), revealed Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or bet by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality deteriorated. <BR/>Review of FDA Food Code 2022 under Disposition revealed, A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under &sect; 3-101.11 shall be discarded or reconditioned according to an APPROVED procedure.

Based on observation, interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience or had completed a training course approved by the State for one (AD) of one Activity Director.<BR/>The facility failed to have a qualified Activity Director. The previous Activity Director left employment five days prior and the facility did not fill the position, only having facility staff try to fill in who were not qualified or had the experience.<BR/>This failure placed all residents at risk of receiving inappropriate activities. <BR/>Findings included:<BR/>During an interview on 05/16/23 @ 10:27 AM, the Administrator revealed they had just lost their Activities Director. He stated she resigned and Friday 05/12/23 was her last day. <BR/>Review of the Active Employee List on 05/16/23 did not identify the presence of an Activity Director.<BR/>During an interview on 05/17/23 at 11:15 PM, the Administrator stated they did not have a Corporate Activities Director. He stated staff were chipping in to carry on the activities for the rest of the month, as the former Activities Director had already completed the Activities Calendar for the month of May 2023. He stated he had not had a chance to fill the position yet.<BR/>Observation of the Activities Calendar, located on the wall across from the common area, there was a full calendar for the month of May 2023.<BR/>During an interview on 05/18/23 at 1:00 PM, the Administrator stated he believed the staff were doing a great job at carrying on the activities and stated staff were doing what they could to keep the residents engaged. He stated did, however, acknowledge understanding the need for a trained and certified Activities Director, because they would be able to engage with each resident, including the ones who had cognitive or behavioral challenges, which regular staff would not have the skills to perform, effectively.<BR/>Review of the facility's policy titled, Activities Program (not dated), reflected, Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. for 1 of 12 residents (Resident #190) reviewed for Baseline Care Plans. <BR/>The facility failed to ensure Resident #190 had a Baseline Case plan developed within 48 hours of a resident's admission.<BR/>This failure placed resident at risk of not receiving immediate care if assistance was needed. <BR/>Findings Included:<BR/>Record review of Resident #190's Face Sheet, dated 05/17/23, revealed he was a 81 -year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (lung disease), chronic kidney disease (kidney failure), chronic congestive heart failure (heart failure), dementia, and repeated falls.<BR/>Record review of Resident #190's MDS on 05/17/23 revealed no BIMS score or any other pertinent information referencing the care needs of the resident. <BR/>Record review of Resident #190's assessments in the facility's system of records for care on 05/17/23, revealed no baseline care plan nor comprehensive care plan for the resident.<BR/>Interview on 05/17/23 at 1:00 PM with MDS Nurse revealed Resident #190 did not have a baseline care plan nor did he have a care plan developed and implemented. She stated that whoever the admitting nurse was at the time, should have completed the resident's base line care plan. She stated the baseline care plan had to be completed within 48 hours of the resident admitting to the facility. She stated the risk of it not being completed could result in the resident not receiving all his required care. <BR/>Interview on 05/18/23 at 11:00 AM with Regional Compliance Nurse (RC) revealed she stated that whenever a resident is admitted to the facility, the nurse on duty had to complete the baseline care plan for the resident. She advised the risk of not completing a base line care plan could result in the resident not receiving the proper care. <BR/>Interview on 05/18/23 at 1:00 PM with Director of Nurses (DON) revealed she was made aware of Resident #190 not having a baseline care plan developed and she stated that whenever a resident is admitted to the facility, the nurse on duty has the responsibility of completing the baseline care plan for residents admitting to the facility. She was unable to advise who completed the admission paperwork for Resident #190. She stated the facility had 48 hours upon the resident being admitted , to complete a baseline care plan, which was not done for Resident #190. She advised the risk of not completing a baseline care plan could result in the resident not receiving the proper care.<BR/>Interview on 05/18/23 at 1:15 PM with Interim Administrator revealed he was made aware of Resident #190 not having a baseline care plan developed. He advised it was solely the responsibility of the charge nurse on duty to complete the baseline care plan. He advised the risk of not completing a base line care plan could result in the resident not receiving the proper care.<BR/>Record review of facility policy, Baseline Care Plans (undated) revealed Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident's safety, and safeguard against adverse events that are most likely to occur right after admission.