The Lev Attown Park

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 10 residents (CR#1) reviewed for physician notification. 1. The facility failed to notify or seek medical guidance from the Medical Doctor or Nurse Practitioner for a change of condition after CR #1 complained of pain and a swollen knee on 11/5/25 at approximately 10:00pm. 2. The facility failed to immediately notify or seek medical guidance from the Medical Doctor or Nurse Practitioner after CR #1's left knee was observed swollen and painful at level 8 out of 10 (most severe) on 11/07/2025 at approximately 2:27 p.m, 3:41pm, and 4:18pm. 3. The facility failed to immediately seek medical guidance from the Medical Doctor or Nurse Practitioner for CR#1 after receiving results of an x-ray, which revealed, CR#1 had a Displaced distal femoral shaft spiral fracture. 4. The facility failed to immediately transport CR#1 to the hospital on [DATE] after becoming aware of the result of an x-ray, which reflected an acute fracture. The facility waited approximately 13 hours to transport CR#1 to the hospital, where CR#1 was diagnosed with a spiral fracture of his femur and required emergency surgery. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk of delayed treatment and continued severe pain. Findings included: Reviewed Record of CR#1's undated face sheet, revealed CR#1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnosis of non-Alzheimer's Dementia (decline in cognitive function), and stroke (loss of blood flow in the brain). Reviewed Record of CR#1's Quarterly MDS (resident assessment) dated 8/11/2025 revealed CR#1's BIMS score of 00 indicated CR#1's cognition is severely impaired. The MDS further revealed CR#1 had severely impaired vision, he uses a wheelchair mobility resident totally dependent on staff for eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, personal care, and sit to lying in bed. Reviewed Record of CR#1's care plan dated 7/28/25 revealed the following:Focus: Resident has an alteration in hematological (clotting problem) status r/t receiving anticoagulant (Date Initiated: 7/21/25 and Revision 11/10/25).Goal: The resident will remain free of complications related to altered hematological (clotting problem) status through the review date (Date Initiated: 7/21/25, Revision date: 11/10/25, and Target date: 1/12/26).Interventions: Complete fall risk assessment and increase vigilance for falls (Date initiated: 7/21/25). Reviewed Record of CR#1's orders dated 7/28/25 revealed:-CR#1 is to be assessed for pain every shift (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); PRN (as needed) -Acetaminophen (Tylenol) oral table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 - 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. Reviewed Record the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm, a telephone interview with FM revealed on Wednesday evening 11/05/25, during a visit with CR #1, she was informed by CR#1 his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with LVN C, who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look (without touching), at both knees, then LVN C told FM that CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/2025 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm, in an interview with LVN A, he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN A stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at that time (2:27pm), he administered a PRN 325 mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm, he then administered 2-325mg Tylenol tablets. LVN A stated when he followed up with CR#1, he stated that he was still in pain. LVN A stated at 5:00pm, LVN stated he called the MD and NP that was assigned to CR#1 and did not get an immediate response. LVN A stated he waited over an hour for a call back before texting the afterhours NP services, which took an additional hour to receive a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility used, and they never arrived. He stated at 8:00pm, they still hadn't arrived. LVN A stated he followed up with the x-ray company and was informed someone was enroute but was not given an ETA. LVN A stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN A stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 had a stroke, he was cognizant and understood when they speak to him, and staff were aware of his needs. On 11/10/25 at 5:45pm, in an interview with LVN B, LVN B stated she only worked on the weekend. LVN B stated on 11/8/25, she was scheduled to work 6:00am - 2:00pm. However, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late, she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am, she observed a paper on the fax machine and when she looked at it, it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. On 11/10/25 at 7:40pm, in an interview with the HN, he stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. The HN stated CR#1 had emergency surgery on 11/09/25 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am, during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with the MD, it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he could not say the fracture was the result of abuse because there were many factors that could cause this. However, CR#1was bedbound. During a telephone interview on 11/11/25 at 3:13pm with the RD. it was revealed the mobile x-ray records showed that on 11/7/25, a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am, a fax was sent to the facility regarding CR#1's diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The RD reported that an electronic medical record, which was part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/25 between 3:00pm - 4:00pm while providing care to CR#1, he told her he was experiencing pain on his, she believed, right side. She told her charge nurse, who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm, DON, it was revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. DON stated it was a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1's pain level was 8, and the MD should have been notified at that same time. The DON stated the x-ray report did come into the facility fax machine at 6:33am and it was also in the electronic health record located on CR#1's dashboard. She stated when nursing staff signed in to the resident file, the dashboard immediately showed an alert and anything new or out of the ordinary was there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. The DON stated CR#1 should have been sent out via 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am, an interview with LVN C, revealed that she worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p, and he stated he did not. LVN C stated she didn't document, because she had just came on shift and it slipped her mind. She stated she did not normally work with CR#1 and that side was unfamiliar to her. LVN C stated she believed she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. An additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am, during a telephone interview with NP, he stated he should have been called immediately. He stated he didn't work the weekend. However, the NP should have been notified after administering Norco. The NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation took longer than 2 hours, then CR#1 should have been sent out in emergency transportation. Record review of the Notifications of Changes policy dated August 2024 reflected: Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include: 1.Accidents Resulting in injury. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment.This may include: A. New treatment. B. Discontinuation of current treatment due to:S Adverse consequences.S Acute condition.S Exacerbation of a chronic condition. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm.and Plan of Removal requested. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F580 Notify of Changes 11/13/25 Plan to remove immediate jeopardyThe facility failed to meet one or more state health, safety, and/or quality regulations. F-580 Notify of ChangesThe facility failed to ensure CR#1 was free from neglect. CR #1 is currently in the hospital. On 11/13/25: DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (Unit Manager or Administrator) are to be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25: Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding.All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/25 through 11/15/25 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted, and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constituted residents' change in condition that may be pain or anything new that happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family were required. Each nursing staff were able to explain the pain assessment process on verbal and non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there was a fall, bleeding, a resident was on anticoagulants and if there was a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CNAs and CMAs were able to explain the Stop N Watch procedure, completing their documentation in the POC (plan of care) as well. Both were to immediately notify charge nurses when a resident appeared different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified. On 11/17/25 at 1:08pm, during an interview with the Admin, she stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 10 residents (CR# 1) reviewed for quality of care. 1. The facility failed to immediately seek medical guidance or send CR#1 out for higher level of care (ER) after receiving results of CR#1's x-ray, which revealed a Left Displaced distal femoral shaft spiral fracture . 2. The facility failed to notify the physician or NP of CR#1's change in condition, failed to monitor, and complete assessments on 11/5/25 and 11/6/25. 3. The facility failed to immediately transport CR#1 to the hospital on [DATE] after becoming aware of the result of an xray, which reflected an acute fracture. The facility waited approximately 13 hours to transport CR#1 to the hospital, where CR#1 was diagnosed with a spiral fracture of his femur and required emergency surgery. These failures could place residents at risk for continued pain, serious injuries, harm and death to residents who require total supervision. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.Findings included: Reviewed Record of CR#1's undated face sheet, revealed CR#1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnosis of non-Alzheimer's Dementia (decline in cognitive function), and stroke (loss of blood flow in the brain). Reviewed Record of CR#1's Quarterly MDS (resident assessment) dated 8/11/2025 revealed CR#1's BIMS score of 00 indicated CR#1's cognition is severely impaired. The MDS further revealed CR#1 had severely impaired vision, he uses a wheelchair mobility resident totally dependent on staff for eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, personal care, and sit to lying in bed. Reviewed Record of CR#1's care plan dated 7/28/25 revealed the following:Focus: Resident has an alteration in hematological (clotting problem) status r/t receiving anticoagulant (Date Initiated: 7/21/25 and Revision 11/10/25).Goal: The resident will remain free of complications related to altered hematological (clotting problem) status through the review date (Date Initiated: 7/21/25, Revision date: 11/10/25, and Target date: 1/12/26).Interventions: Complete fall risk assessment and increase vigilance for falls (Date initiated: 7/21/25). Reviewed Record of CR#1's orders dated 7/28/25 revealed:-CR#1 is to be assessed for pain every shift (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); PRN (as needed) -Acetaminophen (Tylenol) oral table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 - 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm in a telephone Interview with FM revealed on Wednesday evening 11/05/2025, during a visit with CR #1 she was informed by CR#1that his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with the LVN C who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look, without touching, at both knees, then LVN C told CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/25 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm in an Interview with LVN A he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at this time (2:27pm) he administered a PRN 325mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm he then administered 2-325mg Tylenol tablets. LVN A stated he followed up with CR#1 and was informed that he was still in pain. LVN A stated at 5:00pm, he called the MD and NP that is assigned to CR#1 and waited over an hour for a call back. LVN A stated he texted the NP after hours service and after an hour received a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility uses, and they never arrived. He stated at 8:00pm they still hadn't arrived. LVN A stated he followed up with the x-ray company was informed someone was enroute but was not given an ETA. LVN stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 has had a stroke he is cognizant and understands when you speak to him and staff are aware of his needs. On 11/10/25 at 5:45pm in an interview with LVN B regarding CR#1. LVN B stated she only works on the weekend. LVN B stated on 11/8/25 she was scheduled to work 6:00am - 2:00pm; however, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am she observed a paper on the fax machine and when she looked at it it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. Observation and interview on 11/10/25 at 7:00pm at the local hospital of CR#1 where CR#1 was lying in hospital bed. CR#1 initially stated that LVN A was rough with him and admitted he gave him pain medications. However, CR#1 began to fall asleep, at which time No further information could have been gathered regarding CR#1's injury at that time. On 11/10/25 at 7:40pm in an interview with HN who stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. NH stated CR#1 had emergency surgery on 11/09/2025 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with MD it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he can't say the fracture was the result of abuse because there are many factors that could cause this; however, CR#1 is bedbound. During a telephone interview on 11/11/25 at 3:13pm with DR it was revealed the mobile x-ray records show that on 11/7/25 a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am a fax was sent to the facility regarding CR#1 diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The DR reported that an electronic medical record, which is part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/2025 while providing care to CR#1 told her he was experiencing pain on his, she believes, right side. She told her charge nurse who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm with the DON revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. The DON stated it is a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1 pain level was 8, and the MD should have been notified at this same time. The DON stated the x-ray report did come in to the facility fax machine at 6:33am and it was also on the PCC dashboard. She stated when nursing staff sign in to the resident file, the dashboard immediately shows an alert and anything new or out of the ordinary is there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. DON stated CR#1 should have been sent out 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am in an interview with LVN C it was revealed that she worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated the CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p and he stated he did not. LVN C stated she did not document, because she had just came on shift and it slipped her mind. She stated she does not normally work with CR#1 and this side was unfamiliar to her. LVN C stated she believes she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. Additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am during a telephone interview with NP he stated he should have been called immediately. He stated he doesn't work weekends; however, NP should have been notified after administering the Norco. NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation would take longer than 2 hours, then CR#1 should have been sent out in emergency transportation. On 11/17/25 at 1:08pm during an interview with Admin stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. Record review of the Facility's Provision of Quality-of-Care policy (dated: October 2022 revision) reflected:1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.2. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F684 Quality of Care 11/13/25Plan to remove immediate jeopardy Noncompliance: The facility failed to meet one or more state health, safety, and/or quality regulations. F-684 Quality of CareThe facility failed to ensure CR#1 received treatment and are in accordance with professional stances of practice. CR #1 is currently in the hospital. On 11/13/25:DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (which will be the Unit Manager or Administrator), will be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25:Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator) Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding. All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/2025 through 11/15/2025 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constitutes residents' change in condition that may be pain or anything new that has happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family is required. Each nursing staff were able to explain the pain assessment process on verbal and non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there is a fall, bleeding, a resident is on anticoagulants and if there is a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CAN's and CMA were able to explain the Stop N Watch procedure, completing their documentation in POC (plan of care) as well. Both are to immediately notify charge nurses when a resident appears different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (CR #1) of 5 residents reviewed for accuracy of assessments. <BR/>The facility failed to ensure CR#1's behavior was coded on the quarterly MDS dated [DATE].<BR/>This failure could place residents with behavior at risk of not receiving care and intervention that could meet their behavioral needs. <BR/>Findings included:<BR/>Record review of CR #1's face sheet dated 05/16/2025 reflected CR#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 5/15/2025. CR#1's diagnoses included muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination (pattern walking or moving on foot), non- Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior), hypertension (high blood pressure), diabetes (high blood sugar) hyperlipidemia (high levels of fat in the blood), seizure (uncontrolled jerking, loss of consciousness and blank stares), unspecified dementia (memory loss), and psychotic disorder (severe mental disorder that causes abnormal thinking and perception, lose touch with reality).<BR/>Record review of CR#1's nurse's notes revealed the following. <BR/>4/2/2025 at 10:16am Resident observed in the hallway yelling and screaming help, when resident was asked what he needed resident began yelling out curse words towards the staff. Resident upset because he wanted to put the dirty clothes back on after his shower, staff attempted to redirect resident. This resident continued to yell out curse words calling the staff out calling them derogatory names. Resident continued to wheel himself up and down the hall yelling curse words to the top of his lungs.<BR/>4/2/2025 at 9:45pm Assisted the patient to bed and met all needs. The patient continued to shout loudly. Attempted redirection, but the patient was difficult to reorient and continued shouting.<BR/>4/3/2025 at 09:42am. Patient up in w/c, able to make needs known, pt is verbally abusive towards staff during care, constantly cussing at staff for no reason. Pt at nursing station telling staff member he wished death to her kids and wished staff a car wreck. Pt not easily redirected, attempt to redirect, the more he cusses staffs. wheeled self to dining area at this time with no other concerns.<BR/>4/3/2025 at 09:26pm. Assisted the patient to bed and met all needs. The patient continued to shout loudly, repeatedly calling out one resident's name, causing disturbance to others. Attempted redirection, but the patient was difficult to reorient and continued shouting. <BR/>4/4/2025 at 06:35am. Resident was sitting up in bed upon shift rounding, attempting to get out of bed. Writer attempted to redirect him he got so agitated, and was using F-- words, and stating he wants his chair back. Writer was able to redirect him. Resident was assisted, with his pant, reassured him that I 'will be checking on him. Resident stable. Bed low, and locked safety precaution in place. <BR/>4/4/2025 at 09:51am Pt is up in w/c, able to make needs known. Non complaint with use of safe coffee cup. Pt prefers to use plastic drinking cups. cussing staff and insisting to use plastic cup for safety even after pt education on burns safety. no other concerns.<BR/>4/7/2025 at 9:54 pm The patient was in the wheelchair and repeatedly shouted profanities, including the use of FXXX, at the staff. Attempted redirection was made, but the patient continued to verbally abuse all staff members. As a result, staff were unable to assist the patient with getting to bed. <BR/>4/9/2025 at 5:56 am [CR #1] had a behavior this morning during care. He was cursing the aide during care using F- words. <BR/>Record review of CR#1's quarterly MDS dated [DATE] revealed the following:<BR/>Section C 500: CR #1 was coded as having a BIMS score of 14 indicating he was cognitively intact.<BR/>Section E Potential Indicators of Psychosis: <BR/>E100: Hallucination and delusional: he was coded, as having no hallucinations or delusion. <BR/>E200: Behavioral Symptoms:<BR/>Physical behavior, verbal behavior, and other behavioral symptoms such as (screaming, yelling and verbal/vocal) was coded as it did not happen. <BR/>Record review of CR #1's comprehensive care plan dated 5/14/2025 reflected: <BR/>Focus:CR#1 is resistive to care, refuses care at times:<BR/>Goal: CR#1 will, cooperate with care through the next review<BR/>Intervention: Allow CR#1 to make decision.<BR/>Educate resident/family caregiver of the possible outcome(s) of not complying with treatment or care.<BR/>Praise the resident when behavior is appropriate. <BR/>In an interview on 5/16/2025 at 1:45pm with SW C she said she worked with CR#1 and the staff reported he had behavior issues. She said she did not actually witness his behavior, but it was reported to her. She said she heard that he cursed the staff and his family member out. <BR/>In an interview on 5/16/2025 at 2:00pm with RN B she said CR#1 was alert and oriented and could make his needs known. She said CR#1 had behavior of yelling and shouting and cursing at staff. <BR/>In an interview on 5/16/2025 at 2:05pm Nurse Manager LVN A said that CR#1 had behavior of yelling and cursing at staff and his family member. She said CR#1 was alert and oriented and could make his needs known. She said there was an incident with CR#1 and his family member and CR#1 cursed the family member. <BR/>In an interview on 5/16/2025 at 3:15 pm with RN P she said she worked with CR#1 and he was alert but sometimes he was delusional. She said sometimes the resident would be yelling and shouting and he would be telling them there were rats, snakes and racoons in his room. She said he screamed and cursed at the staff. <BR/>In an interview on 5/16/2025 at 4:30pm with CNA B she said she worked with CR#1, and he cursed at the staff and his family member. She said sometimes he would be saying there were rats, snakes, and racoons in his room. <BR/>In an interview with SW C on 5/16/2025 at 5.01 pm she said she was aware of CR #1 having behaviors. She said, however when she assessed CR#1 for the quarterly MDS CR#1 did not display any inappropriate behaviors and that was why she did not code CR#1's behavior section on the MDS as CR#1 having any behavior. Further interview with SW C revealed she did not check the nurse's notes or talk to the nurses and aides. <BR/>In an interview on 5/16/2025 at 5:07pm with the DON she said her expectation of the nurses was to do proper assessment that included talking with the CNAs, and looking at the nurse's progress notes so they can capture all the changes of the resident. She said she will be in- servicing the staff (nurse and social worker) on reviewing nurses notes, CNA's documentations, and interviewing aides when they are completing the MDS.<BR/>In an interview with MDS E on 5/16/2025 at 5:10pm she said she was made aware of the coding for behavior on the MDS and she was going to correct the MDS. She said that the different disciplines should look at the nurse's notes and the CNA's documentation before completing their section of the MDS.<BR/>Record review of the MDS policy and procedures dated 2024 read in part .<BR/>Policy:<BR/>Residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. <BR/>Policy Explanation and Compliance Guidelines:<BR/>1.According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.<BR/>4. Care Plan Team Responsibility for Assessment Completion:<BR/>Coding of Assessment:<BR/>I All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 3 (Resident #17, Resident #31, Resident #48) of 5 residents reviewed for comprehensive care plans.<BR/>- Resident #17 was not care-planned for exit-seeking when she was documented in her progress notes as pushing on the exit door by her room as a behavior.<BR/>- Resident #31 did not have a comprehensive care plan in place with interventions to address oxygen use or anticoagulant use. <BR/>-Resident #48 did not have a comprehensive care plan to address his advanced directive status of DNR<BR/>This deficient practice could place residents at risk of their behaviors and needs being monitored and cared for at the facility.<BR/>Findings included:<BR/>Record review of Resident #17's face sheet dated 06/11/2025, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included basal cell carcinoma of the skin (skin cancer), schizophrenia (a mood disorder characterized by hallucinations, delusions, and disorganized thinking and behavior), insomnia, and pain.<BR/>Record review of Resident #17's Comprehensive MDS dated [DATE], reflected Resident #17 had a BIMS score of 9 out of 15 which suggested she had moderate cognitive impairment related to memory and thinking skills. She required moderate assistance with toileting, dressing, footwear, and personal hygiene. Resident #17 was coded as having no impairments to her upper and lower extremities.<BR/>Record review of Resident #17's care plan last revised 04/28/2025, reflected she was care-planned for impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions including administering medications as ordered and monitoring/documenting for side effects and effectiveness and cueing, reorienting and supervising as needed. There was no care plan for Resident #17's behavior of pushing on the door. A later record review of Resident #17's care plan last revised 06/11/2025 after surveyor intervention, Resident #17 was care-planned for being a wanderer related to being disoriented to place, with interventions including assessing for fall risk, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation and television and monitoring Resident #17 for fatigue and weight loss.<BR/>Record review of Resident #17's Order Summary Report, reflected she had an active order for Lorazepam (generic name of Ativan) Oral Tablet 1 MG, give 1 tablet by mouth three times a day related to Schizophrenia and to hold for excessive sedation with a start date of 06/06/2025. <BR/>Record review of Resident #17's elopement evaluation on 4/2/2025, reflected she was documented as posing no risk for elopement. <BR/>Record review of Resident #17's progress notes, reflected she made attempts to push on the door at the exit near her room on 5/1/2025, 5/7/2025, 6/2/2025, 6/3/2025, and 6/9/2025.<BR/>Record review of Resident #17's medication consent form, reflected she was prescribed Ativan for anxiety and agitation on 6/6/2025.<BR/>Observation and interview with Resident #17 on 06/10/2025 at 9:33am, revealed Resident #17 was in her room sitting on her bed and was holding her head with both hands and talking to herself. She appeared well-groomed and agitated. When asked how she was doing, Resident #17 said thank you and waved the surveyor off. When the surveyor walked past her bedroom, Resident #17 was heard talking progressively louder, Stop looking at me! Later observations of Resident #17 on 6/12/2025 at 10:59am, revealed she was walking around the facility away from the door and at 4:28pm, Resident #17 was in her room in bed.<BR/>Observation on 6/11/2025 at 2:29pm, revealed LVN K pushed on the exit door on Resident #17's hallway, and the alarm rang for 15 seconds before the door fully opened. He turned off the alarm with a key which fit into the alarm box at the top of the doorframe. The door was observed with no damages or concerns.<BR/>In an interview with MDS Nurse LVN F on 6/11/2025 at 1:20pm, she said she was not aware of Resident #17 and that she would care-plan the behavior of pushing on the door and document Resident #17's wandering behavior on her assessments. LVN F said that Resident #17 could get out the door or fall if she left. LVN F said nurses used the care plan to see how to provide care to the residents. <BR/>In an interview with LVN M on 6/11/2025 at 2:29pm, she said Resident #17 would walk with her wheelchair and push it into the door. When the alarm would turn on, Resident #17 would get irritated but was easily redirected away from the door. Resident #17 would move away from the door when the alarm turned on. LVN M had in-services on elopement and resident behaviors such as redirection at the facility. <BR/>In an interview on 6/11/2025 at 2:38pm, the DON said that Resident #17 would not be considered exit-seeking per se, but that she made attempts to push on the doors but would get scared and was easily redirected from the situation. In a later interview with the DON and Administrator on 06/11/2025 at 4:34pm, the Administrator said they were evaluating where they could move Resident #17 so she could be away from the door. The Administrator said the purpose of care plans was to document needs and try to meet them for residents, and that Resident #17's behavior of pushing on the door might need to be documented. The Administrator said Resident #17 had no exit-seeking behavior or the facility would have to find another building for her as they did not have a secured unit. <BR/>In an interview with RN G on 6/11/2025 at 2:55pm, she said that Resident #17 had attempted to push on the door every few days but Resident #17 had not exited or left the building. After each attempt, RN G would give Resident #17 a PRN dose of anxiety medication. Resident #17's NP was notified of her behavior. Resident #17 never told RN G why she attempted to leave but would talk to herself. The facility had working alarms, and RN G and CNAs on the hall watched and redirected her. When Resident #17 would push on the door, RN G called Resident #17's Psychiatric NP, documented it in Resident #17's progress notes, and told the next shift's nurses and aides to continue monitoring. RN G had elopement and resident behavioral training. RN G said Resident #17's behavior should be in her care plan, but she would need to check. Behaviors should be in the care plan so a resident's condition was documented, and nurses could be aware. <BR/>In an interview with the Unit Manager LVN N on 6/11/25 at 3:24pm, she said Resident #17 liked to go to the door but never left the building. LVN N was not aware why Resident #17 would go near the door. Resident #17's NP checked on her and would ask if her medications were effective. She said care plans highlighted resident's care, how they were, medications and behaviors. <BR/>In an interview with NP B on 6/13/2025 at 8:16am, he said that he was Resident #17's Psych NP. NP B said the facility staff called him frequently for her behaviors, including trying to exit. NP B said medications did not treat a specific behavior but were used to treat Resident #17's condition in general. He recently changed her medication to help with her behaviors such as restlessness, anxiety, talking to herself, and getting her to put on her gown and talk to NP B. <BR/>Resident #31<BR/>Record review of Resident #31's facility admission record dated 6/11/25 revealed that Resident #31 had an original admission date of 8/14/2015 and re-admission date of 2/9/25. Resident #31 was a [AGE] year-old male with diagnoses that included Ileus unspecified (a condition where the intestines don't move food and waste along as they should, but there's no physical blockage like a tumor or scar tissue) and Hydronephrosis with renal and ureteral calculous obstruction (the swelling of a kidney due to a blockage in the ureter (the tube carrying urine from the kidney to the bladder) caused by a kidney stone (calculus).<BR/>Record review of Resident #31's Quarterly MDS dated [DATE], revealed a BIMS score of 12 out of 15 indicating a moderate cognitive impairment. Resident #31 was documented to require substantial/maximum assistance from staff for ADLs. He required supervision or touching assistance with eating and oral hygiene. He had an indwelling urinary catheter and was always incontinent with bowels. Section N-Medications indicated he used anticoagulants. Section O-Special Treatments indicated Resident #31 used oxygen.<BR/>Record review of Resident #31's undated care plan, revealed there were no care plans with interventions to address anticoagulant or oxygen use. <BR/>Record review of Resident #31s physician orders for May 2025 revealed an order for oxygen at 2 liters/min via nasal cannula PRN with a start date of 9/25/24.<BR/>Record review of Resident #31's physician orders for May 25 revealed a physician order for Xarelto oral tablet 20 mg. Give 1 tab by mouth in the evening.<BR/>Observation and interview on 6/10/25 at 10:10 AM with Resident #31, revealed the resident appeared to be clean, and had no odors, or visible signs of injury. He said that he felt very pleased with his care at the facility and had no concerns. <BR/>In an interview on 6/11/25 at 9:24 AM with the Administrator, she said care plans for anticoagulants and oxygen should be in place for Resident #31 and the MDS coordinator was responsible for updating. A negative impact could be resident needs not being addressed.<BR/>In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address anticoagulants or oxygen use for Resident #31 and there should have been. Care plans were important because nurses looked at them to provide care for residents. She added the responsibility lied with the IDT.<BR/>In an interview on 6/11/25 at 2:37 PM with the DON, she said that Resident #31's oxygen and anticoagulants status should have been care planned. She said that without the care plan he could have bled out or needed oxygen and the care plans were used to provide care. She said that MDS Coordinator was responsible for updating the care plans.<BR/>Resident #48<BR/>Record review of Resident #48's facility admission record dated 6/11/25 revealed that Resident #48 had an original admission date of 3/2/21 and re-admission date of 5/1/25. Resident #48 was a [AGE] year-old male with diagnoses that included lobar pneumonia (a type of pneumonia where a large portion or entire lobe of one or both lungs becomes inflamed and consolidated, meaning it fills with inflammatory fluid and/or pus) and Parkinson's Disease without Dyskinesia without fluctuations (a specific presentation of Parkinson's disease where patients do not experience involuntary movements (dyskinesia) or noticeable changes in the severity of their symptoms over time (fluctuations).<BR/>Record review of Resident #48's Quarterly MDS dated [DATE], revealed a BIMS score of 8 out of 15 indicating a moderate cognitive impairment. Resident #48 was documented to require partial to moderate assistance to substantial/maximum assistance from staff for ADLs. He required set-up to or clean-up assistance with eating. He was always incontinent with bladder and bowel. <BR/>Record review of Resident #48's undated care plan revealed there was no care plan to address his advanced Directive choice of DNR.<BR/>Record review of Resident #48's physician orders dated 5/2025 revealed a physician order for DNR with OOH DNR signed 5/8/25.<BR/>Record review of Resident #48's DNR dated 5/7/25 revealed that he elected for DNR status. <BR/>Observation on 6/10/25 at 10:03 AM of Resident #48, revealed he appeared to be asleep, very frail, as he laid on his bed.<BR/>In an interview on 6/11/25 at 9:24 AM with the Administrator, she said a care plan to address DNR for Resident #48 should be there to address the needs of the resident and the MDS coordinator was responsible for updating care plans. A negative impact could be resident needs not being addressed.<BR/>In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address DNR status for Resident #48 and there should have been. She said the care plan would be added on 6/11/25.<BR/>In an interview on 6/11/25 at 2:37 PM with the DON, she said that the care plan for Resident # 48's DNR status should have been updated. She said that without the care plan he could have been given CPR (lifesaving interventions) if the DNR status was not care planned. <BR/>Record review of the facility's policy on Comprehensive Care Plans copyrighted 2025 read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .3.The comprehensive care plan will describe, at a minimum . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs and preferences .<BR/>Record review of the facility's policy on Elopements and Wandering Residents copyrighted 2022 read in part, The facility is equipped with door locks/alarms to help avoid elopements . Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .

**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 for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #3 and Resident #4) of 2 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1. <BR/>Resident #3, who required extensive assistance, was provided with timely incontinence care on 01/01/2024. <BR/>2. <BR/>Resident #4 was provided with timely incontinence care on 01/01/2024.<BR/>These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>Record review of Resident #3's face sheet dated 04/11/2024 indicated he was an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including repeated falls, osteoarthritis (wear down of flexible tissue), protein-calorie malnutrition (underweight), benign prostatic hyperplasia with lower urinary tract symptoms (increased urgency to urinate), difficulty in walking, muscle weakness, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), acute respiratory failure with hypoxia (not enough oxygen in the tissues in body), osteomyelitis (swelling of bone tissue causing an infection, age-related osteoporosis (loss of bone mass) without current pathological fracture (broken bone caused by a disease), and metabolic encephalopathy (chemical imbalance in the brain that causes confusion), <BR/>Record review of Resident #3's Care Plan undated indicated Focus: Resident has bowel and bladder incontinence r/t Prostate enlargement Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goals: Resident will remain free from skin breakdown due to<BR/>incontinence and brief use through the review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 6/07/2024. Interventions: Clean peri-area with each incontinence episode. Date Initiated: 07/25/2021. Incontinent: Check frequently and as required for incontinence. Focus: Resident has potential for pressure ulcer development Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goal: Resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 06/07/2024. Interventions: Complete a full body check weekly and document Date Initiated: 07/25/2021. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 07/25/2021. Provide incontinence care after each incontinence episode, or per established toileting plan. Date Initiated: 07/25/2021. Reposition in chair frequently for comfort and pressure reduction. Provide resident/family education as needed. Date Initiated: 07/25/2021. Revision on: 10/05/2022.<BR/>Record review of Resident #3's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Bowel Continence: Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement), and with no toileting program was being used.<BR/>Record review of Resident #4's face sheet dated 04/11/2024 indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses wedge compression fracture (collapsed bone in the front of the spine) of lumbar vertebra (spine bones behind the chest), hypertension (high blood pressure), type 2 diabetes mellitus (cells in your muscles, fat, and liver don't respond well to insulin) without complications, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), history of falling, muscle weakness, and difficulty in walking.<BR/>Record review of Resident #4's Care Plan undated revealed Resident #4 had the potential for pressure ulcer development r/t of ulcers, immobility, and incontinence. Date Initiated: 01/10/2020 Revision on: 01/10/2020. Resident was to have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 01/10/2020 Revision on: 09/12/2023 Target Date: 04/07/2024. Resident was to receive complete a full body check weekly and document Date Initiated: 01/10/2020. Staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 01/10/2020. Provide incontinence care after each incontinence episode, or per established toileting plan Date Initiated: 01/10/2020. Reposition in chair/bed frequently for comfort and pressure reduction. <BR/>Record review of Resident #4's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Occasionally incontinent (less than 7 episodes of incontinence). Bowel Continence: Occasionally incontinent (one episode of bowel incontinence), and with no toileting program was being used.<BR/>Observation on 04/10/2024 at 11:21 a.m., revealed Resident #4 was sitting in a wheelchair in the common area watching television, smiled, and waved. <BR/>Observation on 04/10/2024 at 11:50 a.m., revealed Resident #3 was lying in bed low to ground, fall mat in place. The resident was receiving oxygen and tube-feeding and fluids at bedside, legs propped up on wedge, asleep, did not response and covered with blankets. <BR/>During an interview on 04/11/2024 at 09:07 a.m., the Administrator stated on 01/01/2024 she received a call from CNA G when CNA G she came on shift at 10:00 p.m. and informed that Resident #3 and Resident #4 were left soiled. She stated she asked LVN A who was assigned to those residents, to determine which staff had left residents soiled. She stated that LVN A confirmed that CNA F had worked and was assigned to Resident #3 and Resident #4. <BR/>During an interview on 04/11/2024 at 09:43 a.m., LVN A stated that she was the unit manager on duty on 01/01/2024 and assigned to Resident #3 and Resident #4. She stated on 01/01/2024, the Administrator called and stated that Resident #3 and Resident #4 were left horribly wet and soiled at 9:45 p.m. and that CNA G had to come on shift and clean them up immediately. She stated that CNA G stated it was not just wet it was feces and food on the residents. She stated that she spoke with CNA F who admitted that she missed the two residents but provided no good reason. She stated that CNA F had been terminated for poor work performance. She stated this was not the first time CNA F had failed to perform resident's ADL care. She had left a resident without a shower and left a resident without making sure they had eaten. <BR/>During an interview on 04/11/2024 at 10:29 a.m., CNA F stated she began her employment in April of 2024 and was terminated in January 2024. She stated she was responsible for taking care of Resident #3 and Resident #4 on 01/01/2024. She stated that she had fallen behind and had not change Resident #3 before leaving shift and had not informed the oncoming shift or charge nurse that Resident #3 had not been changed before leaving shift. She stated that residents were to have been checked and changed every 2-hours and before leaving shift. She stated she had changed the residents during her shift but had not provided a time when the residents were changed. She stated she had issues with getting to residents on time, but she would get there as quickly as possible. She stated that the facility put a lot of responsibility on CNAs and nitpicked her unfairly when it came to completing tasks. She stated she never addressed her concerns with any of her superiors about not getting her tasks completed or being nitpicked at. She had not provided a response why she had not addressed her concerns with her superiors. She stated she received training on ANE, incontinent care, and resident rights during her onboarding process with the facility. She stated the importance of not leaving resident soiled for long periods was to avoid rashes and skin irritations. <BR/>During an interview on 04/11/2024 at 10:58 a.m., CNA G stated she had 26 years of experience as a CNA and worked for the facility about 7-months before she resigned in February 2024. She stated she came on shift on 01/01/2024 at 09:34 p.m. and took over the care of residents that CNA F was responsible for on the previous shift of 2 p.m. to 10 p.m. She stated it was routine when she came on shift to put eyes on each of her residents to see if there were any immediate needs of the resident that needed to be addressed first. She stated that when she went to check on Resident #3 and Resident #4, they were both heavily soiled in urine and feces. She stated that their briefs, clothing, and beddings were completely soiled. She stated that was a clear indication that they had not been changed in several hours and that CNA F had not followed policy and procedure by checking and changing residents before leaving shift and before the next shift took over. She stated when she found the resident in that soiled condition, she took pictures of the residents, cleaned, and changed the residents and their bedding, and sent the pictures to the Administrator along with a text message describing the resident's condition upon her arrival coming on shift. She stated that she had pictures in an old phone that she would forward. She stated that she could not remember which resident was which, but the pictures showed the resident's beds soiled in urine and one of the resident's back covered in food crumbs. She stated that she resigned from the facility because of high staffing turn over, and it being custom for her to find residents heavily soiled when she came on shift. She stated that staff that worked the 10 p.m. to 6 a.m. shift did not receive a lot of training in-services and she could not recall ever being in-serviced on ANE or incontinence care. She stated when she resigned, she wrote the Administrator a 3-page letter voicing all her concerns along with the pictures she took of the soiled and uncleaned residents. She stated the importance of checking and changing resident's every 2-hours was to prevent skin breakdowns. <BR/>During an interview on 04/11/2024 at 03:35 p.m. the DON stated that she was on leave when Resident #3 and Resident #4 were discovered soiled. She stated that CNA F was responsible for changing the residents during her shift. She stated that LVN C was responsible for overseeing CNA F. She stated CNA F had disciplinary actions taken against her for failure to address care areas on a few occasions and had been given a chance to make corrective actions. She stated that it was not uncommon for staff to run behind or feel overwhelmed during their shift, but it was their responsibility to notify their unit manager on shift for assistance. She stated that CNA F had never voiced concerns with feeling overwhelmed and had been given several opportunities to make corrective actions and this incident caused her employment to be terminated with the facility. She stated that the resident's family was notified of the incident. <BR/>During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that she had received a text on 01/01/2024 from CNA G who worked the 10 p.m. to 6 a.m. shift. She stated that CNA G told her she followed shift after CNA F who had left Resident #3 and Resident #4 in unchanged briefs before leaving shift. She stated she had spoken to CNA F on several occasions in-servicing her and reminding her to take care of the residents like they were her own mother and father. She also told the staff that if she felt she could not perform the tasks as such, she could not be a part of the team. She stated that all her staff know that if they need to text her, they can do so at any time and they knew there were no exceptions for leaving shift without completing their duties without informing the unit managers that they had fallen behind. <BR/>During an interview on 04/11/2024 at 04:59 p.m., CNA B stated the facility provided an in-service on ANE and incontinent care a couple of weeks ago (exact dates and times unknown). She stated that residents were to be checked on and changed if needed every two hours to avoid skin breakdowns. She stated if she found a resident excessively soiled, she would change the resident and report the to the unit manager on shift. <BR/>During an interview on 04/11/2024 at 05:15 p.m., CNA C stated at shift change there was an overlap of 10-15 minutes where staff consult with each other any concerns to be noted from the previous shift. She stated at that time it should be identified if a resident had not been changed prior to that staff leaving shift. She stated that if she found a resident heavy soiled and was not informed by the previous shifts staff, she would assume that the previous shift neglected to change the resident. She would change the resident and report to the unit manager and/or charge nurse that the previous staff had not completed their rounds before leaving shift. She stated that she was provided an in-service on ANE and incontinent care last week 04/01/2024 and 04/04/2024. <BR/>Record review of the facility's self-report incident dated 01/02/2024 revealed: On 01/01/2024: Description of allegation: Employee failed to perform job duties as assigned. CNA F left Resident #3 and Resident #4 soiled and wet. Beds were wet as well. This was reported to the Administrator. Description of injury: None. Provider response: CNA F was terminated for failure to complete job responsibilities. Investigation Summary: Resident interviews conducted. Employee in-services conducted. Provider Action Taken Post-Investigation: Employee terminated. Signed and dated by Administration on 01/09/2024.<BR/>Record review of the facility's staffing schedule dated 01/01/2024 revealed LVN B was responsible for supervising CNA F during her shift. <BR/>Record review of Policy copy right date of 2022 revealed Promoting-Maintaining-Resident-Dignity. Compliance Guidelines: <BR/>Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.<BR/>Record review of the facility's Policy: Abuse, Neglect and Exploitation, undated revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: <BR/>Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 5 residents (Resident #46) reviewed for incontinent care and indwelling catheter. <BR/>1.The facility failed to ensure CNA A cleaned Resident #46's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care.<BR/>These failures could place residents at risk for pain, infection, injury, and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #46's face sheet revealed an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders (lack interest with daily activities), unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension( high blood pressure), and dysphagia (difficulty swallowing).<BR/>Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function). BIMS score of 7 meaning Resident # 46 was severely impaired.<BR/>Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following:<BR/>1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance<BR/>-Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use<BR/>2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance<BR/>-Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode<BR/>Record review of Resident #46's MAR (Medication Administration Record) for December 2023 to January 2024 revealed resident was given Doxycycline Hyclate Oral Tablet 100 MG, 1 tablet via G-tube every 12 hours for infection for 7 Days until finished. The medication was administered from 12/28/2023 to 1/4/2024. <BR/>Record review of Resident #46's hospital records dated 02/29/2024 revealed they were hospitalized from [DATE] to 02/29/2024 due to UTI. At the hospital, she completed intra venous (IV )meropenem + Sodium Chloride 0.9% IV 100 mL 500 mg IVPB ABXQ8H. 33.33 ml/hr from 02/22/2024 to 02/29/2024.<BR/>Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and CNA D assisting, revealed CNA A washed hands and donned( put on) clean gloves and she did not open the labia to clean. Using the wet wipes, CNA A cleaned the Foley catheter tubing not in a circular motion, C.NA A used the wet wipes, cleaned catheter tubing straight and she changed gloves x 4 times and did not wash her hands or used hand sanitizer.<BR/>Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to open and clean Resident #46's labia and forgot to clean the indwelling catheter from the insertion site in a circular motion. C.NA A said not opening the labia to clean and not cleaning the Foley catheter could result in infection. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. C.NA A said she forget to wash her hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. <BR/>During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward and clean the indwelling catheter in a circular motion. The DON said she was going to start incontinence care skills checks . DON said the ADON and the lead C.NA A does incontinent monitoring. The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. The DON did not have policy for incontinent and Foley catheter care.<BR/>In an interview on 05/08/2024 at 2:35 PM, the Administrator stated her expectation was that incontinent care and hand washing were always done to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record <BR/>review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications <BR/>of enteral feedings for 3 (Resident #8, #62, #78) of 4 residents reviewed for feeding tubes, in that: <BR/>The facility staff failed to verify placement of the feeding tube prior to medication administration for Resident # 78 and Resident #62<BR/>LVN A plunged 60 ml's of water into Resident #8's gastrostomy tube via syringe instead of via gravity flow when there is an interruption of feeding to maintain tube patency for administration.<BR/>This failure could place residents receiving <BR/>enteral feedings at risk for complications such as <BR/>aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization. <BR/>Findings include:<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #78 revealed a [AGE] year old male resident admitted to the facility on 04 07 2022 and was re admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such as epilepsy).<BR/>Record review of Resident #78's last MDS was a quarterly completed on 01 13 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional . Approach as B. Feeding Tube while a resident. <BR/> Record review of physician order's active dated 2/8/23 revealed Senna syrup 5 ml Solution <BR/>Give 5 ml via G Tube two times a day related to constipation.<BR/>Record review of Resident #78's care plan dated of 04 07 2022 revealed the following: Focus: Altered Nutritional Status PEG Feedings . date Initiated: 04 07 2023<BR/>During an observation on 03 28 2023 at 4:28 AM, RN A stopped Resident #78's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did not palpate Resident #78's stomach. RN A used a 60 cc syringe, then installed 20 cc of air via G Tube (gastrostomy tube) without using the stethoscope to auscultate for placement and did not flushed with water before administering medication. RN A picked up the following medication blister packets and placed in the <BR/>medication cups<BR/>Amlodipine 10mg 1 tablet crushed and diluted with 10cc of water,<BR/>Thiamin vitamin B 100 mg 1 tablet crushed and diluted with 10cc of water,<BR/>Poured Senna syrup 7cc a cup and diluted <BR/>with 10 cc of water.<BR/>RN A then poured each medication into the G Tube without flushing with water in between medication administration.<BR/>Resident # 62<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential (primary) hypertension) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by <BR/>involuntary contractures of muscles and associated especially with brain disorders such as epilepsy).<BR/>Record review of Resident #62's last MDS was a quarterly completed on 02 23 2023 with a BIMS of 99 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #62 was also marked in section K0510 Nutritional Approach as B. Feeding Tube while a resident. <BR/>Record review of physician order's active dated 3/8/23 revealed Levetiracetam solution 100 MG/ML Give 10 ml via G Tube two times a day related to conversion disorder with seizures or convulsions.<BR/>Record review of Resident #62's care plan with an quarterly dated of 02 23 2023 revealed the following:Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 07 07 2022<BR/>During an observation on 03 28 2023 at 4:42 PM, RN A stopped Resident #62's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did <BR/>not palpate Resident #62's stomach. RN A used 60 cc syringe, then installed 30 cc of air via G Tube without using the stethoscope to auscultate for placement and did not flush with water before administering medication. RN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's G Tube and flushed with 30 cc of water.<BR/>During an interview with RN A on 03/29/23 at 8:50 AM regarding checking GTube placement and flushing Resident #78 and Resident # 62's GT before medication administration, he said , he checked G tube placement during his initial rounds for breath sound and he always flush G Tube with water after medication administration, RN A said not checking for placement could cause aspiration pneumonia, bloating and being too full. Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON.<BR/> Record review of RN A's personnel file revealed date of hire was 2/24/21 and document regarding his training on medication was on 10/15/22. <BR/>Record review of enteral feed order schedule for [DATE], every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding ,or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift <BR/>flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency.<BR/>Resident #8<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations acute and chronic respiratory failure with hypoxia,( a serious condition that makes it difficult to breathe on your own, the lungs can't get enough) oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy), ` <BR/>Record review of Resident #8's last MDS was a quarterly completed on 02 24 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #8 was also marked in section K0510 Nutritional Approach as B. Feeding Tube while a resident. <BR/> Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML,Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable with status epilepticus.<BR/>Record review of Resident #8's care plan with a quarterly dated of 02 24 2023 revealed the following Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 06 03 2023<BR/>During an observation on 03 29 2023 at 9:38 AM LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A verified placement of the feeding tube. LVN A palpated Resident #8's stomach. LVN A used 60 cc syringe, then plunged 60 cc of water via G Tube without allowing water flow via gravity before administering medication. LVN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 13 cc <BR/>and diluted with 10 cc of water and administered via Resident #8's G Tube and flushed with 10 cc of water.<BR/>During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician and also plunging 60mls of water via G Tube before administering medication. LVN A said she would double check medication before administering. She said she did know that plunging water with the syringe via G Tube was wrong. She further stated she always used the syringe to plunge water via G Tube from that state she used to work and she was corrected by the unit manager <BR/>on 3/29/23 to let the water flow by gravity. LVN A said she had training for medication administration.<BR/>Record review of enteral feed order schedule for [DATE] had every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift <BR/>flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency.<BR/>Record review of LVN A's personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 .<BR/>During an interview on 03/30/23 at 01:40 PM, the DON reported that a feeding tube should be verified with a stethoscope and that a staff <BR/>member should listen to gurgling. The DON reported that if you do not verify that a feeding <BR/>tube is in the right place then a resident could receive a feeding or medication that could result <BR/>in infection, bloating, or discomfort. The DON verified that the two policies provided were what <BR/>the facility had for feeding tube administration and that they did have a policy specific on verifying feeding tube placement. <BR/>Record review of facility provided policy titled Flushing a Feeding Tube revised 2021, revealed the following: Policy Explanation and compliance Guidelines: <BR/>9. Prior to flushing the feeding tube, the administration of medication or providing tube <BR/>feedings, the nurse verifies the proper placement <BR/>by noting the length of the tubing or performing a measure of the PH of gastric secretions , if performed in the facility. <BR/>10. After tube placement has been verified, flush the tube utilizing the 60 ml, catheter tip syringe with the prescribed amount of water every four(4) hours, before and after feedings and medications or as directed by the physician. Allow medications to flow down the medication syringe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 Residents (Residents #46, and #16) and 2 of 2 staffs (CNA A and LVN A) reviewed for infection control. <BR/>1. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #46. <BR/>2. LVN A failed to maintain a sterile technique while providing tracheostomy care to Resident #16. <BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings included:<BR/>Resident #46 was an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders, unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension, and dysphagia( difficulty swallowing)<BR/>Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function), Resident # 46's BIMs score of 7 means she was severely cognitive impaired.<BR/>Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following:<BR/>1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance<BR/>-Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use<BR/>2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance<BR/>-Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode<BR/>Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and C.NA D assisting, revealed CNA A washed hands and don( put on) clean gloves during incontinent/Foley catheter care. Using the wet wipes, CNA A cleaned the Foley catheter tubing and she changed gloves x 4 times and did not wash her hands or used hand sanitizer.<BR/>Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to wash hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. <BR/>During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care, Staff should wash hands or use hand sanitizer with each gloves change. The DON said the facility staffs had monthly in-services with skilled check. The DON said she was going to start incontinence care and hand washing skill checks.<BR/>Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure).<BR/>Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity.,<BR/>Record review of Resident #16's Physician Orders reviewed 5/7/2024 revealed the following:<BR/>1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5<BR/>2.Tracheostomy site dressing change every DAY and PRN if soiled.<BR/>3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes<BR/>4. Trach suctioning every (Q) shift and PRN<BR/>5. Oxygen at 4-6L/min via Tracheostomy<BR/>Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for:<BR/>1. Resident #16 has a Tracheostomy r/t respiratory failure<BR/>-Interventions: Suction as necessary, use Universal Precautions as appropriate<BR/>Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress.<BR/>Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress.<BR/>Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned a clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doffed (take off)gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. <BR/>In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. <BR/>In an interview on 05/08/2024 at 12:45 PM, with the DON, when Surveyor described the observed during trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in September 2023 . The DON said LVN A always worked with Resident #16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one resident (Resident #48) of 10 residents reviewed for resident call system in that: <BR/>The facility failed to ensure Resident #48's call light was in working order. <BR/>This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.<BR/>Findings included:<BR/>Record review of Resident #48's facility admission record dated 6/11/25 revealed that Resident #48 had an original admission date of 3/2/21 and re-admission date of 5/1/25. Resident #48 was a [AGE] year-old male with diagnoses that included lobar pneumonia (a type of pneumonia where a large portion or entire lobe of one or both lungs becomes inflamed and consolidated, meaning it fills with inflammatory fluid and/or pus) and Parkinson's Disease without Dyskinesia without fluctuations (a specific presentation of Parkinson's disease where patients do not experience involuntary movements (dyskinesia) or noticeable changes in the severity of their symptoms over time (fluctuations).<BR/>Record review of Resident #48's Quarterly MDS dated [DATE], revealed a BIMS score of 8 out of 15 indicating a moderate cognitive impairment. Resident #48 was documented to require partial to moderate assistance to substantial/maximum assistance from staff for ADLs. He required set-up to or clean-up assistance with eating. He was always incontinent with bladder and bowel. <BR/>Record review of Resident #48's care plan revealed a care plan to address ADL self-care performance deficit r/t decreased mobility and unsteady gait Date Initiated: 6/1/21. Revision on: 4/10/2024 with a target date of 6/30/25. Interventions included requiring 2 staff to transfer and to encourage the resident to use bell to call for assistance.<BR/>Observation and interview on 6/11/25 at 8:35 AM revealed Resident #48's sitting up in his bed eating breakfast. He said that the staff had not answered his call light for the past week. The surveyor requested Resident #48 to press his call light and when he pressed the call light the light outside the room failed to turn on. Resident #48 said that it made him feel scared when he pressed the call light, and no one responded because he needed help. <BR/>Observation and interview on 6/11/25 at 8:37 AM revealed the surveyor found and asked CNA O to please check Resident #48's call light. CNA O and LVN P came into the room and checked the call light.The call-lights for both beds were unplugged and re-inserted and then the call-light worked. LVN P said that she placed a work order about the call-light immediately with the Maintenance Director. She said that a functional call light was important because the call light was the resident's way to communicate their needs, she also monitored the halls constantly and it was everyone's responsibility to monitor call-lights to make sure resident needs were addressed.<BR/>Observation and interview on 6/11/25 at 8:48 AM with the Maintenance Director, revealed he said that the call light was very important because the residents needed help and all staff were responsible to make sure the resident needs were met. The surveyor observed the Maintenance Director when he gave the new cords for the call light to be replaced to CNA O and he said he would dispose of the faulty cords. <BR/>In an interview on 6/11/25 at 8:55 AM with LVN A/Charge Nurse, she said that safety was number one and making sure the resident needs were met. She said the monitoring and reporting of needed repairs were all staff responsibilities. She said they communicated through an email system in the facility any work orders that needed to be addressed and the email reached all management. <BR/>In an interview on 6/11/25 at 9:24 AM with the Administrator, she said that she was aware of Resident #48's call light and said that the call-light was repaired immediately. She said that she was also conducting a 100 percent audit on all call-lights. She said that all staff were responsible for monitoring call-lights and communicating needed repairs and ambassadors checked call lights daily. She added call lights were important to address and assist with help and a negative outcome could have been if the resident had fallen and required assistance. <BR/>In an interview on 6/11/25 at 10:28 AM with the Infection Control Preventionist-LVN/Unit Manager she acknowledged that she was an ambassador for the residents and checked the call lights daily and that Resident #48's call light not working for approximately the last week was untrue because she always checked the call lights for safety and said all staff were responsible for checking call lights.<BR/>An interview on 6/11/25 at 2:37 PM with the DON, revealed the DON said that if a resident's call light was not functional, the resident would not be capable of calling for help when needed and they could get hurt if they could not call. She said all staff were responsible for monitoring call-lights.<BR/>Review of the facility's undated policy and procedure entitled Call Lights: Accessibility and Timely Response, read in part . The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . Ensure the call system alerts staff members directly or goes to a centralized staff work area.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 9 residents (Resident #13) reviewed for medication administration.<BR/>MA C administered Minocycline ( a drug works by killing bacteria or preventing their growth), along with one daily Multi-Vitamin and Iron tablet to Resident #13, which the medication label warned against it. <BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included: <BR/> Record review of Resident #13's face sheet revealed a 80 years-male admitted on [DATE] and readmitted on [DATE] to the facility. His diagnoses included lymphedema,( swelling due to build-up of lymph fluid in the body) not elsewhere classified, methicillin resistant staphylococcus aureus infection( germ(bacteria) that does not got better with the type of antibiotics that uaslly cure staph infections) as the cause of diseases classified elsewhere, chronic embolism and thrombosis ( blood clot ) of unspecified deep veins of unspecified lower extremity, epilepsy(abnormal electrical brain activity also known as a seizure), chronic venous hypertension (idiopathic) (high blood) with ulcer and inflammation of bilateral lower extremity. <BR/>Record review of Resident #13's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated cognition was intact; no impairment. He needed extensive assistance of 1-2 staff for ADLs.<BR/>Record review of Resident #13's Physician Order Report for 04 /22/2023 revealed an order of Minocycline 100mg 1 capsule per oral/by mouth( PO) every 12 hours for wound infection until 05/10/2024, One daily multi-vitamin with mineral 1 tablet PO daily.<BR/> and Iron tablet 325 mg 1 tablet PO daily.<BR/>In an observation on 5/6/24 at 9:20 AM, of medication administration, MA C, picked up Minocycline 100mg capsule blister packet ( had Take with full glass water. No antacid/vits/iron/dairy within2 hours . May cause increased photosensitivity( is a condition in which skin becomes extremely sensitive to the sun causing skin to the sun causing skin to burn more easily). <BR/>blister packet from the medication cart, punched 1 capsule in a medication cup with One daily multi-vitamin with mineral 1 tablet and Iron tablet 325 mg 1 tablet and other medications and to Resident #13 by mouth. Resident #13 complained of taking too many medications at the same time. MA C said that what I go through every time.<BR/>In an interview with MA C on 5/7/24 at 2:30 PM, MA C said she has been working with facility for over 1 year and she knows the five right of meds administration, she had in-services with the unit manager and was monitored during med pass and was not aware of not taking antacid/vits/iron/dairy within 2 hours after taking minocycline and she did not read it the nurse surveyor showed it to her .<BR/>In an interview on 5/8/24 at 12:38 PM the DON said the staff should read the MAR and blister packet before medication administration to Residents. She said she expected nursing staff to ensure the medication order and inventory matched because the correct dosage needed to be provided to the resident and not pharmacy recommendation could cause stomach cramps and could cause drug interaction. <BR/>In an interview on 5/8/23 at 12:30 PM the facility's policy on Medication Administration was requested from the DON but was not received prior to exit.<BR/>In an interview on 5/8/23 at 12:46 PM the Administrator said he expected nursing staff to follow the physician orders. She said charge nurses, or the nurse managers oversaw medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #1) reviewed for resident rights.<BR/>The facility failed to ensure certified nursing assistant (CNA) A knocked on Resident #1's door prior to entering his room. <BR/>This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 04/10/2024 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses including obstructive and reflux uropathy (urine cannot drain from the urinary track), cellulitis (deep infection caused by bacteria), of unspecified part of limb, chronic embolism and thrombosis of deep veins (blood clots) of lower extremity hypothyroidism (lack of thyroid hormones causing the feeling of cold, pain, skin paleness and sadness), essential hypertension (high blood pressure), essential tremor (shakes), lymphedema (built up of fluid in the body), epilepsy (seizures), pain, ulcer and inflammation (swollen sores), and muscle weakness. <BR/>Record review of Resident #1's annual (Minimum Data Set) MDS assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. <BR/>Record review of Resident #1's Care Plan undated indicated Focus: He had cussed out staff and turned over bedside table when upset on occasions. Goals: Resident will have fewer episodes by review date. Date Initiated: 6/11/2021 Revision on: 08/17/2022 Target Date: 04/22/2024. Interventions: Allow choices within individual's decision-making abilities: Date Initiated: 06/11/2021<BR/>Revision on: 10/24/2022 Certified Nursing Assistant (CNA). Anticipate and meet the resident's needs. Date Initiated: 06/11/2021 Revision on: 10/24/2022 CNA.<BR/>During an observation on 04/10/2024 at 12:49 p.m. while interviewing Resident #1 in resident's room, CNA A opened resident's room door without knocking, walked into the room, and stated, Oh, I did not know anyone was in here, I was making sure that his lunch tray was picked up, looked around the room, exited and closed the door. <BR/>During an interview on 04/10/2024 at 12:50 p.m., Resident #1 stated that staff enter his room all the time without knocking or introducing themselves. <BR/>During an interview on 04/10/2024 at 12:54 p.m., CNA A stated that he had worked with the facility since February 2024. He stated that he had been a CNA for many years in another state and was familiar with the responsibilities and duties of a CNA. He stated that he realized that he entered Resident #1's room without knocking and he apologized. He stated he knew to knock before entering a resident's room to give them privacy. He stated he received training during onboarding with the facility that covered resident's rights and just last week on resident rights and abuse, neglect, and exploitation (ANE). He stated that he had come into Resident #1's room to pick up his lunch tray. <BR/>During an interview on 04/10/2024 at 01:19 p.m., RN A stated that he was CNA A's supervisor. He stated that he had trained CNA A and in-serviced him during onboarding, which covered entering residents' rooms by knocking, introducing oneself and informing the resident what services that staff would be providing. He stated that CNAs were also randomly reminded all the time to knock and announce themselves before entering a resident's room. He stated that CNA A would be written up for failing to knock before entering a resident's room. He stated that CNA A should have made it a practice and he would not have made the mistake. <BR/>During an interview on 04/11/2024 at 03:35 p.m., the DON stated that all staff were to knock and introduce themselves before entering a resident's room. She stated that residents deserve privacy because the facility was their home, and they need to know who was coming into their space. She stated that CNA A should have knocked before entering Resident #1's room.<BR/>During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that there were no exceptions, the staff were to knock before entering resident rooms. <BR/>During an interview on 04/11/2024 at 04:59 p.m., CNA B stated that they received in-services a couple of weeks ago (exact date and time unknown) on resident rights which included knocking and introducing oneself when entering a resident's room. <BR/>During an interview on 04/11/2024 at 05:15 p.m., CNA C stated that she had worked at the facility for 2-years. She stated that staff were to knock and announce themselves before entering a resident's room. <BR/>During an interview on 04/11/2024 at 05:21 p.m., CNA D stated that staff received an in-service on resident rights last week (exact date and time unknown) about knocking before entering a resident's room. <BR/>Record review of facility's in-service dated 03/08/2024 revealed, Resident rights . you should always knock before entering a resident's room, signed by CNA A 03/08/2024.<BR/>Record review of facility's in-service dated 04/10/2024 revealed, Knock on resident's door before entering and resident rights and dignity. Conducted by Licensed Vocational Nurse (LVN) A and signed by CNA A on 04/10/2024.<BR/>Record review of facility's Policy copy right date of 2022 revealed Promoting-Maintaining-Resident-Dignity. Compliance Guidelines: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 7. Explain care or procedures to the resident before initiating the activity. 12. Maintain resident privacy. Knock before entering a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #2) of 8 residents reviewed for abuse.<BR/>The facility failed to ensure each resident was free from abuse when Resident #2 was physically abused by CNA E on 10/16/2023 during her shift. <BR/>This failure placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. <BR/>The noncompliance was identified as past noncompliance and began on 10/16/2023 and ended on 10/18/2023. The facility corrected the noncompliance before the investigation began.<BR/>Findings Include: <BR/>Record review of Resident #2's face sheet dated 04/11/2024 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses including cellulitis (deep infection caused by bacteria), in of right lower limb, cerebral infarction (disrupted blood flow to the brain), type 2 diabetes mellitus (when cells in your muscles, fat, and liver do not respond well to insulin) without complications, atrial fibrillation (irregular heart rate), hyperlipidemia (deposit in blood vessel walls and restricted blood flow), hypertension (high blood pressure), paranoid schizophrenia (brain disorder causing delusion), pain in right ankle and joints of right foot, muscle weakness, lack of coordination, weakness, chronic ischemic heart disease (heart weakening caused by reduced blood flow to heart), morbid (severe) obesity due to excess calories (overweight), intellectual disabilities (limited ability to learn), adjustment disorder with mixed anxiety (restlessness) and depressed mood. <BR/>Record review of Resident #2's annual MDS assessment dated [DATE] revealed a BIMS score of 09 (suggests moderately impaired). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was able to recall prior questions after cueing, able to recall a color with cueing. <BR/>Record review of Resident #2's undated Care Plan revealed, Focus: Resident was dependent on staff for meeting intellectual, physical, and social needs related to (r/t) cognitive deficits. Date Initiated: 11/28/2022. Goal: Resident will be escorted to activities 3-5 times weekly by next review date. Date Initiated: 11/28/2022 Revision on: 02/15/2024 Target Date: 05/24/2024. Intervention: Invite the resident to scheduled activities. Focus: Resident has an activity of daily living (ADL) self-care performance deficit r/t activity intolerance, impaired balance date initiated: 11/21/2022 revision on: 03/28/2023. Goal: Resident will improve current level of function in through the review date. Date Initiated: 03/28/2023 Revision on: 02/15/2024, Target Date: 05/24/2024. Intervention: Toilet use: The resident requires extensive assistance by 1 staff for toileting. Date Initiated: 11/21/2022 Revision on: 03/28/2023 Focus: Resident has a communication problem r/t cognitive deficit. Date initiated: 11/21/2022 Revision on: 03/28/2023. Goal: Resident will be able to make basic needs known on a daily basis through the review date. Date Initiated: 11/21/2022 Revision on: 02/15/2024 Target Date: 05/24/2024. Intervention: Anticipate and meet needs. Date Initiated: 11/21/2022. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 11/21/2022. Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off television/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, and use alternative communication tools as needed. Date Initiated: 11/21/2022.<BR/>During an interview on 04/10/2024 at 12:02 p.m., Resident #2 stated that staff do not always respect her and are rude, but she would not say anything else because every time she had someone was fired. She stated she knows she can report ANE to the Administrator, because she had before, and the Administrator had fired everyone who was not doing their job or not being respectful. <BR/>During an interview on 04/11/2024 at 03:05 p.m., Resident #2 stated that she remembered something happened one evening in her bathroom with a staff, but she could not remember what or if a nurse made her feel unsafe or if she had been slapped or hit. She stated the next thing she had known that staff was fired. She stated she feels safe and was not worried about ANE.<BR/>During an interview on 04/11/2024 at 03:17 p.m., LVN A stated that on 10/18/2023 at about 10:15 a.m., she was called to Resident #1's room and resident told her that CNA E had slapped her in the face for pulling the call bell. She stated resident told her that the CNA E told her I am not playing with you, you going to wake everyone up. She stated the resident told her she was upset and had been crying. She stated that the resident was physically assessed finding no injuries or pain, and the resident stated she had no injuries or pain. She stated she immediately reported the incident to the Administrator who completed the incident report, and an investigation was started. The Administrator ultimately terminated CNA E.<BR/>During an interview on 04/11/2024 at 03:35 p.m., the DON stated that she was not on shift when it was reported CNA E slapped Resident #2. She stated it happened on the night shift and the resident reported it to certified medical technician (CMT) the next day. She stated it was found that CNA E hit Resident #2 in the face and scared her, making the resident feel unsafe. She stated that CNA E had no previous allegations of ANE against her and no previous disciplinary actions in her employee file. She stated the incident was reported to the resident's family. She stated that the resident had made complaints about likes and dislikes and wanting to discharge home but had not made any similar allegations of that kind in the past. She stated that CNA E was terminated based on the Administrator's investigation. <BR/>During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that she was the Abuse Coordinator. She stated on 10/18/2023 in the morning from LVN A that Resident #2 had something that she wanted to tell her. She stated she interviewed Resident #2 who told her that CNA E had slapped her in the face while helping her in the bathroom. She stated Resident #2 told her she was crying and waving her hands and the staff tried to stop her from crying and pulling the call bell and slapped her. She stated that she interviewed CNA E and CNA E told her that on 10/23/2023 in the earlier morning, Resident #2 was in the bathroom crying, acting confused and constantly pulling the bathroom call bell. She stated that CNA E told her that the resident had been waving her hands and acting confused and she accidently hit Resident #2 in the face. She stated CNA E believed that there were active cameras recording her and apologized that the hit was an accident. She stated that CNA E was immediately suspended, and Resident #2's family and physician were contacted. She stated the incident investigation was started, the incident report was completed and called in to the state. She stated that Resident #2 had a history of making false accusations, but never against a staff for abuse. She stated she believed what the resident had told her, and she terminated CNA E. She stated she did not call the police and there were no marks or bruises on the resident's face. She stated that it was her expectation that staff kept their hands off residents. <BR/>During an interview on 04/11/2024 at 04:59 p.m., CNA B stated the facility provided an in-service on ANE a couple of weeks ago (exact dates and times unknown). She stated if an ANE was reported to her or witnessed she would immediately report to the Administrator.<BR/>During an interview on 04/11/2024 at 05:15 p.m., CNA C stated that she was provided an in-service on ANE and incontinent care last week 04/01/2024 and 04/04/24. She stated that if she witnessed or ANE was reported to her she would immediately report to the Administrator. <BR/>During an interview on 04/12/2024 at 10:03 a.m., CNA E stated that she had worked at the facility about a year. She stated on 10/23/2023 in the middle of the morning she was at the nurse's station when the call bell went off in Resident #2's bathroom. She stated the bell was very loud and she rushed to the resident's room. She stated when she entered the room, the resident's bed was covered in blood and the resident was in the bathroom screaming, also covered in blood from the waist down. She stated that the resident had come on her monthly menstrual cycle. She stated she turned off the call bell and asked the resident what was wrong. She stated that the resident continued to scream and pulled the call bell again and again. She stated that she told the resident not to pull the call bell because it made a very loud sound that would wake everyone up in the facility. She stated then she wiped down the resident's bed and cleaned and changed the resident and helped her get back to bed. She stated that later in the morning before leaving shift, the resident allowed her to change her, and the resident never made mention of what happened or voiced any concerns. She stated, the resident was a lot of personality, and never had any problems voicing her concerns. She stated the next day she was approached by LVN A and surprised that she was being suspended for allegations of abuse. She stated that the resident was not swinging her hands and she did not try to stop the resident's hands nor purposefully or accidently hit her in the face, and she did not tell the Administrator that she had accidently hit the resident in the face. She stated that she would never abuse or hit a resident. She stated that the resident and her were friends. She stated that she was then terminated. She stated all the staff would at the facility would say she was a good employee. She stated that she received training all the time on ANE, and she knew not to abuse residents. <BR/>During an interview on 04/23/2024 at 02:13 p.m., CMT stated she did not recall an incident where Resident #2 reported being slapped by CNA E.<BR/>Record review of the facility's in-service training dated 10/20/2023 revealed an in-serviced on ANE was conducted by Director of Social Services (DSS) was signed by several of the facility's staff acknowledging the in-service. <BR/>Record review of CNA E's typed and signed statement dated 10/18/2023 revealed, CNA E rushed to Resident #2's room. Resident sitting on the toilet seat, covered with blood. CNA E asked resident to turn off the light because it was going to wake up everyone and CNA E turned off the light. Resident started crying, CNA E asked why she was crying, what was the problem, did I touch you? CNA stated that she held the resident and told her she was there to help her. CNA E standing at the door, and resident sitting on toilet. CNA E cleaned resident up and resident's bed.<BR/>Record review of the facility's Staff Disciplinary Action Record against CNA E dated 10/18/2023 revealed, Suspended. List below an account of the actions leading to counseling: including dates, times, and any other supposing information: Administrator received a report that employee hit resident in the face. Employee statement attached that there was no physical contact. This was reported to have occurred on 10/16/2023 at 10 p.m. to 6 a.m. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetables for follow-up. Suspended pending abuse investigation. Signed by Supervisor LVN A and witnessed by Administrator.<BR/>Record review of the facility's Staff Disciplinary Action Record against CNA E dated 10/20/2023. Category III, Disciplinary Level: Termination. List below an account of the actions leading to counseling: including dates, times and any other supposing information: Investigated for claim of abuse. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetables for follow-up. Terminated via telephone. Signed by Supervisor LVN B and witnessed by the DON.<BR/>Record review of Resident #2's Progress Notes dated 10/20/2023 15:45 Behavior Note Text created by LVN C: Resident made remark to CMT on duty stating, you're the one that hit me that night. CMT informed this nurse, facility Administrator and the DON made aware. When this nurse asked resident if CMT on duty hit her resident stated no, it wasn't her. When asked resident why she made that statement resident replied Hell, I don't know! why don't you go get me some more juice! Resident education conducted regarding safety and reporting abuse, resident displayed understanding. <BR/>Record review of the facility's self-report dated 10/24/2023 revealed, an abuse incident occurred on 10/18/2023 at 3:00 a.m. and learned by facility on 10/18/2023 at 10:15 a.m. that Resident #2 was sitting on toilet covered in blood, CNA E came into the bathroom and turned off the light said you going to wake everyone. Resident started crying and CNA E told the resident she was there to help her, cleaned resident, and assisted residents to bed. Description of allegation: Resident stated that she was in restroom and pulled the call light button. According to resident, CNA E was mad and was yelling at her and hit her in the face on her left cheek. The resident started crying and CNA E told the resident, You know I am just playing with you. Resident reported to administration 2-days later. There was not bruising on resident's face. Provider response: CNA E was called into the office, a statement was taken, employee immediately suspended until investigation was complete. Resident payee, physician notified, and resident interviewed. Record review of the facility's conducted. Investigation Summary: After investigation, employee terminated. Unable to confirm abuse. Provider Action Taken Post-Investigation: Staff in-serviced on abuse and neglect. Signed and dated by Administration on 10/23/2024.<BR/>Record review of the facility's Policy: Abuse, Neglect and Exploitation, undated revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.<BR/>Record review of the facility's Policy Promoting-Maintaining-Resident-Dignity. Compliance Guidelines copy right date of 2022 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5. When interacting with a resident, pay attention to the resident as an individual. 10. Speak respectfully to residents.

**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 for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #3 and Resident #4) of 2 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1. <BR/>Resident #3, who required extensive assistance, was provided with timely incontinence care on 01/01/2024. <BR/>2. <BR/>Resident #4 was provided with timely incontinence care on 01/01/2024.<BR/>These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>Record review of Resident #3's face sheet dated 04/11/2024 indicated he was an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including repeated falls, osteoarthritis (wear down of flexible tissue), protein-calorie malnutrition (underweight), benign prostatic hyperplasia with lower urinary tract symptoms (increased urgency to urinate), difficulty in walking, muscle weakness, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), acute respiratory failure with hypoxia (not enough oxygen in the tissues in body), osteomyelitis (swelling of bone tissue causing an infection, age-related osteoporosis (loss of bone mass) without current pathological fracture (broken bone caused by a disease), and metabolic encephalopathy (chemical imbalance in the brain that causes confusion), <BR/>Record review of Resident #3's Care Plan undated indicated Focus: Resident has bowel and bladder incontinence r/t Prostate enlargement Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goals: Resident will remain free from skin breakdown due to<BR/>incontinence and brief use through the review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 6/07/2024. Interventions: Clean peri-area with each incontinence episode. Date Initiated: 07/25/2021. Incontinent: Check frequently and as required for incontinence. Focus: Resident has potential for pressure ulcer development Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goal: Resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 06/07/2024. Interventions: Complete a full body check weekly and document Date Initiated: 07/25/2021. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 07/25/2021. Provide incontinence care after each incontinence episode, or per established toileting plan. Date Initiated: 07/25/2021. Reposition in chair frequently for comfort and pressure reduction. Provide resident/family education as needed. Date Initiated: 07/25/2021. Revision on: 10/05/2022.<BR/>Record review of Resident #3's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Bowel Continence: Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement), and with no toileting program was being used.<BR/>Record review of Resident #4's face sheet dated 04/11/2024 indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses wedge compression fracture (collapsed bone in the front of the spine) of lumbar vertebra (spine bones behind the chest), hypertension (high blood pressure), type 2 diabetes mellitus (cells in your muscles, fat, and liver don't respond well to insulin) without complications, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), history of falling, muscle weakness, and difficulty in walking.<BR/>Record review of Resident #4's Care Plan undated revealed Resident #4 had the potential for pressure ulcer development r/t of ulcers, immobility, and incontinence. Date Initiated: 01/10/2020 Revision on: 01/10/2020. Resident was to have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 01/10/2020 Revision on: 09/12/2023 Target Date: 04/07/2024. Resident was to receive complete a full body check weekly and document Date Initiated: 01/10/2020. Staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 01/10/2020. Provide incontinence care after each incontinence episode, or per established toileting plan Date Initiated: 01/10/2020. Reposition in chair/bed frequently for comfort and pressure reduction. <BR/>Record review of Resident #4's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Occasionally incontinent (less than 7 episodes of incontinence). Bowel Continence: Occasionally incontinent (one episode of bowel incontinence), and with no toileting program was being used.<BR/>Observation on 04/10/2024 at 11:21 a.m., revealed Resident #4 was sitting in a wheelchair in the common area watching television, smiled, and waved. <BR/>Observation on 04/10/2024 at 11:50 a.m., revealed Resident #3 was lying in bed low to ground, fall mat in place. The resident was receiving oxygen and tube-feeding and fluids at bedside, legs propped up on wedge, asleep, did not response and covered with blankets. <BR/>During an interview on 04/11/2024 at 09:07 a.m., the Administrator stated on 01/01/2024 she received a call from CNA G when CNA G she came on shift at 10:00 p.m. and informed that Resident #3 and Resident #4 were left soiled. She stated she asked LVN A who was assigned to those residents, to determine which staff had left residents soiled. She stated that LVN A confirmed that CNA F had worked and was assigned to Resident #3 and Resident #4. <BR/>During an interview on 04/11/2024 at 09:43 a.m., LVN A stated that she was the unit manager on duty on 01/01/2024 and assigned to Resident #3 and Resident #4. She stated on 01/01/2024, the Administrator called and stated that Resident #3 and Resident #4 were left horribly wet and soiled at 9:45 p.m. and that CNA G had to come on shift and clean them up immediately. She stated that CNA G stated it was not just wet it was feces and food on the residents. She stated that she spoke with CNA F who admitted that she missed the two residents but provided no good reason. She stated that CNA F had been terminated for poor work performance. She stated this was not the first time CNA F had failed to perform resident's ADL care. She had left a resident without a shower and left a resident without making sure they had eaten. <BR/>During an interview on 04/11/2024 at 10:29 a.m., CNA F stated she began her employment in April of 2024 and was terminated in January 2024. She stated she was responsible for taking care of Resident #3 and Resident #4 on 01/01/2024. She stated that she had fallen behind and had not change Resident #3 before leaving shift and had not informed the oncoming shift or charge nurse that Resident #3 had not been changed before leaving shift. She stated that residents were to have been checked and changed every 2-hours and before leaving shift. She stated she had changed the residents during her shift but had not provided a time when the residents were changed. She stated she had issues with getting to residents on time, but she would get there as quickly as possible. She stated that the facility put a lot of responsibility on CNAs and nitpicked her unfairly when it came to completing tasks. She stated she never addressed her concerns with any of her superiors about not getting her tasks completed or being nitpicked at. She had not provided a response why she had not addressed her concerns with her superiors. She stated she received training on ANE, incontinent care, and resident rights during her onboarding process with the facility. She stated the importance of not leaving resident soiled for long periods was to avoid rashes and skin irritations. <BR/>During an interview on 04/11/2024 at 10:58 a.m., CNA G stated she had 26 years of experience as a CNA and worked for the facility about 7-months before she resigned in February 2024. She stated she came on shift on 01/01/2024 at 09:34 p.m. and took over the care of residents that CNA F was responsible for on the previous shift of 2 p.m. to 10 p.m. She stated it was routine when she came on shift to put eyes on each of her residents to see if there were any immediate needs of the resident that needed to be addressed first. She stated that when she went to check on Resident #3 and Resident #4, they were both heavily soiled in urine and feces. She stated that their briefs, clothing, and beddings were completely soiled. She stated that was a clear indication that they had not been changed in several hours and that CNA F had not followed policy and procedure by checking and changing residents before leaving shift and before the next shift took over. She stated when she found the resident in that soiled condition, she took pictures of the residents, cleaned, and changed the residents and their bedding, and sent the pictures to the Administrator along with a text message describing the resident's condition upon her arrival coming on shift. She stated that she had pictures in an old phone that she would forward. She stated that she could not remember which resident was which, but the pictures showed the resident's beds soiled in urine and one of the resident's back covered in food crumbs. She stated that she resigned from the facility because of high staffing turn over, and it being custom for her to find residents heavily soiled when she came on shift. She stated that staff that worked the 10 p.m. to 6 a.m. shift did not receive a lot of training in-services and she could not recall ever being in-serviced on ANE or incontinence care. She stated when she resigned, she wrote the Administrator a 3-page letter voicing all her concerns along with the pictures she took of the soiled and uncleaned residents. She stated the importance of checking and changing resident's every 2-hours was to prevent skin breakdowns. <BR/>During an interview on 04/11/2024 at 03:35 p.m. the DON stated that she was on leave when Resident #3 and Resident #4 were discovered soiled. She stated that CNA F was responsible for changing the residents during her shift. She stated that LVN C was responsible for overseeing CNA F. She stated CNA F had disciplinary actions taken against her for failure to address care areas on a few occasions and had been given a chance to make corrective actions. She stated that it was not uncommon for staff to run behind or feel overwhelmed during their shift, but it was their responsibility to notify their unit manager on shift for assistance. She stated that CNA F had never voiced concerns with feeling overwhelmed and had been given several opportunities to make corrective actions and this incident caused her employment to be terminated with the facility. She stated that the resident's family was notified of the incident. <BR/>During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that she had received a text on 01/01/2024 from CNA G who worked the 10 p.m. to 6 a.m. shift. She stated that CNA G told her she followed shift after CNA F who had left Resident #3 and Resident #4 in unchanged briefs before leaving shift. She stated she had spoken to CNA F on several occasions in-servicing her and reminding her to take care of the residents like they were her own mother and father. She also told the staff that if she felt she could not perform the tasks as such, she could not be a part of the team. She stated that all her staff know that if they need to text her, they can do so at any time and they knew there were no exceptions for leaving shift without completing their duties without informing the unit managers that they had fallen behind. <BR/>During an interview on 04/11/2024 at 04:59 p.m., CNA B stated the facility provided an in-service on ANE and incontinent care a couple of weeks ago (exact dates and times unknown). She stated that residents were to be checked on and changed if needed every two hours to avoid skin breakdowns. She stated if she found a resident excessively soiled, she would change the resident and report the to the unit manager on shift. <BR/>During an interview on 04/11/2024 at 05:15 p.m., CNA C stated at shift change there was an overlap of 10-15 minutes where staff consult with each other any concerns to be noted from the previous shift. She stated at that time it should be identified if a resident had not been changed prior to that staff leaving shift. She stated that if she found a resident heavy soiled and was not informed by the previous shifts staff, she would assume that the previous shift neglected to change the resident. She would change the resident and report to the unit manager and/or charge nurse that the previous staff had not completed their rounds before leaving shift. She stated that she was provided an in-service on ANE and incontinent care last week 04/01/2024 and 04/04/2024. <BR/>Record review of the facility's self-report incident dated 01/02/2024 revealed: On 01/01/2024: Description of allegation: Employee failed to perform job duties as assigned. CNA F left Resident #3 and Resident #4 soiled and wet. Beds were wet as well. This was reported to the Administrator. Description of injury: None. Provider response: CNA F was terminated for failure to complete job responsibilities. Investigation Summary: Resident interviews conducted. Employee in-services conducted. Provider Action Taken Post-Investigation: Employee terminated. Signed and dated by Administration on 01/09/2024.<BR/>Record review of the facility's staffing schedule dated 01/01/2024 revealed LVN B was responsible for supervising CNA F during her shift. <BR/>Record review of Policy copy right date of 2022 revealed Promoting-Maintaining-Resident-Dignity. Compliance Guidelines: <BR/>Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.<BR/>Record review of the facility's Policy: Abuse, Neglect and Exploitation, undated revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: <BR/>Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. <BR/>The facility failed to ensure Resident #1 did not have a working and running electric space heater in his room.<BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 04/10/2024 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses including obstructive and reflux uropathy (urine cannot drain from the urinary track), cellulitis (deep infection caused by bacteria), of unspecified part of limb, chronic embolism and thrombosis of deep veins (blood clots) of lower extremity hypothyroidism (lack of thyroid hormones causing the feeling of cold, pain, skin paleness and sadness), essential hypertension (high blood pressure), essential tremor (shakes), lymphedema (built up of fluid in the body), epilepsy (seizures), pain, ulcer and inflammation (swollen sores), and muscle weakness. <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. <BR/>Record review of Resident #1's Care Plan undated indicated Focus: Resident had heat intolerance. Date Initiated: 06/11/2021.<BR/>During an observation on 04/10/2024 at 11:36 a.m., Resident #1 was lying in bed partially covered with bare legs and feet exposed. Both right and left feet were hanging off the bed and wrapped in medical gauze and ace bandages. Across from the foot of resident's bed approximately 2.5 feet on the wall sat a running electric space heater. Resident's room contained items on every part of the resident's floor aligning the wall including the bathroom and empty bed containing cardboard boxes with papers and other unknown articles, several plastic lock boxes, in addition to the resident's wheelchair. <BR/>During an observation on 04/10/2024 at 11:55 a.m., Resident #1 rested in bed with eyes closed, and covered with sheet and blanket. Resident did not appear to have a runny nose. <BR/>During an observation on 04/10/2024 at 12:46 p.m., Resident #1 was shivering under 3-layers of blankets. Resident's room did not feel uncomfortably cold, felt warmer than the hallway, and warmer than resident rooms on the same hall. The space heater previously observed had been removed from resident's room.<BR/>During an interview on 04/10/2024 at 11:36 a.m., Resident #1 stated repeatedly that he had been cold. He stated that he had constantly asked the staff to raise the temperature so that his room would be warmer. Resident stated that he purchased the space heater and had been using it a couple of weeks. He stated he knew he was not supposed to have the space heater, and staff had taken previous space heaters he had in the past, but he needed it to keep himself warm. <BR/>During an interview on 04/10/2024 at 11:42 a.m., LVN A stated that she was not the Resident #1s nurse, she was answering the resident's call light. She stated that she would bring the resident some more blankets and cover him up. <BR/>During an interview on 04/10/2024 at 12:40 p.m., the Maintenance Director stated he had worked for the facility for 10 years. He stated he was familiar with Resident #1 being cold. He stated he often adjusted the temperature to the resident's liking while taken into consideration the other residents on the hall who never complained about the temperature. He stated that the temperature on the resident's hall was 73 degrees. He stated he was the only staff in the building that could control the temperatures on the units as it was locked by code. He stated in the warm or summer months he kept the temperature on the halls between 70-75 degrees and in the colder or winter months between 70-89 degrees. He stated that the resident mainly complained of the temperature at night at bedtime. <BR/>During an interview on 04/10/2024 at 12:46 p.m., Resident #1 stated that the temperature was always 66 degrees or lower. He stated that old people need more heat than young people. <BR/>During an interview on 04/10/2024 at 12:54 p.m., CNA H stated that she had known Resident #1 to have space heater in his room for weeks. She stated as soon as the Maintenance Director removed the space heater, the resident would replace the space heater with another.<BR/>During an interview on 04/10/2024 at 12:56 p.m., RN B stated that Resident #1 brought space heaters into the facility all the time. She stated as soon as it was known he had one, it would be immediately removed, and the resident would buy another.<BR/>During an interview on 04/10/2024 at 01:49 p.m., Maintenance Director stated that he was not aware that Resident #1 had a space heater plugged up and running in his room. He stated he was the resident's ambassador which meant he was responsible for checking on the resident every morning between 8 a.m., 8:30 a.m. and again at 8:45 a.m., to report any concerns or findings about the resident during the facility's daily morning meeting at 9 a.m. He stated had had checked on the resident 04/10/2024 before the morning meeting and there was no heater in the resident's room. He stated that the resident was a hoarder and the resident's room was often cluttered with items. He stated that he had explained to the resident on many occasions of the life safety fire hazard reasons it was not safe to have space heater sin the facility. He stated he had removed space heaters from resident's room in the past. He stated as soon as one space heater was removed; the resident purchased another. He stated he would find out who removed the space heater observed in the resident's room and ensure that it would be removed from the facility. <BR/>During an interview on 04/10/2024 at 4:01 p.m., LVN A stated she had worked for the facility for 13 years. She stated that she and RN B moved the space heater out of Resident #1's room when she brought him blankets on 4/10/2024 at 11:42 a.m. She stated she had never seen that space heater in the resident's room before and was not aware of him having heaters in his room. She stated she visited the resident's room on her shifts occasionally. She stated the resident was aware and educated that he was not supposed to have space heaters in his room for safety reasons. She stated when she moved the heater from his room, she did not speak to him about the items being moved. She stated that Social Worker (SW) would speak to the resident about the heater. <BR/>During an interview on 04/11/2024 at 09:17 a.m., SW stated that she worked for the facility for 6 years. She stated that Resident #1 had a history of hoarding and she had to constantly remind him about keeping his room decluttered and that space heaters are not allowed due to being a fire hazard. <BR/>During an interview on 04/11/2024 at 03:35 p.m., the DON stated that Resident #1 should not have space heaters in his room due to it being a fire safety issue. She stated before morning meetings and during random rounds, the Maintenance Director checked on resident daily and had reported on occasion that the resident had a space heater in his room. She stated if staff see a space heater in the resident's room, they were to immediately notify the Maintenance Director so it could be removed. She stated she was not aware of resident's complaints of being cold. She stated that resident will be offered more blankets and she will have maintenance check the temperature on the floor. She stated if that does not resolve the resident's cold concerns, he could be offered to move to another room. <BR/>During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that the facility has an ambassador program where staff are assigned to specific residents and check on them every morning before the daily morning meeting. She stated that Resident #1 was assigned to the Maintenance Director who checked on the resident in the morning and again in the afternoon. She stated that SW had spoken with the resident about space heaters not being allowed in the facility because it was a fire hazard. She stated that the resident would be offered pajamas and more blankets to address his issues with temperatures. She stated that the resident probably had not had the space heater out when the Maintenance Director had done his ambassador rounds 04/10/2024, then brought the space heater out once the Maintenance Director left. She stated that the resident debated the Maintenance Director on a regular about the temperature in the room and the Maintenance Director often adjusted the temperature to make the resident more comfortable.<BR/>During an interview on 04/11/2024 at 04:59 p.m., CNA B stated that if she found a space heater in a resident's room, she would unplug it, notify that resident's unit manager, and/or report to the Maintenance Director. <BR/>During an interview on 04/11/2024 at 05:15 p.m., CNA C stated that if she found a safety hazard item plugged in a resident's room, she would unplug the item, notify the unit's charge nurse and/or follow the chain of command to have it removed. She stated all safety hazards issues were reported to the Maintenance Director. <BR/>During an interview on 04/11/2024 at 05:21 p.m., CNA D stated that if she found a space heater in a resident's room, she would report to the unit manager and/or charge nurse and allow them to handle it. <BR/>Record review of Physical Environment: Electrical Equipment Policy: Copyright date 2024. Policy: The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment. 2. Frequency of inspection and maintenance shall be in accordance with the facility's Electrical Safety policy, current Life Safety Code requirements, and manufacturer recommendations.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 9 residents (Resident #13) reviewed for medication administration.<BR/>MA C administered Minocycline ( a drug works by killing bacteria or preventing their growth), along with one daily Multi-Vitamin and Iron tablet to Resident #13, which the medication label warned against it. <BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included: <BR/> Record review of Resident #13's face sheet revealed a 80 years-male admitted on [DATE] and readmitted on [DATE] to the facility. His diagnoses included lymphedema,( swelling due to build-up of lymph fluid in the body) not elsewhere classified, methicillin resistant staphylococcus aureus infection( germ(bacteria) that does not got better with the type of antibiotics that uaslly cure staph infections) as the cause of diseases classified elsewhere, chronic embolism and thrombosis ( blood clot ) of unspecified deep veins of unspecified lower extremity, epilepsy(abnormal electrical brain activity also known as a seizure), chronic venous hypertension (idiopathic) (high blood) with ulcer and inflammation of bilateral lower extremity. <BR/>Record review of Resident #13's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated cognition was intact; no impairment. He needed extensive assistance of 1-2 staff for ADLs.<BR/>Record review of Resident #13's Physician Order Report for 04 /22/2023 revealed an order of Minocycline 100mg 1 capsule per oral/by mouth( PO) every 12 hours for wound infection until 05/10/2024, One daily multi-vitamin with mineral 1 tablet PO daily.<BR/> and Iron tablet 325 mg 1 tablet PO daily.<BR/>In an observation on 5/6/24 at 9:20 AM, of medication administration, MA C, picked up Minocycline 100mg capsule blister packet ( had Take with full glass water. No antacid/vits/iron/dairy within2 hours . May cause increased photosensitivity( is a condition in which skin becomes extremely sensitive to the sun causing skin to the sun causing skin to burn more easily). <BR/>blister packet from the medication cart, punched 1 capsule in a medication cup with One daily multi-vitamin with mineral 1 tablet and Iron tablet 325 mg 1 tablet and other medications and to Resident #13 by mouth. Resident #13 complained of taking too many medications at the same time. MA C said that what I go through every time.<BR/>In an interview with MA C on 5/7/24 at 2:30 PM, MA C said she has been working with facility for over 1 year and she knows the five right of meds administration, she had in-services with the unit manager and was monitored during med pass and was not aware of not taking antacid/vits/iron/dairy within 2 hours after taking minocycline and she did not read it the nurse surveyor showed it to her .<BR/>In an interview on 5/8/24 at 12:38 PM the DON said the staff should read the MAR and blister packet before medication administration to Residents. She said she expected nursing staff to ensure the medication order and inventory matched because the correct dosage needed to be provided to the resident and not pharmacy recommendation could cause stomach cramps and could cause drug interaction. <BR/>In an interview on 5/8/23 at 12:30 PM the facility's policy on Medication Administration was requested from the DON but was not received prior to exit.<BR/>In an interview on 5/8/23 at 12:46 PM the Administrator said he expected nursing staff to follow the physician orders. She said charge nurses, or the nurse managers oversaw medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 Residents (Residents #46, and #16) and 2 of 2 staffs (CNA A and LVN A) reviewed for infection control. <BR/>1. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #46. <BR/>2. LVN A failed to maintain a sterile technique while providing tracheostomy care to Resident #16. <BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings included:<BR/>Resident #46 was an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders, unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension, and dysphagia( difficulty swallowing)<BR/>Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function), Resident # 46's BIMs score of 7 means she was severely cognitive impaired.<BR/>Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following:<BR/>1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance<BR/>-Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use<BR/>2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance<BR/>-Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode<BR/>Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and C.NA D assisting, revealed CNA A washed hands and don( put on) clean gloves during incontinent/Foley catheter care. Using the wet wipes, CNA A cleaned the Foley catheter tubing and she changed gloves x 4 times and did not wash her hands or used hand sanitizer.<BR/>Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to wash hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. <BR/>During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care, Staff should wash hands or use hand sanitizer with each gloves change. The DON said the facility staffs had monthly in-services with skilled check. The DON said she was going to start incontinence care and hand washing skill checks.<BR/>Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure).<BR/>Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity.,<BR/>Record review of Resident #16's Physician Orders reviewed 5/7/2024 revealed the following:<BR/>1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5<BR/>2.Tracheostomy site dressing change every DAY and PRN if soiled.<BR/>3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes<BR/>4. Trach suctioning every (Q) shift and PRN<BR/>5. Oxygen at 4-6L/min via Tracheostomy<BR/>Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for:<BR/>1. Resident #16 has a Tracheostomy r/t respiratory failure<BR/>-Interventions: Suction as necessary, use Universal Precautions as appropriate<BR/>Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress.<BR/>Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress.<BR/>Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned a clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doffed (take off)gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. <BR/>In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. <BR/>In an interview on 05/08/2024 at 12:45 PM, with the DON, when Surveyor described the observed during trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in September 2023 . The DON said LVN A always worked with Resident #16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 5 residents (Resident #46) reviewed for incontinent care and indwelling catheter. <BR/>1.The facility failed to ensure CNA A cleaned Resident #46's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care.<BR/>These failures could place residents at risk for pain, infection, injury, and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #46's face sheet revealed an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders (lack interest with daily activities), unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension( high blood pressure), and dysphagia (difficulty swallowing).<BR/>Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function). BIMS score of 7 meaning Resident # 46 was severely impaired.<BR/>Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following:<BR/>1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance<BR/>-Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use<BR/>2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance<BR/>-Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode<BR/>Record review of Resident #46's MAR (Medication Administration Record) for December 2023 to January 2024 revealed resident was given Doxycycline Hyclate Oral Tablet 100 MG, 1 tablet via G-tube every 12 hours for infection for 7 Days until finished. The medication was administered from 12/28/2023 to 1/4/2024. <BR/>Record review of Resident #46's hospital records dated 02/29/2024 revealed they were hospitalized from [DATE] to 02/29/2024 due to UTI. At the hospital, she completed intra venous (IV )meropenem + Sodium Chloride 0.9% IV 100 mL 500 mg IVPB ABXQ8H. 33.33 ml/hr from 02/22/2024 to 02/29/2024.<BR/>Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and CNA D assisting, revealed CNA A washed hands and donned( put on) clean gloves and she did not open the labia to clean. Using the wet wipes, CNA A cleaned the Foley catheter tubing not in a circular motion, C.NA A used the wet wipes, cleaned catheter tubing straight and she changed gloves x 4 times and did not wash her hands or used hand sanitizer.<BR/>Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to open and clean Resident #46's labia and forgot to clean the indwelling catheter from the insertion site in a circular motion. C.NA A said not opening the labia to clean and not cleaning the Foley catheter could result in infection. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. C.NA A said she forget to wash her hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. <BR/>During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward and clean the indwelling catheter in a circular motion. The DON said she was going to start incontinence care skills checks . DON said the ADON and the lead C.NA A does incontinent monitoring. The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. The DON did not have policy for incontinent and Foley catheter care.<BR/>In an interview on 05/08/2024 at 2:35 PM, the Administrator stated her expectation was that incontinent care and hand washing were always done to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #16)<BR/>A) The facility failed to ensure LVN A used sterile technique during tracheotomy suctioning for Resident #16.<BR/>B) The facility failed to ensure Resident #16's oxygen was set per physician orders.<BR/>These failures placed residents with tracheostomies requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. <BR/>Findings included.<BR/>Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure).<BR/>Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity,<BR/>Record review of Resident #16's Physician Orders reviewed 08/24/2016 revealed the following:<BR/>1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5<BR/>2.Tracheostomy site dressing change every DAY and PRN if soiled.<BR/>3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes<BR/>4. Trach suctioning Q shift and PRN<BR/>5. Oxygen at 4-6L/min via Tracheostomy<BR/>Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for:<BR/>1. Resident #16 has a Tracheostomy r/t respiratory failure<BR/>-Interventions: Suction as necessary, use Universal Precautions as appropriate<BR/>Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress.<BR/>Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress.<BR/>Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doff gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. <BR/>In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. <BR/>In an interview on 05/08/2024 at 12:45 PM, when Surveyor described the observed trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was September 2023. The DON said LVN A always worked with Resident #16. <BR/>Review of the website www.tracheostomyeducation.com dated 09/21/2022 reflected The upper airway plays an important role in immune defenses of the lung by filtering, humidifying, and warming inspired gases before they reach the trachea, preventing dehydration of airway secretions. The nose and oropharynx perform most of this conditioning. For the lower airways and alveoli to properly function, it is important that inspired gases are fully saturated with water vapor .With a cuffed tracheostomy tube, the airflow is redirected out through the tracheostomy tube and air does not flow through the nose or nasopharynx. The natural warming, humidification and filtration system are bypassed resulting in cool and dry air entering directly through the tracheostomy tube which can easily result in: damage to the ciliated tracheal mucosa, thickening and retention of airway secretions, impaired mucociliary transport, inflammatory changes and necrosis of epithelium, impaired [NAME] activity, destruction of cellular surface of airway causing inflammation, ulceration and bleeding , reduced lung function (atelectasis/pneumonia), increased risk of bacterial infiltration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs, for one (Resident #1) of five residents reviewed for call light access.<BR/>The facility failed to ensure the call light was within reach for physically impaired resident (Resident #1) who needed assistance with incontinent care. <BR/>This failure could place residents at risk for not being able to call for assistance from staff.<BR/>Findings included:<BR/>Record review of Resident #1's facesheet revealed she was sixty-nine-year-old woman who was admitted to the facility on [DATE]. Her diagnoses included a cerebrovascular disease (condition that affects the blood flow to your brain), dementia (memory loss), hemiplegia and hemiparesis (paralysis of one side of the body), hypertension (high blood pressure) and noted a need for personal assistance with care. <BR/>Record review of Resident #1's care plan revised 10/05/2022 revealed:<BR/>- Resident #1 had the potential for pressure ulcer r/t immobility, incontinence, and friction. The intervention listed stated that the facility would provide incontinence care after each incontinence episode or per established toileting plan. <BR/>-Resident #1 had an ADL self-care performance deficit r/t hemiplegia from stoke. The intervention listed stated that Resident #1 required extensive assistance by two staff to move between surfaces and the facility encouraged resident to use call bell for assistance. <BR/>-Resident #1 had a fall r/t poor body control with hemiplegia and remains at risk for further falls. Her last reported fall with injury was on 02/08/2023 and had post complaints of pain to the right shoulder. Interventions stated to ensure call light was within reach, encouraged the resident to use it for assistance as needed, and the resident needed a prompt response to all requests for assistance. After a fall that occurred on 10/09/2019, the care plan was updated to include to not leave the resident up in her wheelchair inside of room unattended. <BR/>Record review of Resident #1's BIMS assessment revealed a score of 11 out of 15. <BR/>In an observation on 12/12/2023 at 10:16 am, Resident #1 was sitting in her wheelchair in front of the television. She was positioned in front of the roommate's bed, which was closest to the door and a tray table was in front of her. Packaging from the morning breakfast was still on her tray table and her call light was placed across the room on her bed. <BR/>In an interview on 12/12/2023 at 10:17 am, the surveyor knocked on Resident #1's door and she immediately screamed out in distress Help me! Please help me!! Resident #1 explained that she had went number two (had a BM) and she hated to sit in it after she had messed on herself. She stated that staff placed her in her wheelchair that morning after her shower and that was the last time she had been changed. Resident #1 stated that she was a stroke victim and was paralyzed and could not walk, which was why she was not able to move/transfer herself to the bed to reach her call light to ask for help. She revealed that she had fallen at the facility in the past and she was afraid to fall again and hit her head. The surveyor pressed the call light on the resident's behalf to summon assistance.<BR/>In an interview on 12/12/23 at 10:22 am, CNA A entered the room to change Resident #1. She stated that she woke Resident #1 up that morning and changed her at 7:10 am. The resident finished her shower with the shower tech and was sitting in her wheelchair by 7:30 am to receive her morning breakfast tray. During incontinent care, CNA A said, ooh you pooped to Resident #1, who responded I know, I couldn't get anybody to change me.<BR/>In an interview on 12/12/23 at 10:30 am, Resident #1 said that she felt much better now that she had been cleaned up. <BR/>In an interview on 12/12/23 at 10:35 am, CNA A stated that residents are supposed to be changed every 2 hours or immediately if they have made a bowel movement. She explained that Resident #1 was normally in bed, which she preferred, but she took her out of the bed to switch things up. CNA A apologized to Resident #1 for getting her up out of bed. The CNA was not knowledgeable if Resident #1 was a fall risk or her diagnoses but admitted to having access to PCC (resident information portal). CNA A further explained that she normally worked on another hall, but she worked that hall on that day to fill in. <BR/>In an interview with CNA B on 12/12/23 at 10:58 am, she explained that Resident #1 was allowed to sit up in her chair for 2-3 hours. She explained that as a safety precaution, the facility had to have someone watch Resident #1 at all times so that she would not aspirate due to her previous stroke and that she required multiple check-ins. CNA B also stated that Resident #1 could wheel herself around, but she would not, and the call light should be within reach of her. <BR/>In an interview with the DON on 12/12/23 at 12:33 pm, she stated that rounds were ideally done every 2 hours, however this was a long-term care facility. She explained that Resident #1 would ask her roommate to press her call light on her behalf because she would often yell out for help, but she admitted that the call light should have been in reach of the resident. The DON stated that if a resident was not able to reach their call light, they were at risk of not receiving the assistance they need. <BR/>Record review of the facility's policy titled Call Lights: Accessibility and Timely Response, (no date) stated: <BR/>1. <BR/>All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.<BR/>2. <BR/>All residents will be educated on how to call for help by using the resident call system.<BR/>3. <BR/>Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.<BR/>4. <BR/>Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.)<BR/>5. <BR/>Staff will ensure the call light is within reach of resident and secured, as needed.<BR/>6. <BR/>The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.<BR/>7. <BR/>The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 3 (Resident #17, Resident #31, Resident #48) of 5 residents reviewed for comprehensive care plans.<BR/>- Resident #17 was not care-planned for exit-seeking when she was documented in her progress notes as pushing on the exit door by her room as a behavior.<BR/>- Resident #31 did not have a comprehensive care plan in place with interventions to address oxygen use or anticoagulant use. <BR/>-Resident #48 did not have a comprehensive care plan to address his advanced directive status of DNR<BR/>This deficient practice could place residents at risk of their behaviors and needs being monitored and cared for at the facility.<BR/>Findings included:<BR/>Record review of Resident #17's face sheet dated 06/11/2025, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included basal cell carcinoma of the skin (skin cancer), schizophrenia (a mood disorder characterized by hallucinations, delusions, and disorganized thinking and behavior), insomnia, and pain.<BR/>Record review of Resident #17's Comprehensive MDS dated [DATE], reflected Resident #17 had a BIMS score of 9 out of 15 which suggested she had moderate cognitive impairment related to memory and thinking skills. She required moderate assistance with toileting, dressing, footwear, and personal hygiene. Resident #17 was coded as having no impairments to her upper and lower extremities.<BR/>Record review of Resident #17's care plan last revised 04/28/2025, reflected she was care-planned for impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions including administering medications as ordered and monitoring/documenting for side effects and effectiveness and cueing, reorienting and supervising as needed. There was no care plan for Resident #17's behavior of pushing on the door. A later record review of Resident #17's care plan last revised 06/11/2025 after surveyor intervention, Resident #17 was care-planned for being a wanderer related to being disoriented to place, with interventions including assessing for fall risk, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation and television and monitoring Resident #17 for fatigue and weight loss.<BR/>Record review of Resident #17's Order Summary Report, reflected she had an active order for Lorazepam (generic name of Ativan) Oral Tablet 1 MG, give 1 tablet by mouth three times a day related to Schizophrenia and to hold for excessive sedation with a start date of 06/06/2025. <BR/>Record review of Resident #17's elopement evaluation on 4/2/2025, reflected she was documented as posing no risk for elopement. <BR/>Record review of Resident #17's progress notes, reflected she made attempts to push on the door at the exit near her room on 5/1/2025, 5/7/2025, 6/2/2025, 6/3/2025, and 6/9/2025.<BR/>Record review of Resident #17's medication consent form, reflected she was prescribed Ativan for anxiety and agitation on 6/6/2025.<BR/>Observation and interview with Resident #17 on 06/10/2025 at 9:33am, revealed Resident #17 was in her room sitting on her bed and was holding her head with both hands and talking to herself. She appeared well-groomed and agitated. When asked how she was doing, Resident #17 said thank you and waved the surveyor off. When the surveyor walked past her bedroom, Resident #17 was heard talking progressively louder, Stop looking at me! Later observations of Resident #17 on 6/12/2025 at 10:59am, revealed she was walking around the facility away from the door and at 4:28pm, Resident #17 was in her room in bed.<BR/>Observation on 6/11/2025 at 2:29pm, revealed LVN K pushed on the exit door on Resident #17's hallway, and the alarm rang for 15 seconds before the door fully opened. He turned off the alarm with a key which fit into the alarm box at the top of the doorframe. The door was observed with no damages or concerns.<BR/>In an interview with MDS Nurse LVN F on 6/11/2025 at 1:20pm, she said she was not aware of Resident #17 and that she would care-plan the behavior of pushing on the door and document Resident #17's wandering behavior on her assessments. LVN F said that Resident #17 could get out the door or fall if she left. LVN F said nurses used the care plan to see how to provide care to the residents. <BR/>In an interview with LVN M on 6/11/2025 at 2:29pm, she said Resident #17 would walk with her wheelchair and push it into the door. When the alarm would turn on, Resident #17 would get irritated but was easily redirected away from the door. Resident #17 would move away from the door when the alarm turned on. LVN M had in-services on elopement and resident behaviors such as redirection at the facility. <BR/>In an interview on 6/11/2025 at 2:38pm, the DON said that Resident #17 would not be considered exit-seeking per se, but that she made attempts to push on the doors but would get scared and was easily redirected from the situation. In a later interview with the DON and Administrator on 06/11/2025 at 4:34pm, the Administrator said they were evaluating where they could move Resident #17 so she could be away from the door. The Administrator said the purpose of care plans was to document needs and try to meet them for residents, and that Resident #17's behavior of pushing on the door might need to be documented. The Administrator said Resident #17 had no exit-seeking behavior or the facility would have to find another building for her as they did not have a secured unit. <BR/>In an interview with RN G on 6/11/2025 at 2:55pm, she said that Resident #17 had attempted to push on the door every few days but Resident #17 had not exited or left the building. After each attempt, RN G would give Resident #17 a PRN dose of anxiety medication. Resident #17's NP was notified of her behavior. Resident #17 never told RN G why she attempted to leave but would talk to herself. The facility had working alarms, and RN G and CNAs on the hall watched and redirected her. When Resident #17 would push on the door, RN G called Resident #17's Psychiatric NP, documented it in Resident #17's progress notes, and told the next shift's nurses and aides to continue monitoring. RN G had elopement and resident behavioral training. RN G said Resident #17's behavior should be in her care plan, but she would need to check. Behaviors should be in the care plan so a resident's condition was documented, and nurses could be aware. <BR/>In an interview with the Unit Manager LVN N on 6/11/25 at 3:24pm, she said Resident #17 liked to go to the door but never left the building. LVN N was not aware why Resident #17 would go near the door. Resident #17's NP checked on her and would ask if her medications were effective. She said care plans highlighted resident's care, how they were, medications and behaviors. <BR/>In an interview with NP B on 6/13/2025 at 8:16am, he said that he was Resident #17's Psych NP. NP B said the facility staff called him frequently for her behaviors, including trying to exit. NP B said medications did not treat a specific behavior but were used to treat Resident #17's condition in general. He recently changed her medication to help with her behaviors such as restlessness, anxiety, talking to herself, and getting her to put on her gown and talk to NP B. <BR/>Resident #31<BR/>Record review of Resident #31's facility admission record dated 6/11/25 revealed that Resident #31 had an original admission date of 8/14/2015 and re-admission date of 2/9/25. Resident #31 was a [AGE] year-old male with diagnoses that included Ileus unspecified (a condition where the intestines don't move food and waste along as they should, but there's no physical blockage like a tumor or scar tissue) and Hydronephrosis with renal and ureteral calculous obstruction (the swelling of a kidney due to a blockage in the ureter (the tube carrying urine from the kidney to the bladder) caused by a kidney stone (calculus).<BR/>Record review of Resident #31's Quarterly MDS dated [DATE], revealed a BIMS score of 12 out of 15 indicating a moderate cognitive impairment. Resident #31 was documented to require substantial/maximum assistance from staff for ADLs. He required supervision or touching assistance with eating and oral hygiene. He had an indwelling urinary catheter and was always incontinent with bowels. Section N-Medications indicated he used anticoagulants. Section O-Special Treatments indicated Resident #31 used oxygen.<BR/>Record review of Resident #31's undated care plan, revealed there were no care plans with interventions to address anticoagulant or oxygen use. <BR/>Record review of Resident #31s physician orders for May 2025 revealed an order for oxygen at 2 liters/min via nasal cannula PRN with a start date of 9/25/24.<BR/>Record review of Resident #31's physician orders for May 25 revealed a physician order for Xarelto oral tablet 20 mg. Give 1 tab by mouth in the evening.<BR/>Observation and interview on 6/10/25 at 10:10 AM with Resident #31, revealed the resident appeared to be clean, and had no odors, or visible signs of injury. He said that he felt very pleased with his care at the facility and had no concerns. <BR/>In an interview on 6/11/25 at 9:24 AM with the Administrator, she said care plans for anticoagulants and oxygen should be in place for Resident #31 and the MDS coordinator was responsible for updating. A negative impact could be resident needs not being addressed.<BR/>In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address anticoagulants or oxygen use for Resident #31 and there should have been. Care plans were important because nurses looked at them to provide care for residents. She added the responsibility lied with the IDT.<BR/>In an interview on 6/11/25 at 2:37 PM with the DON, she said that Resident #31's oxygen and anticoagulants status should have been care planned. She said that without the care plan he could have bled out or needed oxygen and the care plans were used to provide care. She said that MDS Coordinator was responsible for updating the care plans.<BR/>Resident #48<BR/>Record review of Resident #48's facility admission record dated 6/11/25 revealed that Resident #48 had an original admission date of 3/2/21 and re-admission date of 5/1/25. Resident #48 was a [AGE] year-old male with diagnoses that included lobar pneumonia (a type of pneumonia where a large portion or entire lobe of one or both lungs becomes inflamed and consolidated, meaning it fills with inflammatory fluid and/or pus) and Parkinson's Disease without Dyskinesia without fluctuations (a specific presentation of Parkinson's disease where patients do not experience involuntary movements (dyskinesia) or noticeable changes in the severity of their symptoms over time (fluctuations).<BR/>Record review of Resident #48's Quarterly MDS dated [DATE], revealed a BIMS score of 8 out of 15 indicating a moderate cognitive impairment. Resident #48 was documented to require partial to moderate assistance to substantial/maximum assistance from staff for ADLs. He required set-up to or clean-up assistance with eating. He was always incontinent with bladder and bowel. <BR/>Record review of Resident #48's undated care plan revealed there was no care plan to address his advanced Directive choice of DNR.<BR/>Record review of Resident #48's physician orders dated 5/2025 revealed a physician order for DNR with OOH DNR signed 5/8/25.<BR/>Record review of Resident #48's DNR dated 5/7/25 revealed that he elected for DNR status. <BR/>Observation on 6/10/25 at 10:03 AM of Resident #48, revealed he appeared to be asleep, very frail, as he laid on his bed.<BR/>In an interview on 6/11/25 at 9:24 AM with the Administrator, she said a care plan to address DNR for Resident #48 should be there to address the needs of the resident and the MDS coordinator was responsible for updating care plans. A negative impact could be resident needs not being addressed.<BR/>In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address DNR status for Resident #48 and there should have been. She said the care plan would be added on 6/11/25.<BR/>In an interview on 6/11/25 at 2:37 PM with the DON, she said that the care plan for Resident # 48's DNR status should have been updated. She said that without the care plan he could have been given CPR (lifesaving interventions) if the DNR status was not care planned. <BR/>Record review of the facility's policy on Comprehensive Care Plans copyrighted 2025 read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .3.The comprehensive care plan will describe, at a minimum . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs and preferences .<BR/>Record review of the facility's policy on Elopements and Wandering Residents copyrighted 2022 read in part, The facility is equipped with door locks/alarms to help avoid elopements . Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication <BR/>error rate was not five percent (%) or greater. The facility had a medication error rate of 7%, based <BR/>on 3 errors out of 38 opportunities, which involved 3 of 11 residents (Resident #8, #62, and <BR/>#78) reviewed for medication administration.<BR/>LVN A did not administer Resident #8's Levetiracetam medication ( medication used to <BR/>treat seizures epilepsy , is classified as anticonvulsants) according to Physician orders<BR/>RN A did not administer Resident #62's Levetiracetam medication ( medication used to treat seizures epilepsy , is classified as anticonvulsants)) according to Physician orders.<BR/>RN A did not administer the prescribed amount of Senna syrup ( a laxative medication) to Resident # 78 according to Physician orders.<BR/>These failures could place residents at risk of inadequate therapeutic outcomes and a decline in health. <BR/>Findings included:<BR/>Resident #78<BR/>Record review of the face sheet dated 3 30 2023 revealed Resident #78 was a [AGE] year old male resident admitted to the facility on 04 07 2022, and was re admitted on [DATE] with diagnoses <BR/>to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to <BR/>understand or express speech caused by brain <BR/>damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain <BR/>disorders such as epilepsy). <BR/>Record review of physician order's dated 2/8/23 revealed Senna syrup 5 ml Solution .Give 5 ml via G Tube two times a day related to constipation.<BR/>During an observation on 03 28 2023 at 4:28 AM,RN A stopped Resident #78's enteral feeding to <BR/>start his medication administration. RN A did not flushed with water before administering medication. RN A <BR/>picked up the following medication bottle and poured in the medication cups. Poured 7 cc of Senna Syrup in a cup and diluted with 10 cc Of water.<BR/> RN A then poured each medication into the GTube without flushing with water in between medication administration.<BR/>Resident # 62<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include <BR/>pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential <BR/>(primary) hypertension) dysphagia; <BR/>oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia, <BR/>(loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such as epilepsy),<BR/> Record review of physician order's active dated <BR/>3/8/23 revealed Levetiracetam Solution 100 <BR/>MG/ML. Give 10 ml via G Tube two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS.<BR/>During an observation on 03 28 2023 at 4:42 PM,RN A stopped Resident #62's enteral feeding to start his medication administration. RN A picked up the following medication bottle poured in the medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's GTube and flushed with 30 mls of water. ( instead of Levetiracetam Solution 10 ml as ordered by physician)<BR/>During an interview with RN A on 03/29/23 at 8:50 AM, he always flush G <BR/>Tube with water after medication administration, <BR/>Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam Solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON.<BR/> Record review of RN A's personnel file revealed <BR/>date of hired was 2/24/21 and document regarding his training on medication was on 10/15/22 <BR/>Resident #8<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness <BR/>that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health <BR/>disorder that is marked by a combination of <BR/>schizophrenia symptoms such as hallucinations <BR/>acute and chronic respiratory failure with hypoxia, ( a serious condition that makes it <BR/>difficult to breathe on your own, the lungs can't get enough oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular <BR/>movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such <BR/>as epilepsy). <BR/>Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML<BR/>Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and <BR/>epileptic syndromes with complex partial seizures, not intractable with status epilepticus.<BR/>During an observation on 03 29 2023 at 9:38 AM, <BR/>LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A picked up the following medication bottle poured in the <BR/>medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 13 cc and diluted with 10 cc of water and administered via Resident #8's GTube and flushed with 10 cc of water.<BR/>During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician LVN A said she would double check medication before administering. <BR/> Record review of LVN A personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 .<BR/>During an interview on 3/30/23 at 1:40 PM, the DON said nursing staff were to identify the resident's name, medication and to compare the information on the MAR when a medication is prepared, give medication as ordered by the physician. She said she would be in servicing the <BR/>nursing staff on medication administration.<BR/>Record review of facility provided policy titled Medication Administration Via Enteral Tube revised 2022, revealed the following: Policy : It is <BR/>the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . <BR/>9. Procedure: <BR/>j. Dilute the solid or liquid medication as <BR/>appropriate and administer using a clean oral syringe( &gt; 30 mL in size).<BR/>k. Flush tube again with at least 15 mL water taking into account resident's volume status<BR/>l. Repeat with the next medication ( if appropriate)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 Residents (Residents #46, and #16) and 2 of 2 staffs (CNA A and LVN A) reviewed for infection control. <BR/>1. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #46. <BR/>2. LVN A failed to maintain a sterile technique while providing tracheostomy care to Resident #16. <BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings included:<BR/>Resident #46 was an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders, unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension, and dysphagia( difficulty swallowing)<BR/>Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function), Resident # 46's BIMs score of 7 means she was severely cognitive impaired.<BR/>Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following:<BR/>1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance<BR/>-Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use<BR/>2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance<BR/>-Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode<BR/>Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and C.NA D assisting, revealed CNA A washed hands and don( put on) clean gloves during incontinent/Foley catheter care. Using the wet wipes, CNA A cleaned the Foley catheter tubing and she changed gloves x 4 times and did not wash her hands or used hand sanitizer.<BR/>Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to wash hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. <BR/>During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care, Staff should wash hands or use hand sanitizer with each gloves change. The DON said the facility staffs had monthly in-services with skilled check. The DON said she was going to start incontinence care and hand washing skill checks.<BR/>Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure).<BR/>Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity.,<BR/>Record review of Resident #16's Physician Orders reviewed 5/7/2024 revealed the following:<BR/>1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5<BR/>2.Tracheostomy site dressing change every DAY and PRN if soiled.<BR/>3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes<BR/>4. Trach suctioning every (Q) shift and PRN<BR/>5. Oxygen at 4-6L/min via Tracheostomy<BR/>Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for:<BR/>1. Resident #16 has a Tracheostomy r/t respiratory failure<BR/>-Interventions: Suction as necessary, use Universal Precautions as appropriate<BR/>Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress.<BR/>Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress.<BR/>Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned a clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doffed (take off)gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. <BR/>In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. <BR/>In an interview on 05/08/2024 at 12:45 PM, with the DON, when Surveyor described the observed during trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in September 2023 . The DON said LVN A always worked with Resident #16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record <BR/>review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications <BR/>of enteral feedings for 3 (Resident #8, #62, #78) of 4 residents reviewed for feeding tubes, in that: <BR/>The facility staff failed to verify placement of the feeding tube prior to medication administration for Resident # 78 and Resident #62<BR/>LVN A plunged 60 ml's of water into Resident #8's gastrostomy tube via syringe instead of via gravity flow when there is an interruption of feeding to maintain tube patency for administration.<BR/>This failure could place residents receiving <BR/>enteral feedings at risk for complications such as <BR/>aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization. <BR/>Findings include:<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #78 revealed a [AGE] year old male resident admitted to the facility on 04 07 2022 and was re admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such as epilepsy).<BR/>Record review of Resident #78's last MDS was a quarterly completed on 01 13 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional . Approach as B. Feeding Tube while a resident. <BR/> Record review of physician order's active dated 2/8/23 revealed Senna syrup 5 ml Solution <BR/>Give 5 ml via G Tube two times a day related to constipation.<BR/>Record review of Resident #78's care plan dated of 04 07 2022 revealed the following: Focus: Altered Nutritional Status PEG Feedings . date Initiated: 04 07 2023<BR/>During an observation on 03 28 2023 at 4:28 AM, RN A stopped Resident #78's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did not palpate Resident #78's stomach. RN A used a 60 cc syringe, then installed 20 cc of air via G Tube (gastrostomy tube) without using the stethoscope to auscultate for placement and did not flushed with water before administering medication. RN A picked up the following medication blister packets and placed in the <BR/>medication cups<BR/>Amlodipine 10mg 1 tablet crushed and diluted with 10cc of water,<BR/>Thiamin vitamin B 100 mg 1 tablet crushed and diluted with 10cc of water,<BR/>Poured Senna syrup 7cc a cup and diluted <BR/>with 10 cc of water.<BR/>RN A then poured each medication into the G Tube without flushing with water in between medication administration.<BR/>Resident # 62<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential (primary) hypertension) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by <BR/>involuntary contractures of muscles and associated especially with brain disorders such as epilepsy).<BR/>Record review of Resident #62's last MDS was a quarterly completed on 02 23 2023 with a BIMS of 99 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #62 was also marked in section K0510 Nutritional Approach as B. Feeding Tube while a resident. <BR/>Record review of physician order's active dated 3/8/23 revealed Levetiracetam solution 100 MG/ML Give 10 ml via G Tube two times a day related to conversion disorder with seizures or convulsions.<BR/>Record review of Resident #62's care plan with an quarterly dated of 02 23 2023 revealed the following:Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 07 07 2022<BR/>During an observation on 03 28 2023 at 4:42 PM, RN A stopped Resident #62's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did <BR/>not palpate Resident #62's stomach. RN A used 60 cc syringe, then installed 30 cc of air via G Tube without using the stethoscope to auscultate for placement and did not flush with water before administering medication. RN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's G Tube and flushed with 30 cc of water.<BR/>During an interview with RN A on 03/29/23 at 8:50 AM regarding checking GTube placement and flushing Resident #78 and Resident # 62's GT before medication administration, he said , he checked G tube placement during his initial rounds for breath sound and he always flush G Tube with water after medication administration, RN A said not checking for placement could cause aspiration pneumonia, bloating and being too full. Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON.<BR/> Record review of RN A's personnel file revealed date of hire was 2/24/21 and document regarding his training on medication was on 10/15/22. <BR/>Record review of enteral feed order schedule for [DATE], every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding ,or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift <BR/>flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency.<BR/>Resident #8<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations acute and chronic respiratory failure with hypoxia,( a serious condition that makes it difficult to breathe on your own, the lungs can't get enough) oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy), ` <BR/>Record review of Resident #8's last MDS was a quarterly completed on 02 24 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #8 was also marked in section K0510 Nutritional Approach as B. Feeding Tube while a resident. <BR/> Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML,Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable with status epilepticus.<BR/>Record review of Resident #8's care plan with a quarterly dated of 02 24 2023 revealed the following Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 06 03 2023<BR/>During an observation on 03 29 2023 at 9:38 AM LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A verified placement of the feeding tube. LVN A palpated Resident #8's stomach. LVN A used 60 cc syringe, then plunged 60 cc of water via G Tube without allowing water flow via gravity before administering medication. LVN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 13 cc <BR/>and diluted with 10 cc of water and administered via Resident #8's G Tube and flushed with 10 cc of water.<BR/>During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician and also plunging 60mls of water via G Tube before administering medication. LVN A said she would double check medication before administering. She said she did know that plunging water with the syringe via G Tube was wrong. She further stated she always used the syringe to plunge water via G Tube from that state she used to work and she was corrected by the unit manager <BR/>on 3/29/23 to let the water flow by gravity. LVN A said she had training for medication administration.<BR/>Record review of enteral feed order schedule for [DATE] had every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift <BR/>flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency.<BR/>Record review of LVN A's personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 .<BR/>During an interview on 03/30/23 at 01:40 PM, the DON reported that a feeding tube should be verified with a stethoscope and that a staff <BR/>member should listen to gurgling. The DON reported that if you do not verify that a feeding <BR/>tube is in the right place then a resident could receive a feeding or medication that could result <BR/>in infection, bloating, or discomfort. The DON verified that the two policies provided were what <BR/>the facility had for feeding tube administration and that they did have a policy specific on verifying feeding tube placement. <BR/>Record review of facility provided policy titled Flushing a Feeding Tube revised 2021, revealed the following: Policy Explanation and compliance Guidelines: <BR/>9. Prior to flushing the feeding tube, the administration of medication or providing tube <BR/>feedings, the nurse verifies the proper placement <BR/>by noting the length of the tubing or performing a measure of the PH of gastric secretions , if performed in the facility. <BR/>10. After tube placement has been verified, flush the tube utilizing the 60 ml, catheter tip syringe with the prescribed amount of water every four(4) hours, before and after feedings and medications or as directed by the physician. Allow medications to flow down the medication syringe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication <BR/>error rate was not five percent (%) or greater. The facility had a medication error rate of 7%, based <BR/>on 3 errors out of 38 opportunities, which involved 3 of 11 residents (Resident #8, #62, and <BR/>#78) reviewed for medication administration.<BR/>LVN A did not administer Resident #8's Levetiracetam medication ( medication used to <BR/>treat seizures epilepsy , is classified as anticonvulsants) according to Physician orders<BR/>RN A did not administer Resident #62's Levetiracetam medication ( medication used to treat seizures epilepsy , is classified as anticonvulsants)) according to Physician orders.<BR/>RN A did not administer the prescribed amount of Senna syrup ( a laxative medication) to Resident # 78 according to Physician orders.<BR/>These failures could place residents at risk of inadequate therapeutic outcomes and a decline in health. <BR/>Findings included:<BR/>Resident #78<BR/>Record review of the face sheet dated 3 30 2023 revealed Resident #78 was a [AGE] year old male resident admitted to the facility on 04 07 2022, and was re admitted on [DATE] with diagnoses <BR/>to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to <BR/>understand or express speech caused by brain <BR/>damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain <BR/>disorders such as epilepsy). <BR/>Record review of physician order's dated 2/8/23 revealed Senna syrup 5 ml Solution .Give 5 ml via G Tube two times a day related to constipation.<BR/>During an observation on 03 28 2023 at 4:28 AM,RN A stopped Resident #78's enteral feeding to <BR/>start his medication administration. RN A did not flushed with water before administering medication. RN A <BR/>picked up the following medication bottle and poured in the medication cups. Poured 7 cc of Senna Syrup in a cup and diluted with 10 cc Of water.<BR/> RN A then poured each medication into the GTube without flushing with water in between medication administration.<BR/>Resident # 62<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include <BR/>pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential <BR/>(primary) hypertension) dysphagia; <BR/>oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia, <BR/>(loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such as epilepsy),<BR/> Record review of physician order's active dated <BR/>3/8/23 revealed Levetiracetam Solution 100 <BR/>MG/ML. Give 10 ml via G Tube two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS.<BR/>During an observation on 03 28 2023 at 4:42 PM,RN A stopped Resident #62's enteral feeding to start his medication administration. RN A picked up the following medication bottle poured in the medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's GTube and flushed with 30 mls of water. ( instead of Levetiracetam Solution 10 ml as ordered by physician)<BR/>During an interview with RN A on 03/29/23 at 8:50 AM, he always flush G <BR/>Tube with water after medication administration, <BR/>Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam Solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON.<BR/> Record review of RN A's personnel file revealed <BR/>date of hired was 2/24/21 and document regarding his training on medication was on 10/15/22 <BR/>Resident #8<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness <BR/>that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health <BR/>disorder that is marked by a combination of <BR/>schizophrenia symptoms such as hallucinations <BR/>acute and chronic respiratory failure with hypoxia, ( a serious condition that makes it <BR/>difficult to breathe on your own, the lungs can't get enough oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular <BR/>movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such <BR/>as epilepsy). <BR/>Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML<BR/>Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and <BR/>epileptic syndromes with complex partial seizures, not intractable with status epilepticus.<BR/>During an observation on 03 29 2023 at 9:38 AM, <BR/>LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A picked up the following medication bottle poured in the <BR/>medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 13 cc and diluted with 10 cc of water and administered via Resident #8's GTube and flushed with 10 cc of water.<BR/>During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician LVN A said she would double check medication before administering. <BR/> Record review of LVN A personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 .<BR/>During an interview on 3/30/23 at 1:40 PM, the DON said nursing staff were to identify the resident's name, medication and to compare the information on the MAR when a medication is prepared, give medication as ordered by the physician. She said she would be in servicing the <BR/>nursing staff on medication administration.<BR/>Record review of facility provided policy titled Medication Administration Via Enteral Tube revised 2022, revealed the following: Policy : It is <BR/>the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . <BR/>9. Procedure: <BR/>j. Dilute the solid or liquid medication as <BR/>appropriate and administer using a clean oral syringe( &gt; 30 mL in size).<BR/>k. Flush tube again with at least 15 mL water taking into account resident's volume status<BR/>l. Repeat with the next medication ( if appropriate)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication <BR/>error rate was not five percent (%) or greater. The facility had a medication error rate of 7%, based <BR/>on 3 errors out of 38 opportunities, which involved 3 of 11 residents (Resident #8, #62, and <BR/>#78) reviewed for medication administration.<BR/>LVN A did not administer Resident #8's Levetiracetam medication ( medication used to <BR/>treat seizures epilepsy , is classified as anticonvulsants) according to Physician orders<BR/>RN A did not administer Resident #62's Levetiracetam medication ( medication used to treat seizures epilepsy , is classified as anticonvulsants)) according to Physician orders.<BR/>RN A did not administer the prescribed amount of Senna syrup ( a laxative medication) to Resident # 78 according to Physician orders.<BR/>These failures could place residents at risk of inadequate therapeutic outcomes and a decline in health. <BR/>Findings included:<BR/>Resident #78<BR/>Record review of the face sheet dated 3 30 2023 revealed Resident #78 was a [AGE] year old male resident admitted to the facility on 04 07 2022, and was re admitted on [DATE] with diagnoses <BR/>to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to <BR/>understand or express speech caused by brain <BR/>damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain <BR/>disorders such as epilepsy). <BR/>Record review of physician order's dated 2/8/23 revealed Senna syrup 5 ml Solution .Give 5 ml via G Tube two times a day related to constipation.<BR/>During an observation on 03 28 2023 at 4:28 AM,RN A stopped Resident #78's enteral feeding to <BR/>start his medication administration. RN A did not flushed with water before administering medication. RN A <BR/>picked up the following medication bottle and poured in the medication cups. Poured 7 cc of Senna Syrup in a cup and diluted with 10 cc Of water.<BR/> RN A then poured each medication into the GTube without flushing with water in between medication administration.<BR/>Resident # 62<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include <BR/>pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential <BR/>(primary) hypertension) dysphagia; <BR/>oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia, <BR/>(loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such as epilepsy),<BR/> Record review of physician order's active dated <BR/>3/8/23 revealed Levetiracetam Solution 100 <BR/>MG/ML. Give 10 ml via G Tube two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS.<BR/>During an observation on 03 28 2023 at 4:42 PM,RN A stopped Resident #62's enteral feeding to start his medication administration. RN A picked up the following medication bottle poured in the medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's GTube and flushed with 30 mls of water. ( instead of Levetiracetam Solution 10 ml as ordered by physician)<BR/>During an interview with RN A on 03/29/23 at 8:50 AM, he always flush G <BR/>Tube with water after medication administration, <BR/>Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam Solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON.<BR/> Record review of RN A's personnel file revealed <BR/>date of hired was 2/24/21 and document regarding his training on medication was on 10/15/22 <BR/>Resident #8<BR/>Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness <BR/>that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health <BR/>disorder that is marked by a combination of <BR/>schizophrenia symptoms such as hallucinations <BR/>acute and chronic respiratory failure with hypoxia, ( a serious condition that makes it <BR/>difficult to breathe on your own, the lungs can't get enough oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems <BR/>occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and <BR/>convulsions (a sudden, violent, irregular <BR/>movement of a limb or of the body, caused by involuntary contractures of muscles and <BR/>associated especially with brain disorders such <BR/>as epilepsy). <BR/>Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML<BR/>Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and <BR/>epileptic syndromes with complex partial seizures, not intractable with status epilepticus.<BR/>During an observation on 03 29 2023 at 9:38 AM, <BR/>LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A picked up the following medication bottle poured in the <BR/>medication cup:<BR/> Levetiracetam Solution 100 MG/ML poured 13 cc and diluted with 10 cc of water and administered via Resident #8's GTube and flushed with 10 cc of water.<BR/>During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician LVN A said she would double check medication before administering. <BR/> Record review of LVN A personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 .<BR/>During an interview on 3/30/23 at 1:40 PM, the DON said nursing staff were to identify the resident's name, medication and to compare the information on the MAR when a medication is prepared, give medication as ordered by the physician. She said she would be in servicing the <BR/>nursing staff on medication administration.<BR/>Record review of facility provided policy titled Medication Administration Via Enteral Tube revised 2022, revealed the following: Policy : It is <BR/>the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . <BR/>9. Procedure: <BR/>j. Dilute the solid or liquid medication as <BR/>appropriate and administer using a clean oral syringe( &gt; 30 mL in size).<BR/>k. Flush tube again with at least 15 mL water taking into account resident's volume status<BR/>l. Repeat with the next medication ( if appropriate)

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of fifteen rooms (Resident #61's room) as evidenced by:<BR/>-Resident #61 had medication on top of bedside table and was unattended.<BR/>This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion.<BR/>The findings include:<BR/>Observation on 3/28/2023 at 10:20 a.m., on top of the Resident #61's bedside table a bottle of liquid medicine labeled Polyethylene Glycol 3350 milliliters (medication to treat constipation) and a bottle of pills labeled Bisacodyl 5 mg EC tablets (medication to treat constipation). Continued to monitor medications on the bedside table until 12:00 pm.<BR/>Observed on 3/28/23 at 12:00 p.m., LVN X walking out of Resident #61's room with two medications in her right hand. <BR/>Interviewed LVN X on 3/28/23 at 12:01 p.m., she stated no medications were to be in resident room without being locked and should have been placed in medication cart. She stated the reason medications are to be in the Medication cart are a residents could take too much medication, a confused resident could walk into the room and take medications that are not for them causing an adverse effect.<BR/>Interview on 3/28/23 at 12:11 p.m., LVN Z said he was responsible for the care of resident#61. He stated resident came from the hospital via EMS at 8:00 am and did not receive medications from EMS or see any medications on the bedside table. He reported residents are not allowed to have medications at bedside as there is a potential for overdose, other residents could possibly take the medications and become ill.<BR/>Interviewed on 3/28/23 CNA Z at 12:25 p.m., she stated she did not see any medications on Resident #61's bedside table. She stated she is aware that medications are not allowed in patient rooms as it is dangerous if the resident takes too much, or another resident takes medications that is not theirs.<BR/>Interviewed on 3/30/23 at 10:02 a.m., the Director of Nurses (DON), she stated she was made aware of medication at bedside on 3/28/23 not under lock and key for Resident#61. She stated it is important to have all medications under lock and key for safety, because the resident is not able to remember if they took medications or may take too much, also the nurses don't know what medication have been taken, and any resident wonder into room may take medication and could potentially have adverse reaction. <BR/>Interviewed on 3/30/23 at 10:30 a.m., the Administrator regarding medication found at bedside not under lock and key without staff being aware it was there. She stated medication should always be under lock and key for safety, so resident doesn't take wrong amount of medication, or taken by another resident. <BR/>Record review of the facility policy titled Medication Storage (Copyright 2022 The Compliance Store, LLC. All rights reserved. Page 1 of 2) read in part: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safer and sanitary enteral feeding process for five (Residents #1, #2, #3, #4, #5) of eleven residents reviewed for receiving enteral feeding via a pump. <BR/>The facility failed to clean enteral feeding pumps and poles, which were dirty on 07/11/23 for Residents #1, #2, #3, #4, #5.<BR/>This failure could affect the residents who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination, and possible infection.<BR/>Findings included :<BR/>Observations on 07/11/23 at 1:15 PM revealed Resident #1 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; and top and bottom of the pump.<BR/>Observations on 07/11/23 at 1:25 PM of Resident #2 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; and top and bottom of the pump.<BR/>Observations on 07/11/23 at 2:45 PM of Resident #3 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; and top and bottom of the pump.<BR/>Observations on 07/11/23 at 2:55 PM of Resident #4 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; and top and bottom of the pump.<BR/>Observations on 07/11/23 at 3:05 PM of Resident #5 in bed receiving active feeding via peg tube revealed a light cream-colored substance on the base of the pole, up and down the pole, and numerous splatter markings of a light cream-colored substance on the front, right and left side; and top and bottom of the pump.<BR/>Interview and observation on 7/12/2023 at 12:25 PM with the DON, of the condition of the enteral feeding pumps and poles of Residents #1, #2, #3, #4, and #5, the DON stated she was not aware nursing staff was not cleaning the pumps and poles of the residents as they should be. The DON stated she also had not noticed the poles and pumps for the residents being dirty and could clearly see they were dirty. The DON stated nursing staff was responsible for cleaning enteral feeding pumps and poles. The DON stated there was no scheduled cleaning for enteral feeding pumps and poles and for right now they should be cleaned when they needed it. She stated her expectation was for nursing to clean enteral feeding pumps and poles and to make sure they stayed clean. The DON stated the negative impact of dirty enteral pumps and poles could potentially cause infection and emotional distress and was a dignity issue. <BR/>Review of facility policy titled Cleaning and Disinfection of Resident-Care Equipment copyright 2022, revealed, Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control (CDC) recommendations in order to break the chain of infection, 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: c. Direct care staff are responsible for cleaning resident equipment when visibly soiled, and according to routine schedule (where applicable)

Based on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.<BR/>1. <BR/>The facility failed to maintain proper temperature for leftover food from the breakfast tray line serving cart. <BR/>2. <BR/>The facility failed to ensure frozen food was safely thawed.<BR/>These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. <BR/>Findings Included:<BR/>Observation and record temperature of the facility's food saved from the breakfast tray line serving cart on 05/05/24 at 1:15 PM revealed it was below the recommended temperature.<BR/>During the observation dietary cook A took food temperature. Temperature of food taken were as follow:<BR/>1. <BR/>A plastic bag of Scrambled eggs stored in the refrigerator since 8:00 AM with a temperature of 72 degrees Fahrenheit.<BR/>2. <BR/>A plastic bag of Hard-Boiled Eggs stored in the refrigerator since 8:00 AM with a temperature of 49.2 degrees Fahrenheit.<BR/>Observation of the facility Kitchen on 05/06/24 at 8:05 AM revealed a pan of frozen Pork Chops and a pan of frozen cubed pork immersed in stagnant water in the sink. The temperature of the pork chops was 69.1- and 64.2-degrees Fahrenheit. The temperature of the pork cubes was 48 degrees Fahrenheit. The temperature of the water was 75.6 degrees Fahrenheit.<BR/>Interview with the Dietary Food Service Manager on 05/06/24 at 8:25 AM she stated that she is responsible in making sure that proper food temperature is always maintained. The food temperature was in the danger zone' indicating bacteria and other foodborne pathogen can grow quickly in the temperature - The Danger Zone' was 41 to 135 degrees Fahrenheit. Proper holding temperature of food is critical for resident safety and wellness. <BR/>During observation and interview with the Dietary Food Service Manager on 05/06/24 at 8:30 AM she stated that frozen food must be thawed the proper way to make sure that the proper temperature is always maintained to prevent/minimize food temperature at the danger zone.<BR/>Record review of the facility's policies and procedures for Cooling and heating Foods dated 10/01/18 read in part 1.Cooling Foods: Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees Fahrenheit or below with in six hours or less.<BR/> All foods are stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods are maintained at 140 degrees Fahrenheit or higher and cold foods are maintained at 40 degrees Fahrenheit or below. At point of service.<BR/>Record review of the facility's policies and procedures for Food Preparation & Handling dated 05/10/18 read in part .Foods may also be thawed using the following procedures: 1. Completely submerged under cold potable running water (less than 70 degrees Fahrenheit) with sufficient water velocity to agitate and float off loosened food particles into overflow. b. For a period that does not allow thawed portions of a raw animal food requiring cooking to be above 41 degrees Fahrenheit for more than 4 hours including the time the food is exposed to the running water and the time needed for preparation for cooking.<BR/> <BR/>

Based on observation, interview, and record review the facility failed to protect the personal and medical records of residents reviewed for privacy and confidentiality in that:<BR/>On 06/11/25 MA B was not at her medication cart when her computer screen was showing numerous profiles on the computer screen of resident's pictures.<BR/>This failure placed residents at risk of breach in confidentiality of medical information.<BR/>Findings:<BR/>Observation on 06/11/25 at 10:43AM revealed MA B left her computer open with resident records easily accessible showing their photo and names.<BR/>In an interview on 06/11/25 at 10:44AM MA B said she had forgotten to lock her computer when she walked away from it to go to the medication room to check for a medication. MA B said she should not have done that because it placed the resident at risk for their medical records being exposed to the public. MA B said this was a HIPAA violation. MA B said she had received in-service on protecting the residents' medical records and that she did not mean to leave her computer unlocked. <BR/>In an interview on 06/11/25 at 3:15PM the Administrator regarding HIPPA said the staff needed to always protect resident medical records. The Administrator said when a staff did not always protect a resident's medical record, it placed the resident at risk of their privacy being invaded.<BR/>Record review of the facility policy on Confidentiality of Personal and Medical Records copyright 2022 reflected in part:<BR/> .This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's record regardless of the form of storage or location of the record . keep confidential is defined as safeguarding the content of information including written documentation, video. Audio, or other computer stored information from unauthorized disclosures without the consent of the individual and/or the individual surrogate or representative .