Based on observation, record review, and interview, the facility failed to prevent accidents for 1 (#54) of 3 residents sampled for accident hazards. The DON identified three residents ambulated with wheelchairs independently. Findings: On 05/13/25 at 9:00 a.m., Resident #54 was observed ambulating in a wheelchair. Resident #54's hands were observed to have bruising on their right and left knuckles and the back of their hands. A facility policy titled Accident and Incidents -Investigating and Reporting, dated 07/2017, read in part, All accidents or incidents involving residence, employees, visitors, vendors, etc. [et cetera], Occurring on premises shall be investigated and reported to the administrator.Incident/accident reports will be reviewed for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Resident #54's admission record, dated 07/05/22, showed they were admitted with diagnoses which included edema, muscle weakness, and hyperlipidemia. Resident #54's care plan, dated 03/25/25, read in part, Approach: Xarelto [anticoagulant] Use - Many drugs interact with Xarelto to affect clotting time: most antibiotics, antifungals, anticonvulsants, anti-ulcer drugs, SSRI [selective serotonin reuptake inhibitors] antidepressants, various other drugs. Use caution when starting, changing, or discontinuing any medications on residents taking Xarelto. Monitor for S/S of bleeding. Notify Physician of any change in condition. Resident #54's quarterly MDS assessment, dated 04/05/25, showed their BIMS score was 15 indicating their cognition was intact for decision making. The assessment showed they ambulated with the assistance of a wheelchair independently and was prescribed and taking an anticoagulant. Resident #54's physician orders, dated 04/28/25, read in part, Xarelto (rivaroxaban) tablet; 20 mg; amt: 1 tab; oral at Bedtime. On 05/13/25 at 9:01 a.m., Resident #54 stated they bumped and hurt their hands while ambulating with a wheelchair and bruised easily due to taking an anticoagulant. On 05/14/25 at 9:42 a.m., LPN #1 was asked to discuss the bruising observed on Resident #54's hands. They stated the resident self propelled in their wheelchair and bumped into things and bruised because they were prescribed an anticoagulant. LPN #1 was asked what was done to prevent the injury. LPN #1 stated they had not done anything and did not document the bruising to the hands in the TAR for side effect monitoring of anticoagulants and did not complete an incident report. On 05/14/25 at 9:52 a.m., the ADON stated Resident #54's hands had several bruises on the backs of both hands due to Resident #54's hands on the doors while ambulating with a walker and a wheelchair. They stated the injuries had occurred since admission. They were asked what interventions were in place to prevent injury to the resident's hands. They stated the last intervention was educating the resident on 07/18/22. The ADON stated they needed to do an incident report and care plan and intervention to prevent further injury. On 05/14/25 at 10:19 a.m., the DON stated Resident #54 was not assessed after they reported the injuries to their hands and nursing should of assessed the resident and completed an incident report . The DON stated there were no interventions to prevent the bruising of the hands related to the resident ambulating with a wheelchair or walker.

Based on record review and interview, the facility failed to ensure a resident received pain medication in a timely manner for 1 (#315) of 2 sampled residents reviewed for pain management. The administrator identified 115 residents resided in the facility Findings: A policy titled Administering Pain Medications, revised 10/2022, read in part, Administer pain medications as ordered. Resident #315's medications administration history, dated 05/2025, showed the resident had diagnoses which included displaced intertrochanteric fracture of right femur, sequela and unspecified pain. Resident #315's physician's order, dated 05/05/25, showed tramadol (opioid pain medication) 50 mg oral, may take one tablet every four hours as needed by mouth for pain and diagnosis of displaced intertrochanteric fracture of right femur, sequela. A baseline care plan, dated 05/06/25, showed Resident #315's cognition was intact. Resident #315's medications administration history, dated 05/12/25, showed the resident received tramadol at 9:06 a.m. Resident #315's medications administration history, dated 05/12/25, showed the resident received tramadol at 2:09 p.m. On 05/12/25 at 1:03 p.m., Resident #315 asked CNA #1 for their pain medication. On 05/12/25 at 1:08 p.m., Resident #315 stated they had right hip surgery. They stated it took a long time to receive their pain medicine when they asked for it. On 05/12/25 at 1:10 p.m., Resident #315 stated their pain rating was a 10 out of 10 on the numerical pain scale because they wheeled themselves back to their room from the dining room. They stated their pain was all over. On 05/13/25 at 2:28 p.m., CNA #1 stated if a resident request pain medication, they would inform the nurse as soon as they were through and the nurse would inform the CMA. On 05/13/25 at 2:29 p.m., CNA #1 stated they informed LPN #2 and LPN #2 informed CMA #1 that Resident #315 needed pain medication. They stated CMA #1 stated it was not time for the resident to received their pain medication. CNA #1 stated they could not recall the time they told the nurse. On 05/13/25 at 2:36 p.m., CMA #1 stated if a resident request pain medication, they would inform the nurse and the nurse would assess the resident and tell the CMA what to give. On 05/13/25 at 2:37 p.m., CMA #1 stated they offered residents pain medication right away to keep their pain under control. On 05/13/25 at 2:38 p.m., CMA #1 stated Resident #315's tramadol order was for every four hours as needed. On 05/13/25 at 2:41 p.m., CMA #1 stated they administered the tramadol twice on 05/12/25. They stated at 9:06 a.m. and 2:09 p.m. CMA #1 stated Resident #315 did not receive any pain medication between 1:00 p.m. and 2:00 p.m. On 05/13/25 at 2:42 p.m., CMA #1 stated LPN #2 informed them of the resident's request for pain medication some time after 2:00 p.m. on 05/12/25. On 05/13/25 at 2:44 p.m., CMA #1 stated they did not remember discussing with CNA #1 about the resident's request of pain medication. They stated they did not remember telling CNA #1 and LPN #2 that it was not time for the resident to have their pain medication on 05/12/25. On 05/13/25 at 2:45 p.m., CMA #1 stated it was not acceptable for the resident to wait an hour for their pain medication. On 05/13/25 at 2:53 p.m., the DON stated it was not acceptable for the resident to wait an hour for the pain medication if the resident could have it.

Based on observation, record review, and interview, the facility failed to document side effect monitoring for the use of anticoagulants for 1 (#54) of 5 residents sampled for side effect monitoring of anticoagulants. The DON identified 22 residents were prescribed anticoagulants. Findings: On 05/13/25 at 9:00 a.m., Resident #54 was observed ambulating in a wheelchair. Resident #54's hands were observed to have bruising on their right and left knuckles and back of their hands. A facility policy titled High Risk Medications-Anticoagulants, read in part, The facility recognizes that some medication's, including anticoagulant, are associated with greater risk of adverse consequences than other medications.The residents plan of care shall alert staff to monitor for adverse consequences. Resident 54's admission record, dated 07/05/22, showed they were admitted with diagnoses which included edema, muscle weakness, and hyperlipidemia. Resident #54's TAR, dated 02/01/25 through 05/13/25, did not document bruising on the resident's hands related to side effect monitoring of anticoagulants and/or in the skin inspections. Resident #54's care plan, dated 03/25/25, read in part, Approach: Xarelto [anticoagulant] Use - Many drugs interact with Xarelto to affect clotting time: most antibiotics, antifungals, anticonvulsants, anti-ulcer drugs, antidepressants, various other drugs. Use caution when starting, changing, or discontinuing any medications on residents taking Xarelto. Monitor for S/S, of bleeding. Notify Physician of any change in condition. Resident #54's quarterly MDS assessment, dated 04/05/25, showed their BIMS score was 15 indicating their cognition was intact for decision making. The assessment showed they ambulated with the assistance of a wheelchair independently and was prescribed and taking an anticoagulant. Resident #54's physician orders, dated 04/28/25 read in part, Xarelto (rivaroxaban) tablet; 20 mg; amt: 1 tab; oral at Bedtime. On 05/13/25 at 9:01 a.m., Resident #54 stated they bumped and hurt their hands while ambulating with a wheelchair and bruised easily due to taking an anticoagulant. On 05/14/25 at 9:42 a.m., LPN #1 was asked to discuss the bruising observed on Resident #54's hands. They stated the resident self propelled in their wheelchair and bumped into things and bruised easily because they were prescribed an anticoagulant. LPN #1 stated they did not document the bruising to the hands in the TAR for side effect monitoring of anticoagulants or in the the skin inspections in the TAR. On 05/14/25 at 10:19 a.m., the DON stated Resident #54's TAR from 02/01/25 through 05/13/25 did not document the reported bruising observed on Resident #54's hands in the anticoagulant side effect monitoring or the skin inspections.

Based on observation, record review, and interview, the facility failed to ensure: a. a resident had a physician's order for oxygen administration for 1 (#98); and b. oxygen was administered as ordered for 1 (#11) of 2 sampled residents reviewed for respiratory services. The DON identified 28 residents received oxygen in the facility. Findings: 1. On 05/12/25 at 11:25 a.m., Resident #98 was observed to be on four liters of oxygen via nasal cannula. The oxygen tubing was dated 04/28. There was no documentation Resident #98 had an order for the use of oxygen. A policy titled Oxygen Administration, revised 10/10, read in part, Oxygen is administered under orders of physician, except in the case of resident with shortness of breath or respiratory distress, as needed. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable. Resident #98's physician order report, dated 05/2025, showed the resident had diagnoses which included unspecified combined systolic and diastolic congestive heart failure and dementia. Resident #98's quarterly resident assessment, dated 05/08/25, showed the resident had severe cognitive impairment with a BIMS score of 04. A progress note, dated 05/13/25 at 3:06 p.m., read in part, resident has been complaining of shortness of breath most of the day, lungs clear in all quads, 02 sats 98-96% room air. heart rate 90 -100 .02 2 liters given at 2 liters per n/c [nasal cannula], resident was able to calm down. A progress note, dated 05/09/25 at 3:28 p.m., read in part, Resident complained of shortness of breath, around 3:15, this nurse checked on them. 02 Sat-97%. Placed on 02 at 2 liters, encouraged to take deep breaths. On 05/12/25 at 11:25 a.m., Resident #98 stated they started using oxygen occasionally about a week or two ago. On 05/12/25 at 11:26 a.m., Resident #98 stated they did not know how much oxygen they were receiving. On 05/14/25 at 8:36 a.m., Resident #98 stated they did not need oxygen this morning. They stated the nasal cannula tubing was changed yesterday on 05/13/25. On 05/14/25 at 9:48 a.m., CNA #2 stated Resident #98 used oxygen every night. They stated they cared for the resident last week and this morning. On 05/14/25 at 9:49 a.m., CNA #2 stated the resident had on oxygen this morning on 05/14/25, but took it off when they got up. On 05/14/25 at 9:55 a.m., LPN #3 stated they were not aware the resident used oxygen. On 05/14/25 at 9:57 a.m., LPN #3 stated there was no order for the use of oxygen. On 05/14/25 at 9:59 a.m., LPN #3 stated if a resident had low oxygen saturation, they would call the doctor and get an order. On 05/14/25 at 10:07 a.m., the DON stated if a resident had shortness of breath, or in respiratory distress, they would administer oxygen and notified the provider for orders. 2. On 05/12/25 at 11:39 a.m., Resident #11 was observed to be on five liters oxygen via a nasal cannula. On 05/14/25 at 1:19 p.m., Resident #11 was observed to be on five liters of oxygen via a nasal cannula. A physician's order, dated 01/26/24, showed oxygen at three liters via nasal cannula continuously related to chronic obstructive pulmonary disease. Resident #98's physician order report, dated 04/14/25 to 05/14/25, showed the resident had diagnoses which included chronic obstructive pulmonary disease with acute exacerbation. Resident #11's discharge assessment-return anticipated, dated 05/01/25, showed the resident's memory was ok with some difficulties in cognitive skills for daily decision making. On 05/14/25 at 1:29 p.m., LPN #4 stated they last checked the resident's oxygen saturation at 9:11 a.m. on 05/14/25 and it was 98% on three liters. On 05/14/25 at 1:33 p.m., LPN #4 stated Resident #11's oxygen was set at five liters on the concentrator. On 05/14/25 at 1:34 p.m., LPN #4 stated the oxygen rate was incorrect. They stated it should be three liters as ordered.

Based on observation and interview, the facility failed to ensure incontinent care was provided to dependent residents at least every two hours for two (#4 and #5) of five dependent residents observed for receiving incontinent care. The DON identified 112 residents resided in the facility. Findings: 1. A Comprehensive Assessment for Resident #4, dated 06/10/24, documented they had impaired ROM to both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 2. A Comprehensive Assessment for Resident #5, dated 06/18/24, documented they had impaired ROM to both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. On 08/13/24 at 11:30 a.m., Resident #4 and Resident #5 were observed in the facility dining room on the lower level. On 08/13/24 at 12:30 p.m., Residents #4 was escorted in their reclining geri-chair from the dining room to their room and placed beside their bed by CNA #1. On 08/13/24 at 1:12 p.m., Residents #5 was escorted in their reclining geri-chair from the dining room to their room and placed beside their bed by CNA #2. On 08/13/24 at 2:00 p.m., after uninterrupted observation on the hall from 12:30 p.m., Resident #4 and Resident #5 were observed in their rooms sitting in their reclining geri-chairs, at the side of their beds. No staff had been observed entering or exiting Resident #4's room since 12:30 p.m. No staff had been observed entering or exiting Resident #5's room since 1:12 p.m. On 08/13/24 at 2:50 p.m., after uninterrupted observation from 2:00 p.m. to this time, CNA #1 and CNA #2 were observed while they put Resident #5 in bed and performed peri-care. Resident #5's brief was observed to be grossly saturated and contained a medium bowel movement. On 08/13/24 at 3:14 p.m., after further observation of Resident #4 sitting in their reclining geri-chair at the side of their bed, this surveyor asked CNA #3 who from the day shift was responsible for Resident #4's care. CNA #3 stated, I am, but I'm working 16 hours. CNA #3 was informed of my observations and immediately following our conversation, CNA #3 and CNA #4 were observed while they put Resident #4 in bed and performed peri-care. Resident #4's brief was observed to be moderately saturated and blanchable redness was noted to entire buttocks and sacral area. On 08/14/24 at 2:16 p.m., the DON was asked the facility policy regarding incontinent care for dependent residents. They reported dependent residents should be checked and/or provided incontinent care at least every two hours. The DON was informed of my observation for Residents #4 and #5. They acknowledged facility policy had not been followed for the above residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an MDS was coded accurately for one (#23) of 24 sampled residents whose MDS assessments were reviewed. The Administrator identified 116 residents resided in the facility. The DON stated nine residents were receiving Plavix. Findings: Resident #23 had diagnoses which included atherosclerotic heart disease. An Order Summary report, dated 11/21/23, documented Resident #23 received Plavix once a day. An Annual assessment, dated 01/18/24, documented Resident #23 received an anticoagulant. A MAR, dated January for 2024, did not document Resident #23 received an anticoagulant. On 02/07/24 at 11:10 a.m., MDS Coordinator #1 stated medications were coded on the MDS if the resident took the medication in the seven day look back period. They stated Plavix was coded as an antiplatelet. MDS Coordinator #1 reviewed Resident #23's annual assessment dated [DATE]. They stated an anticoagulant was coded. They weren't able to locate an anticoagulant physician's order. They stated the MDS was not coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure staff locked medication/treatment carts prior to leaving carts unattended for two of two carts observed unlocked. The DON identified five medication carts and five treatment carts were in the facility. Findings: The facility's Storage of Medications policy, revised March 2019, read in part, .Compartments .containing drugs and biologicals shall be locked when not in use, and .carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On 02/01/23 at 10:16 a.m., an unlocked and unattended treatment cart was observed in the hallway, outside rooms [ROOM NUMBERS]. On 02/01/23 at 10:17 a.m., RN #1 was observed to come out of room [ROOM NUMBER], walked to the treatment cart, and locked it. On 02/03/23 at 7:52 a.m., CMA #1 was observed to leave the medication cart outside room [ROOM NUMBER]. CMA #1 was observed to walk down the hall to room [ROOM NUMBER] leaving the medication cart unlocked and unattended. On 02/03/23 at 7:55 a.m., CMA #1 was observed to come back to the unlocked medication cart. They were asked how staff ensured medication carts were locked. CMA #1 stated they pushed the lock in the cart and took the keys when they left the cart. They were asked if the cart had been left unlocked. CMA #1 stated, Yes, I thought I pushed it in but didn't. On 02/03/23 at 8:50 a.m., LPN #1 was asked how staff ensured medication and treatment carts were locked. They stated the staff were to double check prior to walking away from the cart.

Based on record review, observation, and interview, the facility failed to ensure staff wore gloves while administering insulin to one (#252) of two sampled residents reviewed for insulin administration. The ADON identified 13 residents received insulin. Findings: The facility's Subcutaneous Injections policy, reviewed March 2011, read in part, .Put on gloves .inject needle quickly .remove gloves . Resident #252 had diagnoses which included type two diabetes mellitus. A Physician Order, dated 01/21/23, documented to administer Humulin insulin per sliding scale. On 02/01/23 at 7:54 a.m., RN #1 stated to Resident #252, You get two units. RN #1 was observed to administer an injection subcutaneously to Resident #252's left upper arm without wearing gloves. RN #1 was asked what was the protocol for administering insulin. They stated staff checked the blood sugar, checked the physician order, then administered insulin. RN #1 was asked if they wore gloves when administering insulin. They stated they hadn't been taught to wear gloves when administering insulin. On 02/03/23 at 8:48 a.m., LPN #1 was asked if staff wore gloves when administering insulin. They stated, Yes.