**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (#6) of 7 (#6, #12, #14, #15, #16, #17, #18) sampled residents. The facility failed to ensure nursing staff maintained the integrity of Resident #6's medical record.Findings:Review of the facility's policy Nursing Documentation, policy number POL 1008 with an effective date of 10/01/2009 and a reviewed and approved date of 01/11/2023 revealed in part:1.0 Purpose:1.1 The purpose of Nursing policy is to:1.1.1 Define standard of performance for quality patient care2.0 Policy:2.5 Incorrect Entry:2.5.1 Handwritten Documentation: when an incorrect entry is made the nurse shall draw a single line through the incorrect material, making sure it is still legible, date and initial, NEVER obliterate the incorrect entry with overwrites, whiteout, markers, or scratching out, rewrite the correct entry/order underneath the original. Review of Resident #6's medical record on 09/02/2025 revealed in part, Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's orders on 09/02/2025 revealed in part, a telephone order dated 08/25/2025 at 12:20 p.m. which read as follows:Discontinue continuous enteral feeding. Start ensure after meals if eats less than 50%. TORB (Telephone Order Read Back) S3Registerd Dietician/S4Medical Doctor/S2Registered Nurse. Further review of Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. revealed a liquid correction fluid had been used at the beginning of the order and the words Discontinue continuous had been written on top of the dried liquid correction fluid completely concealing what was underneath the liquid correction fluid. During an interview on 09/02/2025 at 4:49 p.m., S1Administrator reported S2Registered Nurse wrote Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. S1Administrator acknowledge the use of a liquid correction fluid on Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. and confirmed the use of liquid correction fluid did not follow the facility's policy regarding documentation and an incorrect entry. S1Administrator confirmed S2Registerd Nurse should not have used a liquid correction fluid to correct an order in Resident #6's medical record.

Based on record review and interview the facility failed to ensure Certified Nurse Aide (CNA) registry verification was completed prior to hire for 3 (S4, S5, S6) of 5 CNA (S4, S5, S6, S7, S8) personnel files reviewed. Review of S4 CNA's (Certified Nursing Assistant) personnel record revealed a hire date of 09/09/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. Review of S5 CNA's personnel record revealed a hire date of 05/01/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. Review of S6 CNA's personnel record revealed a hire date of 09/09/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. During an interview on 11/04/2024 at 4:15 p.m. S1 Administrator reviewed personnel records and verified the registry check had not been completed on hire for S4 CNA, S5 CNA, and S6 CNA and should have been.

Based on record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. Signage was present at Resident #112's door entrance regarding type of precautions required for Resident #112, who had wounds. 2. PPE (personal protective equipment) was available at the entrance to Resident #112's room. 3. Wound care staff wore proper PPE while conducting wound care for Resident #112. Findings: Review of Resident #112's medical record revealed an admit date of 11/01/2024 with diagnoses that included, in part, hypertensive heart disease with heart failure, peripheral vascular disease, stage 1 left heel pressure injury, right heel and right achilles DTPI (deep tissue pressure injury), and stage 1 sacrum pressure injury. Review of Resident #112's physician orders revealed an order dated 11/03/2024 for right heel and right Achilles (DTPI): cleanse with wound cleanser and pat dry with gauze. Cover with 4X4 foam border dressing every 5 days and PRN (as needed) - every 5 days. Review of Resident #112's Wound Initial/Discharge Skin Impairment with an admission date of 11/01/2024 revealed: 11/03/2024 at 10:00 a.m. - admission assessment complete . DTPI to right heel, PTW (partial thickness wound) to 50% of wound bed, while other 50% is intact with maroon discoloration. Area is without drainage. Covered with foam border. DTPI with dark purple coloration to right Achilles, also covered with foam border. Observation on 11/06/2024 at 8:20 a.m. failed to reveal enhanced barrier precaution signage at the entrance to Resident #112's room and failed to reveal PPE cart was immediately available at the entrance to Resident #112's room. Observation on 11/06/2024 at 8:55 a.m. revealed S11 Wound Care Nurse, with assistance of S12 OTR-L (Occupational Therapist, Registered, Licensed), conduct wound care to Resident #112's right heel without wearing a gown. During an interview on 11/06/2024 at 12:50 p.m. S9 RN (Registered Nurse) reported she was aware of enhanced barrier precautions for residents with lines or a Foley but she was not aware a gown was required when working with Resident #112, who had pressure wounds. During an interview on 11/06/2024 at 12:55 p.m. S10 DON (Director of Nursing) reported he was aware of enhanced barrier precautions and that Resident #112 had wounds S10 DON acknowledged PPE should be available at Resideent #112's room entrance, signage should be posted indicating Resident #112 was on enhanced barrier precautions and staff should have worn a gown during Resident #112's wound care. During an interview on 11/06/2024 at 1:16 p.m. S11 Wound Care Nurse acknowledged she did not wear a gown during Resident #112's wound care and should have.

Based on record review, interviews and observation, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure a resident's personal clothing was processed in a safe and sanitary manner for 1 (#1) of 5 (#1, #4, #21, #74, and #124) residents who resided in the facility, according to the Resident Census and Conditions of Residents form. Review of the Infection Control binder failed to reveal a written Policy and Procedure for Laundry Processing was in place. During an interview on 10/02/2023 at 2:00 p.m., S1Administrator reported laundry processing is contracted through a local hospital. S1Administrator further reported the facility has a washing machine on site, which has been used in the past to launder residents' personal clothing. S1Administrator further reported the washing machine does not meet the temperature or sanitation process requirements. S1Administrator further reported he had recently washed Resident #1's clothing on site because family resides out of town. Observation of the Therapy workroom on 10/02/2023 at 3:00 p.m. with S1Administrator revealed a standard washer and dryer set. During an interview on 10/02/2023 at 2:00 p.m., S1Administrator confirmed the Therapy washing machine had been used to launder residents' personal clothing. S1Administrator reported temperature and chemical checks were not monitored on the Therapy washing machine. S1Administrator further reported the facility did not have a process in place to launder residents' personal clothing in-house. During an interview on 10/02/2023 at 4:10 p.m., S1Administrator acknowledged facility did not have a written Policy and Procedure for in-house processing of residents' personal clothing and should.

Based on record reviews and an interview the provider failed to develop a Baseline Care Plan within 48 hours of a resident's admission and/or included needed healthcare information necessary to provide effective and person-centered care for 3 (#4, #74, # 124) of 5 (#1, #4, #21, #74, and #124) sampled residents. Findings: Resident #4 Review of Resident #4's clinical record revealed an admit date of 09/06/2023 and diagnoses which included in part, essential hypertension and chronic diastolic congestive heart failure. Review of Resident #4's admit physician's orders revealed in part: Order dated 09/06/2023 Lasix 40 mg (milligram) one po (by mouth) every day. Review of Resident #4's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for edema checks related to the use of Lasix (diuretic). Review of Resident #4's September 2023 and October 2023 MARs (Medication Administration Record) failed to reveal monitoring for edema related to the use of Lasix. Further review of Resident #4's clinical record failed to reveal any documentation of monitoring for edema related to the use of Lasix. During an interview on 10/03/2023 at 2:35 p.m. S4MDS (Minimum Data Set) Nurse, confirmed monitoring for edema related to the use of Lasix had not been added to Resident #4's Baseline Care Plan and should have been. Resident #74 Review of Resident #74's clinical record revealed an admit date of 09/29/2023 and diagnoses which included in part, cerebral infarction due to unspecified occlusion, or stenosis of right post cerebral artery and chronic systolic congestive heart failure. Review of Resident #74's admit physician's orders revealed in part: Order dated 09/29/2023 Furosemide 20 mg one po every day. Order dated 09/29/2023 Eliquis 5 mg one po twice a day. Review of Resident #74's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for monitoring of bleeding related to the use of Eliquis (anticoagulant) or edema checks related to the use of Lasix. Review of Resident #74''s current MAR failed to reveal monitoring for bleeding related to the use of Eliquis or monitoring for edema related to the use of the Lasix. Further review of Resident #74's clinical record failed to reveal any documentation of monitoring for bleeding related to the use of Eliquis or edema related to the use of Lasix During an interview on 10/03/2023 at 2:35 p.m., S4MDS Nurse confirmed monitoring for edema related to the use of Lasix and monitoring for bleeding related to the use of Eliquis had not been added to the Baseline Care Plan and should have been. Resident #124 Review of Resident #124's clinical record revealed an admit date of 09/22/2023 and diagnoses which included in part, cardiomyopathy, congestive heart failure and generalized anxiety disorder. Review of Resident #124's admitpPhysician's orders revealed in part:: Order dated 09/22/2023 Lasix 40 mg one po every day. Order dated 09/22/2023 Zoloft 100 mg one po every day. Review of Resident #124's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for edema checks related to the use of Lasix and side effect monitoring related to the use of Zoloft (antidepressant). Review of Resident #124's September 2023 and October 2023 MARs failed to reveal monitoring of edema related to the use of Lasix or side effects related to the use of Zoloft. Further review of resident #124's clinical record failed to reveal any documentation of monitoring of edema related to the use of Lasix and monitoring of side effects related to the use of Zoloft. During an interview on 10/03/2023 at 2:35 p.m., S4MDS Nurse confirmed monitoring for edema related to the use of Lasix and side effects related to the use of Zoloft had not been added to Resident #124's Baseline Care Plan and should have been.

Based on observation and interview, the facility failed to ensure drugs were stored and labeled properly in accordance with current accepted professional principles by having expired medications in the Medication Storage room. Findings: Observation of Medication Storage with S2DON (Director of Nursing) and S3RN (Registered Nurse) on 10/03/2023 at1:40 p.m. revealed the following stock medications had expired: - Famotidine 20 mg tablets with an expiration date of 05/02/2023. - Promethazine 25 mg tablets with an expiration date of 08/26/2023. During an interview on 10/03/2023 at 1:40 p.m., S2DON and S3RN acknowledged stock Famotidine and Promethazine medications had expired and should have been discarded.