**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to ensure care plan interventions were implemented for one resident (#6) of three sampled residents related to positioning during enteral nutrition administration.Findings included:Review of Resident #6's care plan revised on 07/25/2025 revealed Resident #6 required tube feeding related to dysphagia. The goal was for the resident to remain free of side effects or complications related to tube feeding through the review date. Interventions included: Resident #6 needs head of bed (HOB) elevated 45 degrees during and thirty minutes after tube feed. On 7/28/25 at 2:00 p.m. Resident #6 was observed in his room lying on his bed with the head of the bed (HOB) elevated approximately 30 degrees as his enteral nutrition pump was administering his tube feeding. On 7/29/25 at 9:10 a.m. Resident #6 was observed in his bed with his eyes closed and his HOB elevated less than 45 degrees as his enteral nutrition pump was administering his tube feeding. On 7/30/25 at 8:20 a.m. Resident #6 was observed in his bed with his eyes closed and his HOB elevated less than 45 degrees as his enteral nutrition pump was administering his tube feeding. Review of Resident #6's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include: unspecified protein calorie malnutrition, dysphagia, oropharyngeal phase, aphasia, cognitive communication deficit, gastrostomy status and need for assistance with personal care. Review of Resident #6's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out 15 indicating moderately impaired cognition. On 7/30/25 at 4:45 p.m. during an interview with Staff B, Licensed Practical Nurse (LPN), he stated the HOB needs to be between 30 and 45 degrees. Staff B, LPN says the Certified Nursing Assistants (CNAs) know to keep the HOB 30 to 45 degrees. On 7/30/25 at 5:00 p.m. an interview was conducted with Staff R, CNA. Staff R, CNA stated they keep the HOB elevated for residents receiving enteral tube feedings. Staff R, CAN stated the head needs to be higher than the feet. On 7/31/25 at 9:40 a.m., an interview was conducted with the Clinical Unit Manager who stated the practice is to keep the HOB elevated during enteral tube feedings but admitted she was unable to verbalize the policy regarding how many degrees. During an interview on 7/31/25 at 10:00 a.m. with Staff C, LPN, Staff C stated the HOB needs to be between 30 and 90 degrees when residents are receiving enteral tube feedings and that the CNAs are educated on the practice. On 7/31/25 at 2:40 p.m. an interview was conducted with MDS Coordinators, Staff D and Staff E. Staff D stated some residents with gastrostomy tubes may be care planned for 45 degrees. Staff D and Staff E reviewed Resident #6's care plan and physician orders and confirmed there were no orders for HOB degree positioning. They stated they would contact the physician. Review of the facility policy titled Enteral Tube Feeding via Continuous Pump revised November 2018 revealed: PurposeThe purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings Steps in the Procedure.4. Position the head of the bed at 30 to 45 degrees (semi-Fowler's position) for feeding, unless medically contraindicated.Review of a facility's policy titled Care Plans, Comprehensive Person-Centered revised on March 2022 showed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan:.e. reflects currently recognized standards of practice for problem areas and conditions. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to assist with the placement of hearing aids for one resident (#17) out of one resident sampled. Findings Included: During an interview on 07/28/2025 at 10:21 a.m. Resident #17 stated You will have to come closer and speak louder, I don't have my hearing aids in, so I can't hear you. I don't know where my hearing aids are you will have to check with my son. Resident #17 was observed to not have hearing aids in during the interview.During a phone interview on 07/29/2025 at 1:08 p.m., Resident #17's Family Member (FM) stated he has spoken with the facility a few times about helping his mom with her hearing aids. He stated they always forget to charge them so she can't use them. We have family who want to call and talk with her, but if she does not have her hearing aids in, she cannot use the phone. I have to remind them to put them on the charger for her. They called me last week because her hearing aids broke. I came and picked them up last week and dropped them off to be fixed on 07/28/2025.Review of Resident #17 admission record revealed an admission date of 06/28/2025. Diagnoses included pneumonia, unspecified organism, and adjustment disorder with other symptoms.Review of Resident #17's admission Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 12 out of 15 showing intact cognition.Review of Resident #17's physician orders revealed:A start date of 07/03/2025, put bilateral hearing aids on in am (morning) and take off at night and place on charger. One time a day and at bedtime.Review of Resident #17's Treatment Administration Report (TAR) revealed Resident#17's hearings aids were marked as being on for 07/28/2025 and 07/29/2025.Review of Resident #17's Care Plan dated 06/30/2025 revealed:Focus:Resident #17 has a communication problem related to hearing deficit.Goal:Resident #17 will be able to make basic needs known on a daily basis through the review date.Interventions:.put bilateral hearing(sic) on in am and take off at night and place on charger.During an interview on 07/30/2025 at 11:59 a.m., Staff X, Certified Nursing Assistant (CNA), stated Resident #17 does not have any issues with hearing. I have not seen her with hearing aids today. The nurses are responsible for putting in and taking out the hearing aids.During an interview on 07/30/2025 at 12:07 p.m., Staff U, Licensed Practical Nurse (LPN) stated Resident #17 does where hearing aids and she has them in today. Resident #17 has had them in all week. The nurses are responsible for helping her with the hearing aids. We document on the TAR (treatment administration record) when she has them in. She was not aware of any concerns with Resident #17's hearing aids being broken and her son having to come and pick them up last week.During an interview on 07/03/2025 at 1:00 p.m., Staff I, LPN, Nurse Manger stated Resident #17 can't hear if she does not have her hearing aids. There are orders to put in her hearing aids and to put them on the charger at night. The nurses are responsible for helping her with her hearing aids. The nurses document the use of hearing aids on the TAR. If Resident #17 does not have her hearing aids in they should be documenting no or off.During an interview on 07/30/2025 at 2:08 p.m., the Director of Nursing (DON) stated Resident #17's family had spoken with them when she first admitted to the facility about putting in her hearing aids. She stated that is why she asked them to add it to the Kardex, so they could remember to place them on the charger at night. I don't think it should have been an order. They should be documenting appropriately whether Resident #17 has her hearing aids in or not.Review of the facility's policy, titled Hearing Aid, Care of, with a revision date of February 2018 revealed, Purpose The purpose of this procedure is to maintain the resident's hearing at the highest attainable level.General Guidelines,Checking the Batteries:1. If the hearing aid is not functioning properly, check the battery.Placement of the Hearing Aid1. Turn the hearing aid off and the volume all the way down before placing the hearing aid into the ear.2. The hearing aid should fit securely, but comfortably, into the ear.Documentation:The following information should be recorded in the resident's medical record:1. The date and time the hearing aid was checked and/or battery was replaced.2. The name and title of the individual(s) who checked the hearing aid and changed the battery.3. If the resident refused the procedure, the reason(s) why and the intervention taken.4. The signature and title of the person recording the data.Review of the facility's policy titled Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed,Policy StatementResidents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:. e. communication (speech, language, and any functional communication systems).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to accurately assess and notify the physician related to resident's pain and ineffectiveness of the prescribed pain medication for one resident (#38) of two sampled residents.Findings included:On 07/28/25 at 3:30 p.m. Resident #38 was observed sitting in the wheelchair in the resident's room. Resident #38 stated staff would not give acetaminophen because they had already given the resident something (for pain). Resident #38 reported a jabbing pain. The observation revealed a wound dressing to the left lower extremity.Review of Resident #38s admission Record showed the resident was admitted on [DATE] with a primary diagnosis of unspecified peripheral vascular disease. The resident's diagnoses included but not limited to cellulitis of left lower limb, unspecified systemic lupus erythematosus, unspecified site unspecified osteoarthritis, and cervical region spinal stenosis. Review of Resident #38's Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 14 of 15 indicating an intact cognitive status. The assessment revealed the resident had pain in the five days prior to the assessment, had not limited the resident's sleeping, rehabilitation therapy or day-to-day activities. The resident rated the worst pain felt was 8 of 10, 10 being the worst. On 07/30/25 at 1:28 p.m. Resident #38 explained (pronoun) was not getting pain medication on time and not wanting the prescribed opioid and they were making the resident suffer and wait. The resident reported telling staff of not wanting the prescribed opioid and asked why did they make (pronoun) suffer, the prescribed opioid did not work, and the alternative was 650 milligrams of acetaminophen. The resident stated therapy was going slow. An interview was conducted with Resident #38's assigned nurse Staff M, Licensed Practical Nurse (LPN) on 07/30/25 at 2:39 p.m. The staff member reported giving the (pain) medication to residents to see if the pain medication really wasn't working, then contacted the physician to let them know the pain medication isn't working. Staff M then reported an assessment was done to determine if pain medication was not working. Staff M, LPN stated Resident #38 had informed (pronoun) yesterday the opioid was not working, Staff M had contacted the physician and was waiting for a response and had not followed up on it. Staff M, LPN stated the residents pain scale assessments can be done whenever during the shift and always rates the pain a 1 (out of 10) since everyone has pain. An interview was conducted with Staff M, LPN on 07/30/25 at 2:55 p.m. Staff M, LPN stated (pronoun) the text message to the physician never went through regarding Resident #38's pain medication not working. Review of Resident #38's July Medication Administration Record (MAR) Resident #38's pain level related to the administration of Tramadol on 07/29/25 at 8:20 a.m. was a 7 and effective according to Staff M's documentation despite the staff member reporting Resident #38 had voiced the Tramadol was not working. Resident #38 did not receive any doses of acetaminophen on 07/29/25. Resident #38 had received another daily dose of Tramadol on 07/29/25 at 10:33 p.m. The MAR showed Resident #38 had not received any pain medication on 07/30/25. The MAR revealed no non-pharmacological interventions had been attempted with the resident. Review of Resident #38s care plan showed the resident was at risk for experiencing pain related to (r/t) osteoarthritis, spinal stenosis, (and) lupus. The associated interventions included:- Administer pain medication as per orders, give 1/ 2 hour before treatments or care as needed, initiated 7/14/25.- Encourage resident to report pain, initiated 7/14/25.- Monitor/ record/ report to nurse resident complaints of pain or request for pain treatment, initiated 7/14/25.- Notify physician if interventions are unsuccessful or if current compliant is a significant change from residents past experience of pain, initiated 7/14/25.- Provide non pharmaceutical pain interventions as indicated: repositioning, back rub, offer food/ drink, music, and adjust lighting/ temperature in room, initiated 7/14/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure timely administration of medications, as prescribed by the medical provider, and did not ensure medications were administered by a medical professional for one Resident (#106) out of one resident reviewed. The facility also failed to administer scheduled psychotropic medication per physician orders for one resident (#110) out of five medication administration observations. Findings included: 1. On 07/28/25 at 2:35 p.m., an interview was conducted with Resident #106 and their family member. Resident #106 stated to speak with their family member due to them being able to, Speak faster and hear better. Resident #106 and the family member expressed the resident was not being administered blood pressure (BP) medications on a timely basis. Resident #106's family member explained Resident #106 had many issues with BP being high and had a systolic reading of 200 multiple times. The family member said Resident #106 is supposed to be provided Losartan 50 milligrams (MG) twice a day, as needed, anytime the residents had a systolic BP of 160 or greater. Resident #106's family member said they had given their personal prescription of hydralazine to Resident #106 whenever the resident's systolic BP was over 170. Resident #106's family member said they sometimes wait over an hour for the resident's medications to be administered. A review of documentation provided by the family member revealed a recent recording of a BP of 217/91 and then provided a dose of hydralazine. On 07/28/25 at 2:55 p.m., a follow-up interview was conducted with Resident #106 and family member. The family member said Resident #106's medications are to be administered every 6 hours but will self-administer the resident's hydralazine after it has been one in a half to two hours after the medications are passed due. The family member said Resident #106 is given hydralazine from previously prescribed medications. The family member said the nursing staff know Resident #106 is being provided the self-administered hydralazine. The family member stated, when they come late to give the medications, I tell them I gave it to the resident half an hour ago and not to give the resident a second dose. The family member confirmed the nursing staff has advised the family member not to do that, but the family member tells them they should have been on time with administering Resident #106's medications. A review of Resident #106's admission Record revealed an admission date of 07/22/2025 with diagnoses of muscle weakness, hyperlipidemia, hypothyroidism, chronic pain and difficulty in walking.A review of Resident #106's quarterly Minimum Data Set (MDS) assessment, dated 07/29/25, in section C - Cognitive Patterns revealed a Brief Interview for Mental Score (BIMS) of 14 out of 15, indicating the resident is cognitively intact. On 07/28/25 at 3:00 p.m., an interview with Staff I, Unit Manager (UM) was conducted and she said she does not know of any residents who self-administer medications. She stated none of the residents on her unit have been evaluated to self-administer medications. On 07/28/25 at 3:15 p.m., an interview with the Director of Nursing (DON) was conducted and she said she was not aware of Resident #106's family member self-administering medications due to late medication administration. On 07/28/25 at 3:25 p.m. an interview with the DON was conducted and she said she talked to Resident #106's family member who confirmed giving extra doses of hydralazine. She said the family member confirmed he made staff aware of him self-administering the medication and has asked for the BP monitoring to be changed from six hours to four hours daily. The DON said they reached out to Resident #106's physician to see if the order can be changed. She said she expected the nursing staff to document when the physician is spoken with. A review of Resident #106's medical record did not reveal documentation related to notifying the physician of late administration of medications and the reasoning for the late administration of medications. A review of Resident #106's care plan revealed the following, [Resident #106], has altered cardiovascular status, dx [diagnosis] of hypertension, hyperlipidemia . The resident will be free from s/sx [signs and symptoms] of complications of cardiac problems through the review date. Administer medications as ordered by physician. Vital Signs as ordered. Notify physician of any abnormal readings. A review of Resident #106's physician orders revealed the following: - Vital signs to be checked every shift, with a start date of 07/22/25. - Losartan potassium 100 mg tablet (tab), give 1 tablet by mouth two times a day for hypertension (htn), with a start date of 07/22/25. - Propranolol 20 mg tablet, give 1 tablet by mouth two times a day for hypertension, with a start date of 07/22/25. - Hydralazine 25 mg tablet, give 1 tablet by mouth every 8 hours for hypertension hold for systolic blood pressure (SBP) less than 110, with a start date of 7/29/25. A review of Resident #106's Medication Administration Audit Report from 07/22/25 through 07/29/25 revealed the following administration times to include: -Losartan 50 MG, give one tablet by mouth two times a day for hypertension, with a set schedule time of 9:00 a.m. and 5:00 p.m. On 07/22/25 administered at 6:30 p.m. On 07/23/25 administered at 10:25 a.m. On 07/24/25 administered at 11:08 a.m. On 07/25/25 administered at 10:30 a.m. -Propranolol 20 MG, give one tablet by mouth two times a day for hypertension, with a set schedule time of 9:00 a.m. and 5:00 p.m. On 7/22/25 administered at 6:30 p.m. On 7/23/25 administered at 10:25 a.m. On 7/24/25 administered at 11:09 a.m. On 7/25/25 administered at 10:30 a.m. On 07/30/2025 at 4:28 p.m., an interview was conducted with the DON. The DON stated the provided medication administration times for Resident #106 were, not okay, and they needed to be provided within the hour. She stated, Anything more than an hour is considered late. The DON stated the expectations for late administered medications are, At least say something, talk to the resident or [family member] and let them know the status of the delay and notify the physician of the delay as well. The DON confirmed the reasoning for medications being late should be documented. A review of the facility's, Medication Administration policy, revised on 04/29/23 revealed the following, POLICY: To accurately prepare, administer, and document all medication administration. PROCEDURES: All residents will be assessed for safe self-administration is assessed to be unsafe [sic]. All medications will be administered as prescribed by the resident's Physician/Healthcare Provider and only by persons lawfully authorized to do so . If unable to administer the medications, initial E-MAR/[NAME] and circle initial document the reason in the medical record. 2. On 7/30/25 at approximately 9:00 a.m. an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of the staff member moving the medication cart from one side of the hallway to outside of Resident #110s room. The staff member placed a blue barrier on the cart and dispensed the following medications:-Omeprazole Delayed Release (DR) over the counter (OTC) 20 milligram (mg) tablet-Ducosate Sodium 100 mg OTC capsule-Loratadine 10 mg OTC tablet-Aspirin 81 mg Enteric Coated (EC) OTC tablet-Magnesium Oxide 400 mg OTC capsule-Clopidogrel 75 mg tablet-Gabapentin 600 mg caplet-Carvedilol 25 mg tablet-Metformin 500 mg tablet-Ferrex (poly Iron) 150 OTC capsuleStaff C entered the resident room and placed the medication cup containing the medications on the over bed table before entering the rooms bathroom to wash hands. Staff C administered the resident's medications then asked the resident if (pronoun) felt sad, the resident said no. Staff C spoke with resident regarding coming back later, returned to the medication cart, and documented Resident #110 had refused the antidepressant medication Sertraline. The staff member stated she had asked the resident if (pronoun) felt sad which the resident denied and that was how the staff member determined whether or not to give the medication.During the observation, Staff C did not ask the resident if (pronoun) wanted Sertraline and the resident did not voice a refusal of the medication.Review of Resident #110s July Medication Administration Record (MAR) revealed the order: Sertraline hydrochloride (HCl) Oral Tablet 50 milligram (mg) - Give 1 tablet by mouth one time a day for crying, isolating, sadness related to Major Depressive Disorder recurrent mild, Gradual Reduction Dose (GDR), started on 7/22/25. The MAR showed Staff C had documented on 7/30/25 the resident had exhibited no behaviors and 02 (Med Refused). The documentation from 7/22 - 7/31/25 revealed Sertraline had been administered daily (except for 7/30) and the resident had exhibited no behaviors.Review of Resident #110s progress notes on 7/30/25 at 11:47 a.m. revealed Staff C documented a medication administration note on 7/30/25 at 9:12 a.m. for the dose of Sertraline Resident refused medication. Not given.An interview was conducted with the Director of Nursing (DON) on 7/30/25 at 3:32 p.m. The DON was notified of Staff C stating and documenting Resident #110 had refused the medication Sertraline and she stated asking the resident if they were sad and not giving the medication was not appropriate, can't believe it. She stated the resident not feeling sad meant the medication was working.During an interview with a facility physician on 7/30/25 at 5:04 p.m. the physician stated missing one dose of Zoloft (Sertraline) could cause dizziness and nausea.Review of the policy - Medication Administration (NUR021PP) revised on 4/29/23, revealed To accurately prepare, administer, and document on medication administration. The procedure included All medications will be administered as prescribed by the resident's Physician/Healthcare Provider and only by persons lawfully authorized to do so. The following process will be followed for all refused medications:a. If unable to administer the medications, initial E-MAR/[NAME] and circle initial, document the reason in the medical record. b. If the resident refuses 2 doses then the nurse will notify MD and family.Review of Sertraline information located at https://medlineplus.gov/druginfo/meds/a697048.html, revealed Sertraline is a class of antidepressant called selective serotonin reuptake inhibitors (SSRIs) and used to treat depression and other mental health conditions. The information showed Do not stop taking sertraline without talking to your doctor. If you suddenly stop taking sertraline, you may experience withdrawal symptoms such as nausea, sweating, depression, mood changes, frenzied or abnormally excited mood, irritability, anxiety, confusion, dizziness, headache, tiredness, seizures, ringing in the ears, numbness or tingling in the arms, legs, hands, or feet, difficulty falling asleep or staying asleep.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an anti-anxiety medication had an appropriate indication for it's use for one resident (#10) out of five residents sampled.Findings included: During an observation on 07/29/2025 at 9:35 a.m., Resident #10 was observed in bed, eyes closed, dressed for the day. Review of Resident #10's admission Record revealed an admission date of 06/16/2025. Resident #10 was admitted to the facility with diagnosis to include Alzheimer's disease, unspecified, vascular dementia, moderate, with other behavioral disturbance, major depressive disorder, recurrent, unspecified severity, with other behavioral disturbance.Review of Resident #10's admission Minimum Data Set (MDS) dated [DATE] revealed Section N. Medications, Antipsychotic, Antianxiety, and Antidepressant.Review of Resident #10's physician orders revealed: A start date of 07/03/2025 for lorazepam oral tablet 0.5 milligrams (MG). Give one tablet by mouth every 12 hours related to Alzheimer's disease, unspecified.During an interview on 07/30/2025 at 12:02 p.m., Staff X, Certified Nursing Assistant (CNA) stated Resident #10 does not have any behaviors related to anxiety. She calls out to ask for help and is always looking for her husband. She does not have anxiety as far as she knows. During an interview on 07/30/2025 at 12:25 p.m., Staff T, Licensed Practical Nurse (LPN) stated when Resident #10 yells out, Resident #10 takes Ativan. Ativan is for anxiety. Alzheimer's is not an appropriate diagnosis for Ativan. During an interview on 07/30/2025 at 1:00 p.m., Staff I, LPN Nurse Manager, stated Ativan is for anxiety. Resident #10 screams and is always anxious. She reviewed Resident #10's order for Ativan and stated the diagnosis is Alzheimer's. That's how the orders came to them when she was admitted . Ativan is not normally prescribed for Alzheimer's. During an interview on 07/30/2025 at 2:51 p.m., the Director of Nursing (DON) stated the diagnosis for Resident #10's Ativan is Alzheimer and that is not appropriate. They reconcile residents' orders every day. They typically review newly admitted residents orders the day after they admit and would correct any errors. Review of the undated facility policy titled Psychotropic Medication Use revealed, Policy Statement Residents will not receive medications that are not clinically indicated to treat specific conditions. Policy Interpretation and Implementation, 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Antipsychotics; b. Antidepressants; c. Anti-anxiety medications; and d. Hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes a. Indications for use;.4. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.8. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident signs and symptoms to identify underlying causes. Resident evaluations 1. Situations which may prompt an evaluation or reevaluation of the resident include a. admission or re admission, b. It is clinically significant change in condition/status; c. A new, persistent, or recurrent clinically significant symptom or problem; d. A worsening of an existing problem or condition; e. An unexplained decline in function or cognition. A new medication order or renewal of orders; or g. irregularity identified in the pharmacist medication regimen review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete the Nursing Home Transfer and Discharge Notice, notify the receiving facility, and document a discharge summary for two residents (#98 and #8) out of two residents sampled.Findings included:1. Review of Resident #98's admission record revealed an admission date of 05/22/2025 and was discharged to an acute care hospital on [DATE]. Resident #98 was admitted to the facility with diagnosis to include nonrheumatic aortic (valve) stenosis, encounter for surgical aftercare following surgery on the nervous system, and acute on chronic diastolic (congestive) heart failure.Review of Resident #98's Nursing Home Transfer and Discharge Notice dated 05/29/2025 revealed Resident #98 was discharged to a hospital because Residents medical needs were unable to be met. The Physician/Designee Name and Signature were blank. The Resident or Representative Name and Signature were blank. The notice given to: resident, legal guardian or representative date was blank. The local Long Term Care Ombudsman Council date was blank and the resident clinical record date was blank.Review of Resident #98's medical record did not reveal a discharge summary or documentation of notification to the receiving facility for Resident #98's discharge on [DATE].2. Review of Resident #8's admission record revealed an initial admission date of 04/07/2025. Resident #8 was admitted to the facility with diagnosis to include traumatic subarachnoid hemorrhage without loss of consciousness, subsequent encounter, contusion and laceration of right cerebrum without loss of consciousness, subsequent encounter, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #8's change of condition dated 05/03/2025 revealed, outcome of physical assessment: fall. Primary care provider feedback: send to emergency room for eval (evaluation).Review of Resident #8's medical record revealed no discharge summary or documentation of notification to the receiving facility for Resident #8's discharge on [DATE].Review of Resident #8's Nursing Home Transfer and Discharge Notice dated 05/03/2025 revealed the Physician/Designee Name and Signature were blank. The Resident or Representative Name and Signature were blank. The notice given to: resident, legal guardian or representative date was blank. The local Long Term Care Ombudsman Council date was blank, and the resident clinical record date was blank.During an interview on 07/30/2025 at 12:08 p.m., Staff T, Licensed Practical Nurse (LPN) stated when a resident is being discharged to the hospital they complete a change of condition, get an order from the physician, and they send them out. She did not know what the Nursing Home Transfer and Discharge form was.During an interview on 07/30/2025 at 12:14 p.m., Staff U, LPN stated when a resident is being transferred to the hospital they get an order, complete a change of condition, and notify the hospital the resident is being discharged to them. She was not sure what the Nursing Home Transfer and Discharge form was.During an interview on 07/30/2025 at 2:18 p.m., Staff V, Medical Records, stated she is responsible for the Nursing Home Transfer and Discharge form when residents leave for the hospital. She sends the Nursing Home Transfer and Discharge form to the resident's representative by mail either the day after discharge or two to three days later. She includes a copy for them to keep and one for them to return to the facility at their earliest convenience. They are all kept in a binder in her office. I mail them and do nothing else with them.During an interview on 07/30/2025 at 3:41 p.m. Staff U, Social Services stated medical records is responsible for completing the Nursing Home Transfer and Discharge form and getting the resident or resident representative's signature. We do not get the physician signature for residents going to the hospital or going home.During an interview on 07/31/2025 at 10:22 a.m., the Director of Nursing (DON) stated we call and do report with the hospital when the resident is being discharged to the hospital. One of the hospitals asked for us to hold off calling and doing report because they are trying to get a better system for reporting. They just started this process, and she is reminding the nurses they should be documenting the discharge in the chart. Social Services and Medical Records are responsible for completing the Nursing Home Transfer and Discharge form.Review of the facility's policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, revealed, Policy StatementOnce admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) .3. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and our safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident, b. The resident's health improves sufficiently to allow more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days. 4. Notice of transfer is provided to the resident and representative as soon as practicable before the transfer into the long-term care (LTC) ombudsman when practicable (e. g., in a monthly list of residents that includes all notice content requirements) .7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Orientation for Transfer or Discharge (Emergent or Therapeutic Leave) 1. The resident is oriented towards and prepared for a facility-initiated transfer (e.g., hospital emergency room or therapeutic leave) when the resident is expected to return and for an emergency or immediate facility-initiated discharge where a complete discharge planning process is not practicable. 2. For an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: . c. Orient/prepare the resident for transfer; and d. Prepare for medical record transfer.5. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Information conveyed to receiving provider 1. Should a resident be transferred or discharged for any reason, the following information is communicated to the perceiving facility or provider. Documentation of Facility-Initiated Transfer or Discharge 1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: a. The basis for the transfer or discharge; 1) if the resident is being transferred to discharge because of his or her needs cannot be met at the facility, documentation will include: a) the specific resident needs that cannot be met; b) the facilities attempt to meet those needs; and c) the receiving facility services that are available to meet those needs; b. That an appropriate notice was provided to the resident and or legal representative, c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the residents' overall medical, physical, and mental condition; g. Disposition of personal effects; h. Disposition of medications; i. Others as appropriate or as necessary; and j. The signature of the person recording the data in the medical record. 2. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge is documented in the residence clinical record by the residence attending physician: a. The transfer or discharge is necessary for the resident's welfare, and the residence needs cannot be met in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide quality care and services related to wound care for three residents (#56, #58, #11) out of three sampled residents. Findings Included: 1. During an observation on 07/28/2025 at 12:23 p.m., Resident #56 was observed sitting in a wheelchair with undated white bandages around both of her lower legs. Review of Resident #56's admission record revealed an initial admission date of 04/17/2025. Resident #56 was admitted with diagnosis to include partial intestinal obstruction, unspecified as to cause, acute embolism and thrombosis of unspecified deep veins of left lower extremity, and peripheral vascular disease, unspecified. Review of Resident #56's Medicare 5-day Minimum Data Set (MDS) revealed Section M. Skin Conditions, revealed venous and arterial ulcers, skin tears, and application of nonsurgical dressings (with or without topical medications) other than to feet. Review of Resident #56’s physician orders revealed: Dated 07/07/2025 Right Lower Leg skin tear: cleanse with normal saline (NS), pat dry, apply triple antibiotic ointment, xeroform sheet, and ABD (abdominal) pad, wrap with Kerlix as needed. Dated 7/23/2025 Left Lower Leg Skin Tear: Cleanse with NS, pat dry, apply Santyl and silver alginate, ABD Pad and wrap with Kerlix. Do not use island dressing/tape every evening shift and as needed for soiled or dislodged dressing. 2. During an observation on 07/28/2025 at 12:23 p.m., Resident #58 was observed with a bandage to her left forearm dated 07/26/2025. Review of Resident #58's admission record revealed an admission date of 07/16/2025. Resident #58 was admitted to the facility with diagnosis of encounter for other orthopedic aftercare, spondylolisthesis, lumbar region, spinal stenosis, lumbar region without neurogenic claudication. Review of Resident #58's Medicare 5-day MDS dated [DATE] revealed Section M. Skin Conditions, surgical wound, skin tears, moisture associated skin damage (MASD), and application of nonsurgical dressings. Review of Resident #58’s physician orders revealed: Dated 07/21/2025 Left forearm cleansed with normal saline apply dry dressing daily until healed monitor any s/s (signs and symptoms) of infection at bedtime for skin tears. 3. Review of Resident #11's admission record revealed an admission date of 07/08/2025. Resident #11 was admitted to the facility with diagnosis to include unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, presence of right artificial hip joint. Review of Resident #11's admission MDS dated [DATE] revealed Section M. Skin conditions, surgical wound. Review of Resident #11’s medical record revealed a handwritten order dated 07/25/2025, wound care- please clean wound two to three times daily with betadine and redress. Review of Resident #11’s electronic medical record revealed a physician order with a start date of 07/31/2025, Right Hip: Wound care clean with betadine pat dry apply island dressing. Two times a day for surgical wound. During an interview on 07/31/2025 at 10:50 a.m., the Assistant Director of Nursing (ADON) stated resident’s bandages should be labeled with the date, nurses’ initials, and the shift they work. Resident #56’s bandages should have been dated. Resident #58’s bandage should have been dated for 07/27/2025 since the order is for daily dressing changes during the evening shift. During an interview on 07/31/2025 at 1:18 p.m., the Director of Nursing (DON) stated the nurses are responsible for entering the handwritten orders into the electronic medical record. Resident #11’s wound care order should have been started on 07/25/2025. The facility was asked to provide a policy related to wound care and it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to accurately assess and implement appropriate interventions for two residents (#2 and #8) of six residents sampled for accidents. Findings included: On 07/28/25 at 9:53 a.m. Resident #2 was observed sitting in a wheelchair alone at table in the common area between rooms [ROOM NUMBERS]. The resident’s wheelchair was pushed up to table with both wheelchair brakes in a locked position. The resident was observed pushing at the table. During the observation, Staff N, Licensed Practical Nurse (LPN) reported the resident’s diagnosis and was Spanish-speaking only. On 07/28/25 at 11:04 a.m. Staff L, Certified Nursing Assistant (CNA) was observed unlocking both of Resident #2’s wheelchair brakes. The staff member reported going to take the resident to assist with toileting and confirmed unlocking the brakes on each side of the wheelchair. Staff L stated the resident moves arms and legs when sitting at tables. On 07/29/25 at 11:12 a.m. Resident #2 was observed sitting at the table in the common area, facing resident rooms with back to hallway, the brakes on each side of the resident’s wheelchair were locked. On 07/31/25 at 8:58 a.m. Resident #2 was observed sitting at the table in the common area in a wheelchair with the brakes locked on each side of the chair. Staff S, Restorative CNA, confirmed both brakes were locked. Staff L stated the resident was able to unlock the brakes. The resident stated “no” when asked if (pronoun) could unlock the brakes. Staff Y, CNA translated and asked the resident if (pronoun) could unlock brakes, again the resident said “no”. The resident did respond appropriately in Spanish when this writer said hello. Staff N, LPN reported the resident could unlock the brakes, does it better in the evenings, doesn’t do it in the mornings. Staff N stated they lock both brakes and push Resident #2 into the common area to watch for (pronoun) safety. Review of Resident #2’s admission Record showed the resident was admitted on [DATE] with a primary diagnosis of subsequent encounter for closed fracture with routine healing (of) displaced intertrochanteric fracture of right femur. The record included additional diagnoses not limited to Parkinson’s disease without dyskinesia without mention of fluctuations, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, difficulty in walking not elsewhere classified, subsequent encounter (of) unspecified fall, and psychotic disorder with delusions due to known physiological condition. Review of Resident #2’s hospital History and Physical, dated 07/06/25, showed the resident presented to the facility after being found on the floor by family. The Xray results revealed an acute displaced intertrochanteric proximal right femur neck fracture. Review of Resident #2’s 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was interviewed for a Brief Interview for Mental Status (BIMS) score. The resident scored “00” of 15 indicating a severe cognitive impairment. The functional abilities assessment revealed the resident had bilateral lower extremity range of motion limitations and was dependent upon others for toileting, bathing, lower body dressing and putting on/taking off footwear. The resident was shown to be dependent with bed mobility, transferring, walking 10 feet, and walking 50 feet with two turns. The MDS revealed the resident had a fall in the last month prior to admission/entry, and a fracture related to a fall in the six months prior to admission/entry, no falls since admission/entry, and had a major surgery in the 100 days prior to admission. Review of the Fall Risk Evaluation, dated 07/09/25 at 6:05 p.m. showed Resident #2 had one to two falls in the past three months, was disoriented x3 (disoriented to person, place, and time) at all times, was ambulatory and incontinent, had one to two predisposing disease(s), no change in condition in the last 14 days, and a recent hospitalization in the last 30 days. The Gait/Balance portion of the evaluation showed the resident’s gait/balance was normal, balance problem while standing, balance problem while walking, decreased muscular coordination, and jerking or unstable when making turns. The evaluation did not show a care plan focus or interventions were initiated to show the resident was a high risk for falls or a risk for falls. Review of Resident #2’s Post-Fall Evaluation, dated 07/27/25 at 2:20 p.m. showed the resident had an unwitnessed fall on 07/27/25 at 2:15 p.m. in the resident’s room. The evaluation revealed the resident was attempting to self-toilet and no injury had occurred. Review of Resident #2’s Fall Risk Evaluation, dated 07/27/25, showed the resident had one to two falls in the past three months, had intermittent confusion, was chairbound and incontinent, and had three or more predisposing diseases. The Gait/Balance of the resident showed a balance problem while standing, balance problem while walking, decreased muscular coordination, and required use of assistive devices (i.e. cane, wheelchair, walker, furniture). Review of Resident #2’s care plan focus initiated on 7/10/25 showing the resident was at risk for falls related to (r/t) Parkinson’s disease, dementia, medication side effects, and history of falls. The interventions included: - Be sure (the resident’s) call light is within reach and encourage the resident to use it for assistance as needed, initiated 07/10/25 and revised on 07/27/25. - Encourage and assist resident to keep bed in the lower position during rest periods with floor mats at bedside, initiated on 07/28/25. - Encourage (resident) to wear appropriate non-skid footwear/gripper socks, initiated 07/10/25 and revised on 07/28/25. - Observe for restlessness when in bed. Offer and assist up to the wheelchair/common area for activities, socialization, and increased monitoring, initiated and revised 07/28/25. - Physical Therapy (PT) screen and treat as ordered, initiated on 07/10/25. - Fall Risk, initiated on 07/10/25. Review of Resident #2’s care plans and focuses did not reveal staff were to place Resident #2 close to table and lock both of the wheelchairs brakes. During an interview on 07/30/25 at 3:32 p.m., the Director of Nursing (DON) stated she doubted Resident #2 would be able to unlock the wheelchair brakes. She stated having the resident pushed up to the table and both brakes locked would be a restraint. The DON stated just because the resident moves legs and arms was not a reason to lock brakes. 2. During an observation on 07/28/2025 at 11:03 a.m., Resident #8 was observed sitting in a wheelchair in the common area. An attempt was made to interview Resident #8, and she was not able to answer questions related to her care. During an observation on 07/29/2025 at 12:14 p.m., Resident #8 was observed sitting in a wheelchair in the dining room. During an interview on 07/29/2025 at 1:30 p.m., Resident #8’s Family Member (FM) stated Resident #8 had a fall in her assisted living apartment and that is what brought her to the nursing facility. He stated she fell at the nursing facility and had to be sent to the hospital. After that incident she has fallen twice, with her most recent fall last week. “She was very independent before the fall that brought her to this facility and still thinks she can do things on her own. She had vertigo for years and I feel like this is what is causing her more recent falls.” Review of Resident #8’s admission record revealed an initial admission date of 04/07/2025 and a re-admission date of 05/06/2025. Resident #8 was admitted to the facility with diagnosis to include traumatic subarachnoid hemorrhage without loss of consciousness (04/07/2025), contusion and laceration of right cerebrum without loss of consciousness (04/07/2025), contusion of scalp (05/06/2025), difficulty in walking (04/07/2025), cognitive communication deficit (04/07/2025), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (04/07/2025) and unspecified fall (04/07/2025). Review of Resident #8 Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of two out of 15 showing severe cognitive impairment. Review of Section GG. Functional Abilities revealed Resident #8 needed partial/moderate assistance showing the helper does less than half the effort. The helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort. For roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed transfers, toilet transfers and wheelchair mobility. Resident #8 was dependent showing the helper does all of the effort, resident does none of the effort to complete the activity, or, the assistance of two or more helpers is required for the resident to complete the activity for walking 10 feet, walking 50 feet, and walking 150 feet. Review of Resident #8’s Care Plan dated 04/08/2025 revealed: Focus: Resident #8 is at risk for falls related to history of falls, dementia and syncope. Date Initiated: 04/08/2025 Goal: Resident #8 will not sustain serious injury through the review date. Interventions: • anti-rollback to wheelchair (date initiated 05/07/2025) • Be sure Resident #8 call light is within reach and encourage the resident to use it for assistance as needed. (date initiated 04/08/2025). • Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. (date initiated 07/26/2025). • Encourage and assist resident to keep bed in the lower position during rest periods (date initiated 05/08/2025). • Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. (date initiated 07/26/2025). • Encourage Resident #8 to wear appropriate non-skid footwear/gripper socks when ambulating or mobilizing in wheel chair (date initiated 04/08/2025). • Floor mats at bedside during rest periods (date initiated 05/08/2025). • Medication Review (date initiated 06/02/2025). • Offer and assist resident out of room to the common area during the day, or if noted to be restless when in bed, for activities, socialization and increased monitoring (date initiated 05/07/2025). • Offer and assist resident to the bathroom during waking hours such as before/after meals or programs, upon awakening and at bedtime. Observe for any symptoms of urinary retention and report to nurse/MD (medical doctor) (date initiated 06/02/2025). • One way glide pad to wheelchair seat (Date Initiated 05/08/2025) • Provide cueing/supervision as indicated (Date Initiated 07/26/2025) • Provide rest periods. (Date Initiated 04/08/2025) • room change closer to the nurses station. (Date Initiated 05/06/2025) • The resident needs activities that minimize the potential for falls while providing diversion and distraction (date initiated 07/26/2025). • Fall risk (date initiated 05/06/2025). • Provide resident appropriate assistive devices as ordered (date initiated 07/26/2025). • Keep needed items in reach (date initiated 07/28/2025). • Encourage and assist resident to keep wheelchair brakes in locked position when not mobilizing (date initiated 07/28/2025). Focus: Risk for falls (date initiated 07/26/2025). Goal: Resident #8 will be free of falls. Interventions: • Assist resident with ambulation and transfers, utilizing therapy recommendations (date initiated 07/26/2025). • Determine residents ability to transfer (date initiated 07/26/2025). • Evaluate fall risk on admission and as needed (date initiated 07/26/2025). • If fall occurs, alert provider (date initiated 07/26/2025). • If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol (date initiated 07/26/2025). • If Resident is a fall risk, initiate fall risk precautions (date initiated 07/26/2025). Review of Resident #8’s fall risk evals revealed 04/07/2025 Fall risk score of 11.0, 05/02/2025 Fall risk score of 18.0, 05/06/2025 Fall risk score of 10.0, 05/09/2025 Fall risk score of 22.0, 05/31/2025 Fall risk score of 11.0, and 07/26/2025 Fall risk score of 22.0, indicating Resident #8 as a high risk for falls with a score of 10 or higher. Review of Resident #8’s Change in Condition Evaluation dated 05/03/2025, revealed Fall, this condition, symptom, or sign has occurred before. Functional Status Evaluation, Falls (one or more). Pain Evaluation not clinically applicable to the change in condition. Neurological Evaluation not clinically applicable to the change in condition being reported. Review of Findings and Provider Notification: “history of fall prior to admission, called into the room by Certified Nursing Assistant (CNA),observed resident lying on her back near the bathroom door, resident was previously seen lying in bed eating dinner, call light within reach but not on, resident stated that she walked out to use the bathroom, slipped and fell, the floor was dry and clear. Resident was assessed for injury, a bump on the back of her head, no other injury and no complaint of pain. MD was immediately notified, order to send to emergency room (ER). 911 called and resident was transported to ER for evaluation.” Review of eINTERACT Change in Condition Evaluation dated 05/31/2025 revealed Situation, Fall. This condition, symptom, or sign has occurred before, unknown. Functional Status Evaluation, Falls (one or more). Pain Evaluation is not clinically applicable to the change in condition. Neurological Evaluation is not clinically applicable to the change in conditions being reported. Review of Findings and Provider Notification: This nurse was notified by CNA that Resident was found on floor, upon entering resident's room, resident was found sitting on bathroom floor in front of toilet. Resident stated, I needed to go to the bathroom, and I slid out of the chair. Resident was assessed, no signs of injury, bruising or hematoma noted. Resident denies pain. Resident was transferred from floor to toilet with assistance of two, neuro (neurological) checks initiated. MD and family notified. No new response from physicians, family notified. Review of eINTERACT Change in Condition Evaluation dated 07/26/2025 revealed Situation, Fall. This condition, symptom, or sign has occurred before, unknown. Functional Status Evaluation, Falls (one or more). Pain Evaluation residents has no pain. Neurological Evaluation no changes observed. Review of Findings and Provider Notification: Patient is unsteady and is unable to ambulate independently. Patient fell and landed on the back of head. Bump on the back of head - Right side, Writer observed resident lying flat on the floor in the common area of 2 south. Writer assessed resident for any skin alterations (bump noted to right side of back of head). Resident denies pain and states that she was ready to eat lunch. Vitals were assessed. Resident was assisted off of the floor via two person assist utilizing a gait belt. Neurological checks initiated. Hospice notified of fall and will visit resident this afternoon to assess. On call MD also notified of fall. Family notified. During an interview on 07/30/2025 at 12:3 p.m., Staff Z, CNA, stated Resident #8 is incontinent and needs help with going to the bathroom, she is confused a lot. “I think she is a fall risk because she tries to get out of bed by herself. She has mats in her room and a anti-lock thing on chair. We also keep her bed low. I am not aware of her having any falls.” During an interview on 07/30/2025 at 12:16 p.m., Staff U, Licensed Practical Nurse (LPN) stated Resident #8 is a long-term resident who is on hospice. She had a fall with a brain bleed before she was admitted . She has had a few falls since being here with her most recent being on the 26th. We do frequent rounds, make sure she has been toileted, if she is in her room. We make sure everything is in reach of her. Sometimes we put her in the common area, and we ensure that her brakes on her wheelchair are locked. Interventions are set in place at admission. If a resident comes in because of a fall we make sure that their bed is in a low position, fall mats and keep them in a room near the nurse’s station. Resident #8 was not her resident when she fell for the first time at the facility. Resident #8 was on a different unit further away from the nurse’s station. During an interview on 07/30/2025 at 2:34 p.m., the Director of Nursing (DON), stated Resident #8 has had three falls at the facility. After the first fall they called and spoke with her son who told them she has been battling vertigo for 20-30 years but did not have an official diagnosis. Resident #8 will sometimes want to get up and change positions because of that she falls. Her cognition fluctuates a lot. “When she first got here, she only wanted to stay in bed. It was a surprise when she wanted to get out of bed.” In the beginning of May Resident #8 was found on her back on the floor outside of her room very close to the bathroom. She told us she was going to the bathroom and slipped and fell. Resident #8 had to go to the hospital after the fall at the beginning of May and was admitted because she had a subdural hematoma that was new. Their risk manager did the investigation. “Alot of times we pre deem residents as a fall risk. They do fall risk assessments at admission and after each fall.” Her initial care plan interventions were “use call lights, no skid footwear. At the time of her admission we did not feel she was a fall risk.” After a resident falls, we update their care plans. During an interview on 07/30/2025 at 5:30 p.m., the Risk Manager stated on 05/03/2025 staff observed Resident #8 lying on her back on the floor in her room. They evaluated her found a “bump” on her head. They notified the physician and transferred her to the emergency room (ER). She was out of the facility for a few days and then returned to them on 05/06/2025. At the time of this fall she reviewed the care plan and Resident #8 was care planned for call light in reach and no skid footwear. At the time of her admission we thought those were appropriate interventions for her. They changed Resident #8’s care plan when she got back and added therapy screen to evaluate her, anti-rollback to her wheelchair, since there was potential for her to stand. Assist her to the common area, for socialization and activities. When in her room bed in lower positions and floor mats at the bedside. We added one way glide pad to her wheelchair. We also moved Resident #8’s room in front of the nurse’s station. She called Resident #8’s son with the DON, who told them Resident #8 had a history of vertigo, that was never really diagnosed. Resident #8 had another fall on May 31st. It was an unwitnessed fall. Resident #8 was observed sitting on the floor in her room. Ten minutes earlier Resident #8 was observed lying in bed in lowest position. Her call light was not activated. Resident #8 was not able to verbalize what she was trying to do. That’s when they added for staff to offer toileting assistance, at the time she was incontinent and was not aware of needs to void. We also added offer routinely to go to the bathroom “we thought that maybe she was trying to get up and go to the bathroom.” We also added another therapy screen and requested a pharmacy review. Resident #8 had another fall on July 26th, and the investigation is ongoing. Nurse stated Resident #8 went to music program and she sat her in the common area after. The nurse left for about five minutes and when she went around the corner, she saw Resident #8 sitting on the floor. Resident #8 did not have any injuries. Resident #8 told the nurse, she saw a piece of paper and leaned forward, and just bounced out of the chair. She reviewed the interventions in the care plan with the nurse, and everything was in place on her wheelchair. After this fall they added, keeping items within reach and having staff lock the wheelchair brakes, “that may keep her from bouncing.” They discuss falls at their morning meetings and Resident #8 was just added to the list to go over her case. Review of the undated facility policy titled “Fall Prevention and Management” revealed, “Policy: It is the policy of our community to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence and quality of life. Purpose: A fall prevention program is used to provide a safe environment for resident of the Health Care Center. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls; improvement quality assurance measures to monitor progress; and provide ongoing staff education. Definition: This community follows the long-term care/CMS guidelines for the definition of a fall. CMS RAI definition of a fall-Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, and an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person-this is still considered a fall. CMS understands that challenging a residence balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. admission: 1. All residents will be assessed for the risk of falling using a standardized fall assessment. 2. The fall risk evaluation will be completed upon admission, quarterly, annually, and/or if a changing condition requiring completion of a new MDS occurs (significant change MDS) and after every fall. An evaluation of all the casual factors leading to a resident fall should be completed. 3. The baseline care plan will address interventions based on the fall risk evaluation results, history, and resident and resident representative input. 4. All residents should be considered at risk for falls for 72 hours following admission due to change in environment. 5. Residents who are identified as high risk will have a prevention care plan in place and individualized precautions will be noted to avoid falls. 6. Shift report will include communication to all nursing staff regarding fall risk for new residents or residents who experience a change in condition. 7. Nursing assistants will be made aware of residents at high risk for falls via resident care information records found in the EMR [electronic medical record] or other tool. Assessment and care planning: 1. the baseline care plan will be followed (and updated as necessary) until the MDS is completed. Following completion of the MDS, if triggered the CAA [Care Area Assessment] for falls will be completed and appropriate interventions will be implemented in the care plan. 2. LCS Does [sic] not recommend the use of restraints as a fall prevention strategy. As noted in the State Operations Manual (Appendix PP), “there is no evidence that the use of physical restraints including but not limited to bed rails and position change alarms will prevent or reduce falls. Additionally falls that occur while a person is physically restrained often result in more serious injuries (e.g., strangulation, entrapment).” Steps following a fall: 1. Head to toe evaluation by a licensed nurse is completed before the resident is moved. 2. If the fall is unwitnessed neurological assessments will be conducted according to the neurological assessment policy. 3. Emergency care will be provided to the resident following appropriate procedures if necessary. Emergency care will be provided to any resident who has had head trauma unless the physician, resident, or family refuses such treatment. 4. Documentation will include incident report/event report completion, the nurses notes, and a fall investigation. 5. Documentation and the nurses notes will include physician and responsible party notification. Notification will occur within two hours if the fall resulted in an injury. 6. During this shift in which the fall occurred an initial review of the circumstances leading to the fall will be completed by the nurse on duty, an initial identification of the root cause of the fall will be determined, and an immediate new fall prevention intervention will be implemented. 7. Physician orders will be obtained and documented for any needed treatment for injury as a result of the fall. 8. The director of nursing[sic] will be notified immediately for any fall that results in significant injury or the needed for emergency medical care. 9. If the fall was a result of staff error, the nurse on duty will provide documented education to the staff on the shift during which the fall occurred. 10. For referral to therapy after a fall to prevent repeat occurrences should be considered. 11. Additional review of the fall will include a root cause analysis, causative factors, fall prevention interventions, care plan, and a fall risk evaluation will be completed. The care the plan[sic] will be updated to reflect the additional fall prevention interventions. 12. Follow up resident assessment and documentation for 72 hours will be completed in the medical record. 13. Nursing staff will make appropriate interventions upon the completion of the report to prevent reoccurrence of a fall or to minimize injury. 14. A review and revision of the side rail assessment, physician order, and authorization should occur as needed. 15. IDT [interdisciplinary team] risk review of fall should occur during the daily clinical meeting, within 24 hours of the event, or by the next business day. Documentation of this review should be included in the resident’s clinical record. 16. The fall information will be added to the facility fall tracking list.

Based on observations and interviews the facility did not ensure food service standards were followed related to hand hygiene and sanitary practices in the main kitchen and in one of three satellite kitchens. Findings included: On 07/28/25 at 9:10 a.m., an initial tour of the kitchen was conducted with the Associate Dining Director. An observation of Staff F, Utility Technician revealed he was using the high temperature dish machine. He was the only staff member using the dish machine during the observation. Staff F was taking the test strip out of a clear tube to check the temperature of the dish machine. He was observed to drop the test strip on the floor and used the same one to verify the final rinse temperature. During the observation he did not have gloves on. After dropping the test strip on the floor, he put the test strip in the water and determined the temperature was appropriate. Staff F, Utility Technician, did not perform hand hygiene after picking up the test strip from the floor and moving on to another task.On 07/28/25 at 9:15 a.m., an observation of Staff H, Dietary Aide revealed she was handling fruit by cutting and plating them on the food preparation table. Staff H, Dietary Aide took off her gloves and put new ones on. Staff H, Dietary Aide did not perform hand hygiene between taking off soiled gloves and putting new ones on. On 07/28/25 at 9:19 a.m., an observation of the prep refrigerator revealed a 16-ounce, clear plastic water bottle. The Associate Dining Director said it could belong to a resident. She said it should have been labeled with resident information. The Associate Dining Director was observed asking Staff H, Dietary Aide who it belonged to, and she responded that she did not know.On 07/28/25 at 9:21 a.m., an observation of the ice cream and bread freezer revealed there was a frozen 16-ounce, clear plastic water bottle. The Associate Dining Director said she did not know who it belonged to and confirmed it should not be there.On 07/28/25 at 9:23 a.m., an observation of the walk-in refrigerator revealed a box of vegetables with stems and leaves that appeared to be a faded green color with multiple black spots. The Associate Dining Director said those were the stems of tomatillo's and proceeded to take one out. An observation of the tomatillo revealed they were a mushy texture with multiple white and black spots. She stated, I didn't know they were like that.On 07/28/25 at 9:25 a.m., an observation of the walk-in freezer revealed ice build-up on top of a white box on the rack next to a box with raisin cinnamon thins. The Associate Dining Director said she was not aware of the ice build-up. She said the unit worked fine and did not have any issues.On 07/28/25 at 9:28 a.m., an observation of one of the racks in the dry storage area, next to multiple cartons of beverage thickeners, revealed a 16-ounce plastic water bottle with approximately 1/4 of liquid left. The Associate Dining Director did not know who it belonged to.On 07/29/25 at 9:21 a.m., an interview with Staff H, Dietary Aide was conducted, she said she switched gloves when cutting and separating fruit. She said she takes off her gloves and washes her hands in between preparation. She said the fruit she was handling on 07/28/25 was for all residents.On 07/29/25 at 11:41 a.m., an observation was conducted of Staff G, Dietary Aide who was moving food items from the meal cart to the steam table. Staff G, Dietary Aide was wearing gloves during the observation. She started taking the meal temperatures without performing hand hygiene. Staff G, Dietary Aide was observed touching the removable divider that was on another preparation table. Then, she put the divider on the steam table to separate two shallow pans of food items. Staff G, Dietary Aide then went back to taking temperatures of the food. Hand hygiene was not performed between changing tasks. Staff G, Dietary Aide was observed taking the temperature of minced and moist vegetables, then took the temperature of chicken without wiping the thermometer probe between the two food items. On 07/30/25 at 4:40 p.m., an interview was conducted with the Associate Dining Director. She said if the testing strip for the dish machine fell on the floor, she expected it to be thrown away. She said another one should have been used. The Associate Dining Director said Staff F, Utility Technician should have washed his hands if he had picked up the testing strip from the floor. She confirmed he was not wearing gloves during the observation. The Associate Dining Director said no staff should have anything personal such as drinks in resident-used refrigerators and freezers. She said there is an associate break room where they can store their personal items. She said staff are aware of those expectations through floor and computer training that she conducts herself or with the primary supervisor. The Associate Dining Director said the utility technician/dish washer or sous chef assisted with putting away vendor delivered items. She said herself or the primary supervisor reviewed the refrigerators and freezers. She said she conducted a daily and weekly audit which included taking pictures of food items. The Associate Dining Director said the observation of the tomatillo's were, not okay for them to be like that. Regarding the ice buildup observed on 07/28/25, she stated the vendor came today and, Something up in the ceiling needed to be fixed. She stated they removed the ice buildup but, It will continue to build up. She said prior to 07/28/25 she did not notice the ice buildup. While taking the temperature of food before the meal service, the Associate Dining Director said she expected staff to wipe the probe with a new wipe every time they take the temperature. She said she expected staff to wash their hands after every glove change. She said Staff H, Dietary Aide, should have washed her hands after changing gloves. She said between each change of task, staff should take off their gloves and wash their hands. The Associate Dining Director stated that, No, not ok to not wash hands between glove changes.A review of the facility's procedure regarding use of the dish machine revealed the following, .2. temp [temperature]/chlorine/Load the dishwasher strategically Test strips are located above dish unit, take a test strip with clean hands dip and remove strip, then compare to color chart .A review of the facility's undated policy regarding personal items revealed the following, Policy Statement To maintain a safe and secure work environment, prevent contamination, and minimize distractions, it is the policy of [Facility] that no personal items are permitted in the designated surveying work areas. This includes, but is not limited to: . Food and drinks, except as provided by the company or pre-approved for specific health reasons.A review of the facility's undated procedure titled, How to use a food thermometer, revealed the following, .5. Once recorded, remove the thermometer and wipe it clean.A review of the facility's undated policy titled, Glove Use Policy, revealed the following, . All employees handling food or utensils must: Wash hands thoroughly prior to putting on gloves and when gloves are changed. Change gloves when: a. Beginning each new task . Further review of the policy revealed the following, When to Change Gloves . Touching items that could be contaminated with bacteria .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to the storage of urinary catheters for one resident (#104) of one resident sampled, failed to perform appropriate hand hygiene during the administration of medications for one resident (#33) of six residents observed during medication administration observation, failed to ensure one Staff (C) out of 25 staff fingernails were kept in a manner that allowed for hand hygiene to be completed in a sanitary manner, and failed to implement Enhanced Barrier Precautions (EBP) for three residents (#56, #58 and #11) of seven residents sampled for infection control practices. 1. Review of Resident #56's admission Record revealed an initial admission date of 04/17/2025. Resident #56 was admitted with diagnoses to include partial intestinal obstruction, unspecified as to cause, acute embolism and thrombosis of unspecified deep veins of left lower extremity, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, and peripheral vascular disease, unspecified. Review of Resident #56's Medicare 5-day Minimum Data Set (MDS) revealed Section M. Skin Conditions, revealed venous and arterial ulcers, skin tears, and application of nonsurgical dressings (with or without topical medications) other than to feet. Review of Resident #56’s physician orders revealed no orders for enhanced barrier precautions. 2. During an observation on 07/28/2025 at 12:23 p.m., Resident#58 was observed with a bandage to her left forearm dated 07/26/2025. Review of Resident #58's admission record revealed an admission date of 07/16/2025. Resident #58 was admitted to the facility with diagnoses of encounter for other orthopedic aftercare, spondylolisthesis, lumbar region, spinal stenosis, lumbar region without neurogenic claudication. Review of Resident #58's Medicare 5-day MDS dated [DATE] revealed Section M. Skin Conditions, surgical wound, skin tears, moisture associated skin damage (MASD), and application of nonsurgical dressings. Review of Resident #58’s physician orders revealed no orders for enhanced barrier precautions. 3. Review of Resident #11's admission Record revealed an admission date of 07/08/2025. Resident #11 was admitted to the facility with diagnosis to include unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, presence of right artificial hip joint. Review of Resident #11's admission MDS dated [DATE] revealed Section M. Skin Conditions, surgical wound. Review of Resident #11’s physician orders revealed no order for enhanced barrier precautions. Review of Resident #11’s lab results revealed 07/25/25 Wound Culture: Heavy pseudomonas aeruginosa (Sens: aztreonam), Moderate E.coli. During an interview on 07/31/2025 at 10:50 a.m., the Assistant Director of Nursing (ADON) stated she is the one who decides what type of precautions, if any, a resident should be on. Residents who have indwelling devices, wounds with heavy draining that cannot be contained in a dressing, or they have a history of multi drug resistant organisms are put onto enhanced barrier precautions. Residents with wounds that have Methicillin/oxacillin-resistant Staphylococcus aureus (MRSA), Extended-spectrum beta-lactamases (ESBL), Vancomycin-resistant enterococci (VRE) and certain bacteria would be put on contact precautions. Residents with a surgical wound that is not draining would not be put on any barrier precautions. There is a bandage covering the surgical wound. “We follow the physicians orders and a lot of times they don’t want us to mess with the area. As long as the wound is not draining, they would not be put on any kind of barrier precautions.” Resident #11 had a wound culture done on 07/25/25 and they got the results on 07/28/25. The results came back positive for pseudomonas and Escherichia coli (E. coli) in the wound. That can be from contamination. Staff would need to be educated on hand hygiene. Resident #11 came in with a surgical wound. She came in with an aqua cell dressing. She was not on any precautions. I was out of on medical leave when she admitted to the facility so I’m not sure if her wound had drainage at that time. Resident #11 was put on contact precautions on 07/30/25 because of her lab results and her wound is draining. During an interview on 07/31/2025 at 11:22 a.m., Staff K, Registered Nurse (RN), Nurse Manager, stated residents with wound drainage, or any tube would be put on enhanced barrier precautions. If it is a dry wound, she would not put the resident on barrier precautions. Surgical wounds do not get any precautions unless it is draining. Contact precautions are mostly infections, like contact with E.coli, or pneumonia. They can also come in on contact isolation from the hospital and she would look at the admission forms and look at the discharge notes. Resident #11 has a right hip surgical wound. The nurse called her the last time she was doing a dressing change and noticed it was red and draining so they did a culture, and it came back positive for pseudomonas and Escherichia coli (E. coli). It could be from stool, the wound not being cleaned correctly, it could be from the linen, or it could be from their clothing. She was not on any precautions when she was admitted . The facility was asked to provide a policy related to enhanced barrier precautions and it was not provided. 4. On 07/28/25 at 11:40 a.m. an observation was made of Resident #104’s shared bathroom. The observation revealed a large urinary catheter drainage bag hanging from the shower’s handrail, urine was observed in the tubing, and the bag was near other items stored in the shower. An observation and interview were conducted on 07/28/25 at 11:46 a.m. with Staff P, Certified Nursing Assistant (CNA) of the urinary drainage bag in the shower. Staff P observed the drainage bag hanging from the handrail and stated it was Resident #104s bag. Review of Resident #104’s admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to benign prostatic hyperplasia without lower urinary tract symptoms, displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, and unspecified subsequent encounter fall on same level. Review of Resident #104s care plan showed the resident had a urinary catheter related to neuromuscular dysfunction of bladder, initiated on 7/28/25. The interventions did not address storage of the drainage bag when not in use. An interview was conducted on 07/30/25 at 1:19 p.m. with Staff Q, CNA, who was assigned to Resident #104. The staff member stated the resident does have a foley urine catheter, (pronoun) checks the resident in the morning, takes the large (drainage) bag off and puts on the resident’s leg bag. Staff Q stated the (large) drainage bag was placed in a plastic bag and stored in the resident’s bin in the bathroom. A large drainage bag was observed in a plastic bag in a drawer of a plastic drawer system in the bathroom. During an interview on 07/30/25 at 2:39 p.m. Staff M, Licensed Practical Nurse (LPN) stated as far as (pronoun) knows “they” put the drainage bag in a bag and store it in the bathroom after draining it. The staff member stated it was not appropriate to hang the drainage bag from the handrail in the bathroom. An interview was conducted on 07/30/25 at 3:30 p.m. with the Director of Nursing (DON). The DON stated the process was the drainage bag is removed, placed into a plastic bag, and stored in a drawer. She stated hanging from the handrail in the bathroom was not appropriate. During an interview on 7/31/25 at 11:22 a.m. the Infection Preventionist (IP) stated a urine drainage bag could be re-used if not dirty, stored in a plastic bag (when not in use), and should not be stored hanging from the handrail in the shower, “not appropriate”. Review of the policy – Urinary Catheter Care, copyrighted 2001, revealed “The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.” The general guidelines included but not limited to: Infection Control: 1. Use aseptic technique when handling or manipulating the drainage system. 2. Be sure the catheter tubing and drainage bag are kept off the floor. The policy did not address storage of a drainage bag when not in use. 5. An observation was conducted on 07/29/25 at 4:10 p.m. with Staff J, LPN of the administration of medication for Resident #33. The staff member dispensed three oral medications, removed a paper tray from the bottom drawer of the medication cart and placed a blue barrier inside of it. The staff member donned gloves, without hand hygiene, removed a bleach wipe from a container and wrapped a glucometer in it before placing it on the barrier. Staff J placed a bottle of glucose testing strips and lances on the barrier and removed gloves (no hand hygiene) before entering the residents room. The staff member returned and assisted the resident with a cup of water, donned gloves (no hand hygiene), removed bleach wipe from glucometer. The staff member obtained a blood glucose level from the resident’s right ring finger. Staff J returned to the med cart, donned gloves (no hand hygiene), cleaned the glucometer with bleach wipe, removed gloves (no hand hygiene) and propelled the resident to the dining room in wheelchair, unwrapped the resident’s dining utensils and placed a napkin in the resident’s lap, then returned to the medication cart. The staff member donned gloves (no hand hygiene), took a blue barrier from drawer, placed it in the paper tray, and placed the glucometer on top of the barrier. The staff member accessed Resident #33’s medication profile saying the resident was to receive insulin per sliding scale. The nurse returned the resident to the room and completed hand hygiene with hand sanitizer. The staff member removed the resident’s bottle of insulin, asked the resident where (pronoun) would like the injection, and donned gloves. The staff member drew up insulin, laid an orange syringe cap on the cart, and inserted the needled syringe into the cap while holding it, removed gloves (no hand hygiene) and donned gloves. The staff member injected the resident, returned to the medication cart, and completed hand hygiene. An interview was conducted with Staff J, LPN on 07/29/25 at approximately 4:40 p.m. The staff member stated hand hygiene was supposed to be done before and after care of each patient and before and after glove use. The staff member confirmed hand hygiene was not done after each glove use. 6. On 07/30/25 at 8:42 a.m. an observation was conducted of Staff C, LPN, standing at a medication cart, dispensing medications. The observation showed the staff member had lavender-tipped fingernails extending ¾ to one inch past the fingertip. Staff C reported knowing (pronoun) fingernails needed to be cut, just got back from vacation and had wanted them to match hair. The staff members hair had untethered purple curls extending to mid-back. On 07/30/25 at 9:03 a.m. an observation was conducted with Staff C, LPN for the administration of medications for Resident #110. The staff member moved the medication cart in front of the resident’s room, placed a blue barrier on the cart, and opened the top drawer, the staff member’s hair drifted into the top drawer of the med cart. Review of Resident #110’s July Medication Administration Record (MAR) showed Staff C, LPN had previously administered seven of eight Sertraline doses to the resident between the dates of 07/22 and 07/29/2025 and documented the resident had refused the dose on 07/30/25. During an interview on 07/31/25 at 11:22 a.m. the Infection Preventionist (IP) reported educating staff on hand hygiene on a weekly basis. The IP stated staff should perform hand hygiene before and after giving medication to a resident using hand sanitizer or washing hands, after removing gloves staff need to use hand sanitizer. Review of the observation with Staff J, LPN during medication administration and lack of hand hygiene, the IP stated donning and doffing (removing) gloves without hand sanitizing was not appropriate and syringes should not be recapped. The IP stated fingernails need to be short and demonstrated when holding palm towards face should not be able to see the back of fingernail, color should be neutral, cannot be long or have diamonds, and should not be fake. Review of the Centers of Disease Control and Prevention (CDC) guidance – Clinical Safety: Hand Hygiene for Healthcare Workers, February 27, 2024, revealed the Key Points was to “Protect yourself and your patients from deadly germs by cleaning your hands” and “All healthcare personnel should understand how to care for and clean their hands.” The guidance showed “Cleaning your hands reduces: the potential spread of deadly germs to patients, the spread of germs, including those resistant to antibiotics, and the risk of healthcare personnel colonization or infection caused by germs received from the patient.” The guidance addressed when to wear (and change) gloves revealing “Gloves are not a substitute for hand hygiene.” - If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. - Always clean your hands after removing gloves. The guidance addressed maintaining fingernail and jewelry safety: - Natural nails should not extend past the fingertip. - Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive care units or operating rooms. o Germs can live under artificial fingernails both before and after using an alcohol- based hand sanitizer and hand washing. 7. On 07/28/25 at 9:24 a.m. Staff O, Certified Nursing Assistant (CNA) was observed coming out of Resident #38’s room with a bag of linen. The area outside of the resident’s room did not have an available personal protective equipment (PPE) caddy and there was not one nearby. Review of Resident #38’s admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified peripheral vascular disease and cellulitis of left lower limb. Review of the Skin & Wound Evaluation, effective 7/22/25 at 11:31 a.m. revealed the resident had a left medial proximal malleolus venous ulcer that was present on admission. The wound measured 3.6 x 2.4 x 0.2 centimeter (cm), with 50% granulation and 50% slough, moderate serosanguineous exudate, and erythema of surrounding tissue. The treatment consisted of enzymatic debridement, calcium alginate, and a silicone secondary dressing. On 07/28/25 at 9:39 a.m. Staff K, Registered Nurse (RN) Manager was observed placing a PPE caddy outside Resident #38’s door. The staff member stated on 7/28/25 at 9:41 a.m. that (pronoun) decides who gets put on Enhanced Barrier Precautions based on wound care providers documentation, Resident #38 had a vascular wound that the wound providers visited last Tuesday (7/22/25) and the staff member had reviewed last night. On 07/28/25 at 9:45 a.m. Staff O, CNA was observed dressing in a PPE gown outside of Resident #38’s room, the staff member reported being in the room this morning without PPE, prior to the placement of the PPE cart, and did not know how long the resident had a wound. On 07/28/25 at 4:06 p.m. Resident #38 was observed with a dressing to left lower leg dated 07/27/25 and initialed “MV”. During an interview on 07/31/25 at 11:22 a.m. the IP stated the CDC recommends the use of EBPs to prevent infection to the resident, they aren’t infected but we may be infected. The IP stated anybody with an indwelling catheter, wound vacuum (vac), percutaneous endoscopic gastrostomy (PEG), peripherally inserted central catheter (PICC)/midline, Jackson Pratt (JP) drain, (and/or) any type of drain should be placed on EBP. She stated anybody with a wound with a lot of drainage that cannot be contained with a dressing, if they are draining a lot they would be exposed and then placed on EBP. Supervisors know when to put (a resident) on EBP and when they have a lot of drainage that cannot be contained by a dressing, moderate or severe drainage, so there’s a risk of the drainage causing the dressing to fall off, get saturated and the dressing falls off. The IP reviewed the EBP policy stating Resident #38 should have been on EBP prior (to observation), EBP should have be placed at admission. The IP stated during an admission nurses can place a resident on barrier precautions. Review of the facility policy – Enhanced Barrier Precautions, revised March 22, 2024 revealed “Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents.” The policy interpretation and implementation included but not limited to: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resist organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: a. Dressing; b. Bathing/ showering; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and h. Wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/ or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident stay or until resolution of the wound or discontinuation of the indwelling medical device that places them increased risk. 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available near or outside of the resident rooms. Review of the CDC guidance – Implementation of Personal Protective Equipment (PPE) us in Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms (MDROs), dated 4/2/24, showed the Key Points: how to implement personal protective equipment (PPE) use in nursing homes to prevent spread of multi-drug resistant organisms (MDROs). The updates as of 7/12/22 showed: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased health care costs. 2. Enhanced barrier precautions (EBP) alright an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: a. Wounds are indwelling medical devices, regardless of MDR O colonization status; b. Infection or colonization with an MDR O. 4. Effective implementation of BP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. The guidance described Enhanced Barrier Precautions: “Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.” Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing. “Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.” The CDC guidance revealed when implementing EBP signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves and to make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the policy – Infection Prevention and Control Program, revised on October 2018, showed “An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections.” 1. The infection prevention and control program is developed to address the saw this specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The Program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 11. Prevention of Infection: a. Important facets of infection prevention include: (1) identifying possible infections or preferential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; (6) immunizing residents and staff to prevent illness; (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease specific guidelines such as those of the Centers for Disease Control (CDC).

Based on observations, interview, and record review, the facility failed to ensure medications stored at the bedside were assessed for safe administration for one (Resident #336) of twenty-five sampled residents. Findings Included: On 05/08/2023 at 09:41 a.m., Resident #336 was observed lying in his bed and was receptive to an interview. When he spoke, his speech was soft toned and garbled at times. His son was present and assisted with the interview. Resident #336 appeared comfortable and denied any discomfort when asked. On his over the bedside table an inhaler was present. Resident #336 stated, it's for my Parkinson's and confirmed he took it on his own as needed. On 05/09/2023 at 2:45 p.m., Resident #336 was lying in his bed with his eyes closed and appeared comfortable. His son was present at the time and confirmed his inhaler remained in his bedroom. Resident #336 remained with his eyes closed and stated softly I used it last night. Medical record review of Resident #336's admission Record form was reviewed and indicated he was geriatric in age and had resided at the facility for less than a month. His primary diagnosis was listed as Parkinson's disease. A review of Resident #336's physician orders included an order for Inbrija Inhaler Capsule 42 MG (Levodopa) 1 capsule inhale orally as need for Parkinson related to PARKINSON'S DISEASE dated 04/19/2023. A review of the Medication Administration Record (MAR) for May 2023 revealed Inbrija Inhaler was not administered in the month of May 2023. Further review of the medical record failed to reflect a physician order to self-administer Inbrija inhaler at the bedside. On 05/09/2023 at 3:04 p.m., an interview was conducted with Staff C, Licensed Practical Nurse. She confirmed she was caring for Resident #336. When asked about his Inbrija inhaler she stated, I think he has this one in his room. If he needs it right away, we can't get back there quick enough, so he takes it himself. Staff C stated, He does not tell me when he takes it. She confirmed she was unaware of the frequency Resident #336 was self-administering his inhaler. HOW TO USE INBRIJA: Use INBRIJA when Parkinson's symptoms start to return. Use INBRIJA as needed when symptoms start to return in between doses of your carbidopa/levodopa medicine. Use it as prescribed when your Parkinson's symptoms start to return. Do not orally inhale more than 1 dose (2 capsules) for any OFF period. Do not take more than 5 doses (10 capsules) in a day. Do not stop taking your daily Parkinson's medicine. INBRIJA does not replace your regular carbidopa/levodopa medicine. Do not swallow or open INBRIJA capsules. Only use INBRIJA capsules with the INBRIJA inhaler. Do not use the INBRIJA inhaler for any other medicine. https://www.inbrija.com/how-to-use. On 05/09/2023 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She said if a resident wanted to take their own meds at bedside, they would let me know. When asked about Resident #336 she stated, I don't think so. The DON was shown the photographic evidence of the Inbrija inhalant on Resident #366's bedside table. She stated, The resident does not have a physician order to take meds at bedside. The DON said the facility had a process in place to determine if a resident could safely administer the medication. She confirmed the facility process was not followed. Review of the facility policy and procedure titled Self-Administration of Medications revision December 2016. Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific assessment, including (but not limited to) the resident's: a. ability to read and understand medication labels; b. comprehension of the purpose and proper dosage and administration time for his or her medications; c. ability to remove medications from a container and to ingest and swallow ( or otherwise administer) the medication; and d. ability to recognize risks and major adverse consequences of his or her medications. 8. Self-administered medications must be stored in a safe and secure place, which is no accessible by other residents. 9. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #187 was observed on 5/8/23 at 10:55 a.m., in bed with oxygen being delivered at 4 liters per minute (lpm). The admission Record for Resident #187 revealed the resident was admitted on [DATE] with diagnoses that included but not limited to cellulitis of right lower limb, acute bilateral embolism and thrombosis of unspecified deep veins of lower extremity, and hypokalemia. A review of a Change in Condition evaluation, dated 5/6/23, revealed Resident #187 was short of breath, with an oxygen saturation of 84% on room air was gasping for breath, and was placed on 2 lpm of Oxygen (O2). The Change in Condition indicated the provider instructed staff to continue to monitor. A progress note, dated 5/7/23 at 11:58 a.m., indicated Resident #187 was alert and oriented x4, appeared to be less anxious, and was receiving 2 lpm of continuous oxygen via nasal cannula (nc). A progress note, dated 5/8/23 at 3:29 a.m., indicated the resident was alert and oriented x2, normal respiratory, short of breath/trouble breathing when lying flat, and using oxygen. A progress note, dated 5/8/23 at 12:15 p.m., indicated Resident #187 had a pulse of 108, respirations of 22, had a sudden change in level of consciousness, and was noted to be lethargic with altered mental status. The physician was made aware and orders were received to send to emergency room for evaluation and treatment. A review of the Order Summary Report, did not include an order for oxygen. The physician progress note, dated 5/8/23, indicated Resident #187 was found to be lethargic, not answering and was on 4 lpm of oxygen at the time of the visit. The note indicated the physician was informed that the resident had been like that all weekend and morning. On 5/12/23 at 9:05 a.m., Staff G, Registered Nurse/Unit Manager (RN/UM), stated oxygen could be placed (on resident) if it was an emergency and if the oxygen (level) was low. Staff G stated respiratory came in every Thursday and put orders into the computer. If the resident had shortness of breath any day other than Thursday, the staff nurse called (physician) and got an order for oxygen. On 5/12/23 at 9:40 a.m., the Director of Nursing stated nurses were allowed to place oxygen on a resident then get an order from the physician. The DON confirmed there was no order for oxygen and an order should have been obtained after the application of oxygen on 5/6/23. Based on observation, record review and interview, the facility failed to ensure that appropriated care and services related to the use of oxygen was provided to 1 of 25 (#187) sampled residents. Findings included:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure recommendations reported by the consultant pharmacist regarding irregularities in the resident's drug regimen were acted upon for one (Resident #12) of five residents reviewed for unnecessary medications. Findings included: A review of Resident #12's medical record revealed he was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) dated 3/24/23 with a score of 15, which indicated intact cognition. The record indicated the resident had diagnoses that included Essential Hypertension. A review of the resident's physician orders revealed he had a current order dated 1/5/23, to check blood pressure every 8 hours. refer to Clonidine HCI Tablet 0.1 MG order, if sbp [systolic blood pressure] is greater than 160 administer medication every shift for elevated b/p [blood pressure]. A review of the March 2023 Medication Administration Record revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 10 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the April 2023 Medication Administration Record revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 11 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the May 2023 Medication Administration Record, from 5/1/23 to 5/10/23, revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 2 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the Consultant Pharmacy Review dated 3/14/23 revealed the following: PRN order for Clonidine is to be given as needed for SBP> 160. This is not always happening. Recommendation: Please remind staff to administer medications as ordered by the prescriber. A review of the record revealed there was no documentation that would indicate the physician had been made aware of this recommendation. A review of the Consultant Pharmacy Review dated 4/11/23 revealed the following: PRN order for Clonidine is to be given as needed for SBP> 160. This is not always happening. Recommendation: Please remind staff to administer medications as ordered by the prescriber. A review of the record revealed there was no documentation that would indicate the physician had been made aware of this recommendation. A review of the care plan dated 3/16/22, revealed the resident, is on diuretic therapy r/t: hypertension with interventions that included Administer medication as ordered A review of the care plan dated 12/7/22, revealed the resident, has hypertension with interventions that included Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic hypertension and increased heart rate (Tachycardia) and effectiveness. An interview on 5/10/23 at 2:07 p.m., with the Consultant Pharmacist revealed his expectation was that recommendations were addressed by the next visit. He reported that related to the recommendation for the blood pressure for Resident #12 and the use of Clonidine, the facility should follow the physicians order. He said during the April Quality assurance review, he let the Director of Nursing (DON) know there was a problem with parameters. An interview on 05/10/23 at 2:39 p.m., with the DON revealed her expectation was for the facility to follow the physician orders. She said she had trained staff on following the physician orders and the parameters. A review of the facility policy titled Administering Medications with a revised date of December 2012 revealed the following: 3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and five errors were identified for three (Residents #73, #50, and #86) of four residents observed. These errors constituted a 16.13% medication error rate. Findings included: 1. On 5/8/23 at 11:13 a.m., an observation was conducted with Staff D, Registered Nurse (RN) of blood glucose monitoring and the administration of insulin for Resident #73. Staff D obtained a blood glucose level of 233. The staff member returned to the medication cart and removed the resident's pen of Insulin Lispro. The pen was dialed to eight (8) units, the staff member returned to the resident's room, and injected 8 units into the back of the residents' left arm. Following the administration of Resident #73's Insulin Lispro, Staff D confirmed she did not prime insulin pens. She said she was told by one person something like 2 units then at another time was told she did not have to prime insulin pens. During an interview, on 5/12/23, the Director of Nursing provided a quick reference guide which was attached to the medication carts that instructed nurses Prime (Air Shot) insulin pens with each administration with 2 units or Manufacturer's recommendations. Hold the pen with the needle up, tap to move any air bubbles to the top. The manufacturers' literature, located at https://www.lillyinsulinlispro.com, instructed users of an Insulin Lispro Kwikpen to Prime before each injection: - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. The literature identified: - Step 6: to prime your pen, turn the Dose Knob to select 2 units, - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops. and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle. 2. On 5/10/23 at 8:19 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #50. Staff E dispensed the following medications: - Metoprolol Tartrate 100 milligram (mg) tablet - Hydralazine 25 mg tablet - Amlodipine 5 mg tablet - Cetirizine hydrochloride (HCl) 10 mg tablet - Calcium 600 mg tablet - Aspirin 81 mg chewable tablet - Vitamin D 25 microgram (mcg) 1000 international units (IU) -2 tablets - Furosemide 80 mg tablet - Potassium Chloride Extended Release 20 milliequivalent (meq) tablet - Vitamin B complex with folic acid & Vitamin C tablet - Dorzolamide eye drops - Combigan 0.2%-0.5% eye drops Staff E watched Resident #50 take the oral medications and explained the procedure for eye drops. On 5/10/23 at 8:32 a.m., Staff E applied one drop of into the resident's right eye and at 8:35 a.m. applied one drop of Dorzolamide into the resident's right eye, a period of 3 minutes in between the different eye drops. A review of Resident #50's physician order included on the May 2023 Medication Administration Record (MAR), identified an order for Cetirizine hydrochloride (HCl) 5 mg - Give 1 tablet by mouth one time a day for allergy symptoms, started on 6/7/22 and discontinued at 3:15 p.m. on 5/10/23. During an interview on 5/10/23 at 2:15 p.m., the Consultant Pharmacist stated different eye drops should be given 5 minutes in between so that the drops did not wash the other one out. During an interview on 5/10/23 at 1:33 p.m., Staff E confirmed the administration of 10 mg Cetirizine to Resident #50. During the interview with the staff member, the Consultant Pharmacist was reviewing the medication cart and confirmed that 5 mg of Cetirizine was not available in the medication cart. According to the website, medline.gov (https://medlineplus.gov/druginfo/meds/a697049.html) before using dorzolamide eye drops, If you are using another topical eye medication, instill it at least 10 minutes before or after you instill dorzolamide eye drops. A review of clevelandclinic.org, (https://my.clevelandclinic.org/health/drugs/19263-dorzolamide-timolol-eye-solution) instructed users, If you use other eye medications, they should be used at least 10 minutes before or after this medication. The facility policy - Instillation of Eye drops, revised January 2014, identified the purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections, and dry eyes. The guidelines indicated When administering two or more different eye drops allow three to five minutes between each application. The facility policy - Administering Oral Medications, revised October 2010) indicated The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The procedure described in step 6 that staff Check the label on the medication and confirm the medication name and dose with the MAR. Step 8 of the procedure instructed staff to Check the medication dose. Re-check to confirm the proper dose. On 5/12/23 the Director of Nursing stated that the placards at each of the medication carts and the policy indicated that different eye drops should administered 3-5 minutes in between so she stood with that and said staff need to follow (physician) orders. 3. On 5/10/23 at 8:45 a.m., an observation of medication administration with Staff F, Licensed Practical Nurse (LPN), was conducted with Resident #86. Staff F dispensed the following medications: - Vemlidy 25 mg tablets - Spironolactone 50 mg tablet - Carvedilol 25 mg tablet - Pyridium 100 mg tablet - Vitamin B12 1000 mcg tablet - Loratadine 10 mg tablet - Flaxseed oil 1000 mg - 4 large brown capsules - Brimondine 0.2% eye drops On 5/10/23 at 8:51 a.m., Staff F administered oral medications to Resident #86 then the eye drops into both eyes. A review of the physician orders included with Resident #86's May Medication Administration Record (MAR) indicated Staff F had documented 4 tablets of Omega 3 Fatty Acids had been administered for the scheduled 9:00 a.m. dose on 5/10/23. The MAR indicated that the resident had received one tablet of Flaxseed Oil twice a daily, scheduled for 9:00 a.m. and 5:00 p.m. on 5/4 through the 9:00 a.m. dose on 5/8/23, then the order was discontinued. The MAR indicated the resident received one capsule of Flaxseed in the evening of 5/9/23 and the medication had not been administered at 5:00 p.m. on 5/10/23. On 5/10/23 at 8:51 a.m., the Consultant Pharmacist confirmed Flaxseed oil was not the same as Omega 3, Flaxseed comes from a plant. The policy - Administering Medications, revised December 2012, indicated that Medications must be administered in accordance with the orders, including any required time frame. The policy identified The individual administering medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observations, record review, and interviews, the facility failed to ensure that the resident care plan for one (Resident #138) of twenty eight sampled residents was revised to reflect the appropriate use of a Cervical Collar. Findings include: 1. Observations of Resident #138 on 07/20/21 at 11:09 a.m., revealed that the resident was noted to have a neck brace lying on his bed. An interview with the resident at that time revealed that the neck brace was for his neck and that he should have it on. Observations of Resident #138 on 07/22/21 at 1:15 p.m., revealed the resident sitting in his wheelchair with his neck brace on. An interview with the resident at this time revealed that he wore the neck brace whenever he was sitting up. He reported that he did not have it on the other day when he was interviewed because he was eating lunch. He reported that staff took it off when he was eating because it got in the way. An interview on 07/22/21 at 1:20 p.m. with Staff I, Registered Nurse (RN), revealed that the resident had Spinal Stenosis, recently had a laminectomy, and needed to wear his cervical collar when sitting up. She reported that nursing would take it off for him when he ate as he felt more comfortable that way. She reported that the attending physician gave the ok to take the cervical collar off when he ate. Staff I reported that this communication was not documented anywhere and there was no physician order to indicate the physician's directives. An interview on 07/22/21 at 1:30 p.m. with Staff J, Certified Nursing Assistant, (CNA) (Agency staff), revealed that the resident had the collar on all the time except when he ate, the nurses took it off for him when it was time for meals. Review of the order summary revealed that the resident had an order dated 7/1/21 for, Immobilizer [brand name] collar to remain on except while showering until seen by surgeon every shift for placement Review of the care plan dated 7/2/21, related to Activities of Daily Living (ADL) indicated that the Immobilizer [brand name] collar to remain on except while showering until seen by surgeon. Review of the care plan dated 7/1/21, with a revision on 7/2/21, revealed an alteration in Musculoskeletal status with interventions that included, Supervise and assist resident, as needed with the use of supportive devices. An interview on 07/23/21 at 7:50 a.m., with the Director of Nursing (DON), revealed that Resident #138 was complaining of discomfort from the collar and the attending physician told him that he could loosen it up and remove it for meals. She reported that there should have been a physician's order for removing the collar during meals. An interview on 07/23/21 at 8:05 a.m., with Staff K, Minimum Data Set (MDS) Coordinator, reported that the care plan was updated on 7/22/21 to reflect taking off the collar for meals. She reviewed the care plan history and reported that up until 7/22/21 Resident #138 was to have his collar on except during showers. 2. Review of the facility policy titled Goals and Objectives, Care Plans with a revised date of April 2009 revealed that: 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. At least quarterly.

Based on record review, and interviews, it was determined that the facility failed to ensure physician orders were followed as written according to professional quality of care standards for nursing for one (Resident #138) of twenty eight sampled residents. Findings include: 1. According to the 2019 Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as: (18) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b)The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. Observations of Resident #138 on 07/20/21 at 11:09 a.m. revealed that the resident was noted to have a neck brace lying on his bed. An interview with the resident at that time revealed that the neck brace was for his neck and that he should have it on. Observations of Resident #138 on 07/22/21 at 1:15 p.m., revealed the resident sitting in his wheelchair with his neck brace on. An interview with the resident at this time revealed that he wore the neck brace whenever he was sitting up. He reported that he did not have it on the other day when he was interviewed because he was eating lunch. He reported that staff took it off when he ate because it got in the way. An interview on 07/22/21 at 1:20 p.m. with Staff I, Registered Nurse (RN), revealed that the resident had Spinal Stenosis, recently had a laminectomy, and needed to wear his cervical collar when sitting up. She reported that nursing would take it off for him when he ate as he felt more comfortable that way. She reported that the attending physician gave the ok to take the cervical collar off when the resident ate. Staff I reported that this communication was not documented anywhere and there was no physician order to indicate the physician's directives. An interview on 07/22/21 at 1:30 p.m. with Staff J, Certified Nursing Assistant, (CNA) (Agency staff), revealed that the resident had the collar on all the time except when he ate, the nurses took it off for him when it was time for meals. Review of the order summary revealed that the resident had an order dated 7/1/21 for Immobilizer [brand name] collar to remain on except while showering until seen by surgeon every shift for placement An interview on 07/23/21 at 7:50 a.m., with the Director of Nursing (DON), revealed that Resident #138 was complaining of discomfort from the collar and the attending physician told him that he could loosen it up and remove it for meals. She reported that there should have been a physician's order for removing the collar during meals. A policy related to following physician orders was requested of the facility, but not provided.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and two errors were identified for two (Residents #21 and #10) of nine residents observed. These errors constituted a 6.67% medication error rate. Findings included: 1. On 7/20/21 at 3:59 p.m., an observation of medication administration with Staff Member D, Registered Nurse (RN), was conducted with Resident #21. Staff D was observed administering the following medications: - Tizanidine 2 milligram (mg) tablet The staff member dispensed the tablet, crushed it, placed it in a medication cup, and entered the residents room. She placed the medication cup, a box of vinyl gloves, and a bottle of hand sanitizer on the over-bed table. She dissolved the medication in 7.5 cubic centimeter (cc) of water, shut the feeding pump off, disconnected the nutrition from the percutaneous endoscopic gastrostomy (PEG), and inserted a 60 cc syringe into the ostomy. The staff member poured 30 cc's of water into the syringe and had to manipulate the tube for the water to flush. The dissolved medication was poured into the PEG and the staff member flushed with with another 30 cc's of water. She stated she should have checked for residual before the medication but had checked it earlier (which was not observed during the medication administration). A review of Resident #21's physician orders included an order, dated 3/31/15, that instructed staff to: - Enteral Feed: Check residual every shift related to Dysphagia unspecified Gastrostomy Status and before medication (med) administration. Hold 1 hour if above 100 milliliter (mL) and recheck residual; if still above 100 mL Call MD. The documentation indicated staff had documented residual on day, evening, and night shift and had not documented the residual obtained prior to any medication administration. On 7/22/21 at 6:04 p.m., the Director of Nursing (DON) stated her expectation for medication administration via a PEG was for medication to be crushed, if unable to get liquid form. She reviewed Resident #21's physician orders and confirmed that the resident did have an order to check residual prior to administration of medications. 2. On 7/21/21 at 8:47 a.m., an observation of medication administration with Staff Member G, Licensed Practical Nurse (LPN), was conducted with Resident #10. Staff G was observed administering the following medications: - 2 Vitamin D 25 microgram (mcg) 1000 international unit (iu) tablets oral - Clopidogrel 75 milligram (mg) tablet oral - Vitamin B-12 1000 mcg tablet oral - Eliquis 5 mg tablet oral - Escitalopram 10 mg tablet oral - Ferrous Sulfate 325 mg tablet oral - 2 Fish Oil 300 mg softgels oral - Furosemide 80 mg tablet oral - Multivitamin with mineral tablet oral - Oyster shell calcium 500 mg tablet oral - Potassium Chloride Extended Release (ER) 20 milliequivalent (meq) tablet oral - Metoprolol Succinate ER 50 mg tablet oral A review of Resident #10's physician orders indicated an order dated 5/27/21 for: - Multiple Vitamin tablet - Give one tablet by mouth one time a day for supplementation. The order did not instruct staff to administer a multivitamin with mineral tablet. On 7/22/21 at 6:12 p.m., the Director of Nursing (DON) reviewed Resident #10's physician orders and confirmed the resident did not have an order for the administration of a multivitamin with mineral. The policy, General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10 and 1/1/13, indicated that Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident and Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, as needed (prn) medications, application sight) on appropriate forms.

Based on observations, policy review, and interviews the facility failed to ensure that a supplement with a shortened shelf life was dated when opened in one (Med Cart 1) out of three Medication Carts sampled, expired medications were disposed of, and inhalation medications were stored appropriately in one (1 South Med Room) of one Medication Preparation room. Findings included: An observation was conducted at 9:12 a.m. on 7/21/21 with Staff Member D, Registered Nurse (RN) of medication cart #1 on the 300-hallway. A half-empty bottle of cherry-flavored [brand name] sugar free liquid protein was located inside the cart. The bottle was undated as to when it was opened. The RN turned the bottle upside down to locate the manufacturer expiration date of August 2021 and stated she did not have anyone taking [the liquid protein] at that time. According to the manufacturer of [brand name] complete liquid protein(https://www.nutricialearningcenter.com/globalassets/pdfs/specialized-adult-nutrition/prostat_pp-card_sep2018.pdf) users were to Record date on bottom of container upon opening. Discard 3 months after opening. An observation was conducted, on 7/21/21 at 10:05 a.m., with Staff Member E, Licensed Practical Nurse (LPN) of the medication prep room on Unit 1 South. The observation of the refrigerator in the medication room identified a medication bottle which contained a vial of [brand name] insulin prescribed to Resident #51. The medication review for Resident #51 indicated that the resident's [brand name] insulin order was discontinued on 7/20/21. The label indicated that the insulin had expired on 7/10 (2021). A bag of an assortment of inhalation medications was discovered in a drawer next to shelving units containing over-the-counter medications. The enclosed shelving unit restricted the staff's ability to open the drawer all the way. The bag contained inhalation medications prescribed to different residents, which included Resident #40. Resident #40 was admitted to the 1 South unit on 6/8/21 and moved to 3 North on 7/15/21. The Unit Manager arrived to the medication room and stated that the residents that the inhalation medication belonged to had been sent to the hospital and some had come back to the facility. She stated that the nebulizer medications should not have been stored in a drawer and should have been either destroyed or moved with the resident to another unit. The Unit Manager identified that the room had a separate bin for medications to be returned and they could not return the opened medications. On 7/23/21 at 1:41 p.m., a review of the medication storage issues were discussed with the Director of Nursing (DON). She stated that staff know better than that regarding the storage of multiple residents inhalation medication together in a bag in a drawer of the medication room. The DON stated staff should have gotten rid of it regarding the bottle of [liquid protein] and the vial of [insulin]. The Consultant Pharmacist stated, on 7/23/21 at 2:23 p.m., that if a medication had a shortened shelf life the bottle should be dated when opened and regarding the storage of inhalation medications in the drawer she stated, maybe that's where they had room (to store the medication). The policy, Storage and Expiration of Medications, Biologicals, Syringes, and Needles effective 12/1/07 and revised 5/1/10 and 1/1/13, identified that facility should ensure that medications and biologicals: - have not been retained longer than recommended by manufacturer or supplier guidelines; - that the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened; - facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines.

Based on observation, interview, and record review, the facility did not maintain the kitchen in a safe and sanitary manner related to failing to ensure that the range hood was free from dust and grease. Findings include: Observations during the initial tour of the facility's kitchen on 7/20/21 at 10:55 a.m., revealed that the kitchen housed a range hood which was located over the kitchen stove, fryer and steam oven. Closer observation of the range hood revealed dust particles on the light covers. Closer observation of the range hood revealed that grease build-up was noted on the inner sides and inner edges of the range hood. (Photographic Evidence Obtained) During the initial tour, Staff H, Certified Dietary Manager (CDM) revealed that the vendor for the range hood came in and serviced/cleaned it quarterly. The company was last in the facility in April and was due to come back this month. He reported that in between the vendor's visits, the kitchen staff wipe down the range hood after every shift. Observations on 7/22/21 at 10:30 a.m. during the comprehensive tour of the kitchen, revealed that the range hood still had dust particles on the light covers, and the grease build-up was still on the inner sides and and inner edges of the range hood. Review of the vendor's last Job Service Report dated 4/26/21, indicated that the system was cleaned. Review of the facility's Log book Documentation revealed that the last monthly inspection of the range hood was completed on 6/9/21. This checklist did not include an inspection of grease build up on the range hood surface or dust build up on any area under the hood. An interview on 7/22/21 at 11:27 a.m. with the full campus Maintenance Director, revealed that the maintenance department received work orders from the kitchen if repairs were needed. He reported that quarterly cleaning was completed by a vendor and that the next visit was scheduled for this Sunday. He reported that in between the vendor's visits the kitchen staff would complete the cleaning of the range hood. Review of the facility policy titled Sanitization with the revised date of October 2008 revealed the following: 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.