Based on observations, record reviews and interviews, the facility failed to follow the plan of care for 1 of 2 residents sampled for pressure injuries. (Resident #36) The findings include: On 5/19/25, Resident #36 was observed lying in bed. There was no low air loss mattress in use. Further observations on 5/20/25 at 1:24 PM and 3:32 PM as well as on 5/21/25 at 8:45 AM and again at 11:40 AM revealed Resident #36 lying in bed with no low air loss mattress in use. On 5/20/25, a record review was conducted for Resident #36. The care plan, revised last on 7/1/24, contained skin impairment interventions which included the use of a low air loss mattress. (photographic evidence obtained). A review of the orders showed no physician orders for a low air loss mattress. On 05/21/25 at 09:49 AM, an interview with the Director of Nursing (DON) was conducted. The DON was asked who is responsible for ensuring care plans are implemented. The DON stated that Minimum Data Set nurses and clinical managers follow up on this. The DON stated the resident had been on a low air loss mattress but it was removed for cleaning and has not been placed back on the bed yet and acknowledged it was not on the bed at this time. On 5/21/25 at 10:01 AM, the Central Supply staff checked the mattress and stated it was a regular mattress.

Based on observations and interviews, the facility failed to maintain 2 of 3 garbage dumpsters located behind the facility for waste managment. The findings include: On 5/19/2025 at approximately 10:40 AM, an observation was made of the 3 dumpsters located to the rear of the facility. This observation revealed that dumpster #1 was without a door on the side to secure the waste located inside the dumpster, which could lead to pests having access to the waste. Dumpster #3 was noted to have a rusted hole area to the right lower front corner. (Photographic evidence obtained) The Registered Dietician was interviewed during these observations. She indicated that she was unaware of how long the dumpsters had been in this condition. On 5/19/25 at approximately 10:58 AM, an interview was conducted with the Administrator, who indicated that she noted the door missing off the garbage dumpster last summer and had contacted the waste managment company, whom she did not get a reply from. The Administrator indicated that she would contact the waste management company to have the dumpsters replaced.

Based on observations and interviews, the facility failed to maintain linens in good condition. The findings include: On 02/26/24 at approximately 2:17 PM, Resident #218 was observed with a large hole in the linens as the resident was resting in bed (photo evidence obtained). When asked abouth this, Resident #218 stated that the staff had recently changed her linens. On 02/27/24 at approximately 1:07 PM, Resident #218 was observed in bed eating lunch. During this observation, it wass noted that the bottom sheet had a large hole in the upper corner. In an interview on 02/28/24 at approximately 8:31 AM, Staff D, a Certified Nusing Assistant, was asked what is their process if they find sheets that are ripped or have holes. She stated that the facility is supposed to throw those out, so she sets it aside and sends it back to laundry. On 02/28/24 at approximately 11:40 AM, a clean bottom fitted sheet was pulled from two different clean linen carts down the 400 hallway. Both sheets were observed to have large holes in the corners. (photo evidence obtained) On 02/28/24 at approximately 11:45 AM in an interview, the Director of Nursing stated they are always checking linen and she was surprised that they had any with holes. On 02/28/24 at approximately 11:52 AM, the Administrator confirmed in an interview that they should not have linens with holes on the beds and they will be completing an overall inventory.

Based on observation, interview, and policy review, the facility failed to secure medications for 1 of 8 residents reviewed. (Resident #54). The findings include: On 2/27/24, an observation was made of Resident #54's room. The resident was lying on their right side, facing away from the door, with a cup of unidentified medications sitting on the residents over the bed table in a medication administration cup. Resident #54 stated the nurse just left them there. (Photographic evidence obtained) On 2/27/24 at approximately 10:25 am, an interview was conducted with Nurse A, a Licensed Practical Nurse, who confirmed the medications on the over the bed table were Resident #54's morning medications. Nurse A stated she left the medications because she needed to get the resident a protein drink and bring it back to the resident. Nurse A went on to state that she was trying to finish up another resident's medications then she was coming back to Resident #54. Nurse A confirmed she should not leave the medications on the over the bed table and should stay with the resident while they took their medications. On 2/27/24 at approximately 10:30 am, an interview was conducted with the Director of Nursing, who indicated her expectation of nurses to stay with the residents and watch them take their medications and to not leave them on the over the bed table. Review of facility policy titled Administration of Drugs, dated October 2019, stated Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Under Policy Interpretation and Implementation: 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. 9. The nurse administering the drug must record such information on the resident's EMAR before administering the next resident's drugs.

Based on observations, interview and record review, the facility failed to maintain infection control practice for 1 of 4 residents observed during medication administration observations. (Resident #60) The findings include: On 2/29/24 at approximately 9:17 am, an observation was made of medication administration to Resident #60 by Nurse B, a Licensed Practical Nurse. Nurse B entered the room to administer medications but did not place a barrier between the medication inhaler for Budesonide-Formoterol Fumarate Aerosol 165-4.5 micrograms (MCG), (a sterodial inhaled medication used to control Chronic obstructive pulmonary disease) and the resident's over the bed table. After the medication was administered, Nurse B returned the inhaler to the medication cart. On 2/29/24 at approximately 9:20 am, an interview was conducted with Nurse B, who indicated that she did not place a barrier between the inhaler and the over the bed table. Nurse B acknowledged that this was an infection control issue. On 2/29/24 at approximately 10:00 am, an interview was conducted with the Director of Clinical Services, who stated his expectation was for the nurse to place a barrier between medications and the over the bed table for infection control. A review of the facility policy titled Administration of Drugs, dated October 2019, indicated, Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director . Policy Interpretation and Implementation: 18. Ensure all infection control practices are followed during the administration of medications (i.e.: using a barrier for multidose medications, cleaning of equipment/tools between residents, hand hygiene, exterior handling of containers, etc.).