THE SPRINGS AT ST. ANDREWS VILLAGE

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 07, 2026, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." This structure is a two-story, Type II (111) construction. This original facility was constructed in 2006. There is a partial basement used for support services, and there is no resident access. There is an assisted living unit and an independent living unit. The Assisted Living and Independent Living areas are separated from the long-term care facility by a two-hour fire-rated wall. The facility is licensed for 58 beds, and the census on the date of the survey was 57. The facility is fully protected by the National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler systems. The facility is classified as fully sprinklered. The results of this survey were discussed with the Maintenance Director during the exit conference conducted on April 07, 2026. No violations were found during the survey; therefore, no action is needed.

A recertification survey with complaint #CO2718022 and #CO2789114 was completed on 3/23/26 to 3/26/26. Ten deficiencies were cited.

An Emergency Preparedness survey was completed on 3/23/26 to 3/26/26. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#19, #74 and #75) of 10 residents reviewed for dignity out of 32 sample residents. Specifically, the facility failed to ensure Resident #19, Resident #74 and Resident #75 had the right to a dignified existence by being provided privacy in their personal bathrooms. Findings include:I. Resident #19A. Resident statusResident #19, age 84, was admitted on 10/10/25. According to the March 2026 computerized physician orders (CPO), diagnoses included stroke, unspecified dementia, anemia and hypertension. The 1/26/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required partial staff assistance for transferring and toileting. She used a wheelchair for mobility and was able to propel herself. B. ObservationResident #19's room was observed on 3/23/26 at 9:13 a.m. The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. Resident #19's room was observed on 3/24/26 at 12:00 p.m. Resident #19 was observed propelling herself out of her bathroom. The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. Resident #19's room was observed again on 3/24/26 at 1:15 p.m. with the maintenance director (MTD). The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. C. Resident interviewResident #19 was interviewed on 3/24/26 at 12:00 p.m. Resident #19 said she took herself to the bathroom and was unable to have privacy in the bathroom because she was supposed to have a curtain to close but she had not had a curtain for at least two days. Resident #19 said she could not get to her room door to close it and then to the bathroom before she had an incontinence episode, so she just had to go straight to the bathroom and hope that no one came into her room. II. Resident #74A. Resident statusResident #74, age 74, was admitted on 3/22/26. According to the March 2026 CPO, diagnoses included sepsis and infection of the spine. The 3/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup from staff for transferring and toileting. She used a wheelchair for mobility and was able to propel herself. B. ObservationResident #74's room was observed on 3/23/26 at 11:45 a.m. The resident’s bathroom had a sliding door but the door would not close all the way and closed less than halfway. Resident #74's room was observed on 3/24/26 at 8:15 a.m. The resident’s bathroom door was still askew and would not shut all the way. Resident #74's room was observed again on 3/24/26 at 1:05 p.m. with the MTD. The resident’s bathroom door was still askew and would not shut all the way. The MTD tried to close the door, but it was not on the track and it took the MTD five minutes to align the door back on the track. C. Resident interview Resident #74 was interviewed on 3/23/26 at 11:45 a.m. Resident #74 said her sliding bathroom door had been broken since she was admitted to the facility on 3/22/26. She said the door would not close all the way when she was trying to use the bathroom and it was embarrassing to her when she tried to use the toilet and could not close the door all the way. III. Resident #75A. Resident statusResident #75, age 84, was admitted on 3/21/26. According to the March 2026 CPO, diagnoses included fracture of the left femur and unspecified fall. The 3/21/26 MDS assessment had not been completed at the time of the survey. According to the 3/21/26 at 1:55 p.m. admission progress note, the resident was alert and oriented times four (person, place, time and reason for care) and required one-person assistance with activities of daily living (ADL) and transfers. B. ObservationResident #75's room was observed on 3/23/26 at 11:45 a.m. The resident shared a room with Resident #74 (see above). The resident’s bathroom had a sliding door but the door would not close all the way and closed less than halfway. Resident #75's room was observed on 3/24/26 at 8:15 a.m. The resident’s bathroom door was still askew and would not shut all the way. Resident #75 was observed walking to the bathroom. When Resident #75 tried to close the bathroom door, she could not get the door to close beyond halfway and she sat on the toilet, visible to anyone in the room. Resident #75's room was observed again on 3/24/26 at 1:05 p.m. with the MTD. The resident’s bathroom door was still askew and would not shut all the way. The MTD tried to close the door, but it was not on the track and it took the MTD five minutes to align the door back on the track. C. Resident interviewResident #75 was interviewed on 3/23/26 at 11:45 a.m. Resident #75 said her sliding bathroom door had been broken since she was admitted to the facility on 3/21/26. Resident #75 said the door was always askew and would not close all the way, leaving her using the bathroom exposed. Resident #75 was interviewed again on 3/24/26 at 1:05 p.m. Resident #75 said not being able to close her bathroom door when using the toilet had been horrible. IV. Staff interviewsThe MTD was interviewed on 3/24/26 at 1:20 p.m. The MTD said his housekeepers cleaned the residents’ bathrooms daily and no one had reported to him that there was a problem with the door in Resident #74 and Resident #75’s shared room. The MTD said that the housekeepers had taken down the privacy curtain in Resident #19’s room to clean the curtain and there was a turnaround time from laundry of 24 to 48 hours on returning the curtain. He said in the meantime, the staff encouraged her to close her bedroom door when using the toilet. Certified nurse aide (CNA) #2 was interviewed on 3/24/26 at 4:12 p.m. CNA #2 said she was aware of the bathroom door in Resident #74 and Resident #75’s shared room that would not close all the way and said she did not submit a work order to maintenance because she thought someone else had. CNA #2 said the residents’ bathroom door had been that way for at least three days. The laundry aide was interviewed on 3/25/26 at 9:00 a.m. The laundry aide said there was not a shortage of bathroom privacy curtains in the laundry room and she showed a stack of clean curtains. The laundry aide said a resident should not have to wait 24 to 48 for a curtain to be replaced. She said when the CNAs sent down a curtain to the laundry, they did not put a room number on it, so if the laundry aide was not made aware of where the curtain needed to be returned to, this delayed getting a curtain put back up. CNA #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said the CNAs put dirty linens down a laundry chute to be collected by the laundry staff and washed. CNA #1 said the CNAs did not touch the bathroom privacy curtains. She said the housekeepers collected the privacy curtains and put them back up after cleaning. Housekeeper (HK) #1 was interviewed on 3/26/26 at 8:39 a.m. HK #1 said the laundry aides took the privacy curtains in the residents’ bathrooms down, cleaned the curtains and then returned the curtains. HK #1 said the housekeepers did not do anything with the privacy curtains. The MTD, the nursing home administrator (NHA) and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m.. The MTD said the curtain in Resident #19’s bathroom had not been replaced yet because there were not any clean curtains that would fit and the only curtains available were too long. He said he had not considered putting a longer curtain up to ensure privacy for the residents, instead he had planned on letting the housekeepers put up the original curtain once it was clean. The MTD was unable to explain the inconsistencies in the process of removing, cleaning, and replacing the privacy curtains reported by the laundry aide, CNA #1 and HK #1 (see interviews above). The NHA said the residents should never be without a curtain for privacy. The regional plant resource said he would order more curtains to ensure a clean curtain could be put up immediately once a dirty curtain was taken down. V. Facility follow upOn 3/26/26 at approximately 11:30 a.m. the MTD provided a training in-service sheet which indicated education had been completed with the housekeepers on 3/26/26 to identify a curtain cleaning schedule that ensured a clean curtain was always available.-However, the curtain cleaning schedule was not created until the concern with residents’ privacy in the bathroom was brought to the facility’s attention during the survey.

Based on observations, record review and interviews, the facility failed to ensure that the residents had a safe, clean, comfortable, and homelike environment for three out of 12 rooms. Specifically, the facility failed to ensure the facility's process of reporting and responding to repairs in the resident's rooms was being utilized to maintain three damaged closets in Resident #8, Resident #74, and Resident #33's rooms. Findings include:I. Observations and staff interviewResident #8's room was observed on 3/23/26 at 9:13 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed on 3/23/26 at 9:20 a.m. The hinge holding the resident's closet door to the frame was detached from the frame. Resident #74's room was observed on 3/23/26 at 11:45 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #8's room was observed again on 3/24/26 at 1:10 p.m. with the maintenance director (MTD). The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed again on 3/24/26 at 1:15 p.m. with the MTD. The hinge holding the resident's closet door to the frame was detached from the frame. Resident #74's room was observed again on 3/24/26 at 1:25 p.m. with the MTD. The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged. The MTD said he was not aware of the damaged closet doors in Resident #8, Resident #33 and Resident #74’s rooms and he had not received a work order to repair them. The MTD said the facility's process when things needed to be fixed was for an electronic work order to be submitted so he could repair items inside of residents’ rooms. II. Resident interviewResident #74 was interviewed on 3/23/26 at 11:45 a.m. Resident #74 said the hinge on her closet door had been loose and coming out of the door since she was admitted to the facility on 3/22/26. Resident #74 said she had complained to the staff and they told her that maintenance would repair it, but no one from maintenance had come to see her about it. III. Additional staff interviewsCertified nurse aide (CNA) #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said when something in the facility needed repair, the CNAs would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents’ rooms that was broken or needed repair. CNA #1 said work orders were submitted by CNAs and nurses. Licensed practical nurse (LPN) #4 was interviewed on 3/25/26 at 1:12 p.m. LPN #4 said when something in the facility needed repair, the nurses would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents’ rooms that was broken or needed repair, such as a bed not working, bathroom doors and or closet doors. LPN #4 said work orders were submitted by CNAs and nurses. LPN #3 was interviewed on 3/25/26 at 1:34 p.m. LPN #3 said she was an agency nurse but most facilities she had worked in used an electronic reporting system to submit work orders to their maintenance department for repairs. She said she would try to submit it that way or ask the charge nurse. The MTD was interviewed again on 3/26/26 at 11:30 a.m. The MTD said he had submitted a ticket to the electronic work order help desk in order to open up access to submitting work orders for all staff, not just CNAs and nurses. IV. Facility follow upOn 3/26/26 at approximately 11:30 a.m. the MTD provided a training in-service sheet, dated 3/26/26, on the importance of the electronic work order system, which indicated education had been completed with the 13 administrative staff, one activities assistant, two transportation drivers and one regional clinical resource. Of the facility’s six housekeeping staff, one was trained; of the facilities 28 CNAs, three were trained; of the facilities nine LPNs, none were trained and of the facility’s nine registered nurses, one was trained. -The MTD did not provide documentation of a plan to ensure all staff were trained and understood the electronic work order system.

Based on observations, record review and interviews, the facility failed to ensure three (#30, #55 and #71) of eight residents received treatment and care in accordance with professional standards of practice out of 32 sample residents. Specifically, the facility failed to:-Ensure physician’s orders for post-void residual measurements (PVR - measures the amount of urine remaining in the bladder immediately after urination) were followed for Resident #71;-Ensure physician’s orders were in place for a wound dressing for Resident #55; and,-Ensure Resident #30 received wound prevention care in accordance with the physician's orders. Findings include:I. Failed to ensure physician’s orders for PVRs were followed for Resident #71A. Resident statusResident #71, age 89, was admitted on 1/1/26 and discharged to the hospital on 1/14/26. According to the January 2026 computerized physician orders (CPO), diagnoses included need for assistance with personal care, cognitive communication deficits, acute kidney failure and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). The 3/15/26 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments, per the staff assessment for mental status. The resident required moderate to substantial assistance from staff for all activities of daily living (ADL). The assessment documented the resident had an indwelling urinary catheter and was frequently incontinent of bowel and bladder. B. Resident #71’s representative interviewResident #71’s representative was interviewed on 3/26/26 at 1:25 p.m. The resident’s representative said the facility removed Resident #71’s indwelling Foley catheter and the physician said the nursing staff would need to scan his bladder several times over the coming days. The resident’s representative said when the nursing staff attempted to scan Resident #71’s bladder, they could not find the bladder scanner. C. Record reviewReview of Resident #71’s January 2026 CPO revealed the following physician’s orders:Remove Foley catheter on 1/9/26 for voiding trial. Check PVR for 48 hours and notify the physician if it is greater than 300 milliliters (ml), ordered 1/8/26 and discontinued 1/11/26. Monitor PVR every six hours, try to check after resident voids, though he is incontinent. Insert Foley catheter if PVR is greater than 300 ml. Notify the physician if you have to insert Foley so a referral to urology can be made, ordered 1/12/26 and discontinued 1/13/26. Monitor PVR every six hours, try to check after resident voids, though he is incontinent. Insert Foley catheter if PVR is greater than 300 ml. Notify the physician if you have to insert Foley so a referral to urology can be made, ordered 1/13/26 and discontinued 1/13/26. Measure PVR every six hours for 24 hours for recent urinary retention after Foley catheter removal, ordered 1/14/26 at 12:46 p.m. A progress note, dated 1/9/26 at 5:07 a.m., revealed Resident #71’s Foley catheter order was discontinued and removed per physician’s order. Physician’s orders for PVRs for the next 48 hours were in place, and the physician was to be notified for any PVR greater than 300 ml. A physician’s note, dated 1/12/26 at 10:38 a.m., revealed Resident #71 was seen by his physician to examine a new skin concern. The note documented the resident’s PVRs had been less than 200 ml each time, according to the nursing staff. Resident #71’s representative was concerned his abdomen looked distended, so the physician performed a bladder scan and observed 600 ml of urine in the resident’s bladder. Resident #71 had a straight catheter placed and 700 ml of urine was drained from the resident’s bladder. The physician documented the resident was scheduled to have PVRs measured every six hours for 48 hours. The physician documented Resident #71 had also reported possible constipation and a suppository was administered. A progress note, dated 1/12/26 at 1:32 p.m., revealed Resident #71 had a PVR of 609 ml and had 700 ml of urine drained from a straight catheter. Resident #71’s physician was notified. A physician’s note, dated 1/13/26 at 8:30 a.m., revealed Resident #71 was seen by his physician for a follow-up visit. The physician documented the resident was scheduled to have PVRs measured every six hours for 48 hours. A physician’s note, dated 1/14/26 at 8:39 a.m., revealed Resident #71 was seen by his physician to follow up on his voiding trial. The note revealed the physician had not seen any documentation of Resident #71’s PVR amounts. The physician spoke with the nursing staff and ordered PVRs to be measured every six hours over the next 24 hours to ensure Resident #71 was not having any urinary retention. A progress note, dated 1/14/26 at 1:27 p.m., revealed Resident #71 had been administered an as-needed opioid pain medication. A progress note, dated 1/14/26 at 2:42 p.m., revealed Resident #71’s pain level had been reassessed by the nursing staff and was measured to be a 3 out of 10. A progress note, dated 1/14/26 at 7:46 p.m., revealed Resident #71 had been transported to the emergency department while attending an outside appointment. The medical director, the director of nursing (DON) and the nursing home administrator (NHA) were notified. Review of Resident #71’s January 2026 medication administration record (MAR), from 1/1/26 through 1/14/26, revealed the following:PVRs were measured and documented twice daily from 1/9/26 through 1/11/26 and were consistently below 300 ml. A PVR was measured on 1/12/26 at 7:07 p.m. -However, the nurse did not document the volume measured on 1/12/26 at 7:07 p.m.-PVRs were measured on 1/13/26 at 6:00 a.m. and 6:00 p.m. The PVRs were documented as 57 ml and 55 ml, respectively.-The January 2026 MAR revealed the facility obtained one PVR measurement on 1/12/26, two PVR measurements on 1/13/26 and no PVR measurements on 1/14/26, despite the physician’s orders indicating PVRs were to be obtained every six hours, beginning on 1/12/26 (see physician’s orders above). D. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said whenever the physician put in orders to remove a Foley catheter, the facility would typically also put in physician’s orders to measure PVRs for the next 72 hours. LPN #4 said the nursing staff recorded the PVR measurements in the MAR. LPN #4 said the frequency of PVR measurements depended on the physician and were typically measured two to three times per shift. The DON, an unidentified member of the regional support team and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 10:44 a.m. The DON said PVRs were used to measure voiding after removing an indwelling urinary catheter for a certain period of time. He said the nursing staff would communicate their measurements with the physician to see if the resident needed to continue using a urinary catheter. The ADON said typically for voiding trials, the nursing staff would monitor PVRs and voiding every six to eight hours for three days, and use a straight catheter if the PVR measured greater than 350 ml. The ADON said Resident #71 had physician’s orders to have a PVR measured every six hours after his Foley catheter was removed on 1/9/26. The regional support team member said the PVR frequency and length of the physician’s order depended on what the resident’s diagnoses were and what the indwelling catheter was being used to treat. The regional support team member said the nursing staff had documented Resident #71’s PVRs in the MAR, and said there was a physician’s order on 1/9/26 to remove the Foley catheter and monitor PVRs twice daily and document their output from 1/9/26 through 1/12/26. The DON reviewed Resident #71’s medical record and said the resident had a physician's order, initiated 1/13/26, to monitor PVRs every six hours for 48 hours.-However, the physician’s order to monitor PVRs every six hours was initiated on 1/12/26 (see physician’s orders above). The regional support member reviewed Resident #71’s MAR and said there were two PVRs recorded on 1/13/26.-However, per the physician’s order, PVRs were supposed to be measured every six hours (see physician’s order above). The DON said Resident #71 had an appointment on 1/14/26 and was picked up for the appointment by the transportation staff at 1:45 p.m. that afternoon. The DON said by the time the physician’s order for additional PVRs was put into the resident’s medical record (on 1/14/26 at 12:46 p.m.), it was too close to his appointment time.-However, according to the resident’s progress notes, the resident was still in the facility on 1/14/26 at 1:27 p.m., when he was administered a medication for pain (see progress notes above). The ADON said the physician may have given the order to the nursing staff later in the morning after Resident #71’s exam on 1/14/26, which would account for the gap between the exam and when the order was put in for additional PVRs. The ADON said the nurse or the physician put in the orders for the PVR and the physician would verify the orders later. The ADON and the DON both said if the physician ordered PVRs to be measured every six hours, they would expect the nursing staff to measure the resident’s PVR every six hours. Resident #71’s physician was interviewed on 3/26/26 at 11:24 a.m. The physician said orders for PVRs after removing a Foley catheter typically involved measuring the PVR every six hours for two days to see if there were any significant measurements. The physician said he would expect the nursing staff to measure and record the PVR every six hours if the physician’s order specified to measure the PVR every six hours. II. Failed to ensure physician’s orders were in place for a wound dressing for Resident #55A. Resident statusResident #55, age greater than 65, was admitted on 3/8/26. According to the March 2026 CPO, diagnoses included cognitive communication deficits, need for assistance with personal care and fracture of the right fibula (the smaller bone in the lower leg). The 3/11/26 MDS assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident required supervision to maximum assistance from staff for all ADLs. The assessment documented the resident did not have any issues with her skin. B. ObservationsOn 3/24/26 at 8:30 a.m. Resident #55 was lying in bed in her room. Resident #55 had a dressing on her right forearm arm, dated 3/19/26. On 3/25/26 at 8:50 a.m. Resident #55 was sitting up in her wheelchair in her room. Resident #55 had a dressing on her right forearm, dated 3/19/26. C. Resident #55’s representative interviewResident #55’s representative was interviewed on 3/25/26 at 8:50 a.m. The resident’s representative said she had seen that Resident #55 had a big bandage on her arm. The resident’s representative said she had no idea why Resident #55 had the dressing on her arm. The resident’s representative said she had hoped the facility would have contacted her if Resident #55 had any changes, or if she had fallen or had any procedures done. D. Record reviewReview of Resident #55’s March 2026 CPO revealed the following physician’s order:Monitor the right forearm dry skin patch to ensure proper healing. The area is currently approximately 1 centimeter (cm) by 1 cm with no open areas noted. Monitor for redness, drainage, signs and symptoms of infection and notify the physician if noted, ordered 3/27/26 at 9:21 a.m. (during the survey process). A skilled nursing note, dated 3/19/26 at 8:49 p.m., revealed Resident #55 had some healing bruising above her right eye with no other skin issues or concerns noted, and no active skin conditions or treatments observed. A skin assessment, completed 3/21/26 at 10:09 p.m., revealed Resident #55’s skin was assessed by the nursing staff. Resident #55 had redness noted to her coccyx with treatments in place and her heels and all other bony prominences were intact.-The assessment did not document Resident #55’s dressing in place or any irritated areas on her arm. A progress note, dated 3/25/26 at 4:27 p.m., revealed the nursing staff assessed the bandage on Resident #55’s right forearm and noted there appeared to be a patch of dry skin under the bandage with no open areas noted. Resident #55 denied any pain to the area and declined to have the dressing removed.-However, a physician’s order for the dressing that was observed on the resident’s right forearm by the nurse on 3/25/26 at 4:27 p.m. was not obtained until 3/27/26 at 9:21 a.m., during the survey (see physician’s orders above). E. Staff interviewsThe infection preventionist (IP) was interviewed on 3/25/26 at 9:06 a.m. The IP said for any dressings, the nursing staff needed to get orders from the physician for wound care. The IP said all wounds, no matter the size, were to be dressed appropriately and followed by the in-house wound care nurse (WCN). The IP reviewed Resident #55’s March 2026 CPO and found wound care orders including for barrier cream to the resident’s coccyx and monitoring her pacemaker site. The IP said she was not sure why Resident #55 had a dressing on her arm but thought the WCN may have been following the resident. The IP contacted the WCN by phone, who said she did not see any other wound care orders for Resident #55. The IP said she thought maybe the resident had a bony prominence on her arm that the nursing staff were trying to cover. The IP said residents had their skin assessed on admission and weekly. The IP said if the nursing staff saw any changes with a resident’s skin, they would document it in the assessment, consult the physician and fill out a change in condition report. The WCN was interviewed on 3/25/26 at 10:53 a.m. The WCN said she reviewed Resident #55’s EMR and did not see any physician’s orders for wound care, so she was not sure why she had any dressings on. The WCN said Resident #55’s skin was assessed on admission and not found to have any skin tears or areas of concern, and the resident had been assessed weekly since her admission. Certified nurse aide (CNA) #4 was interviewed on 3/25/26 at 1:23 p.m. CNA #4 said if she noticed any changes with a resident’s skin, she would notify the nurse and document the change in the resident’s tasks in the electronic medical record (EMR). CNA #4 said she would also pass along the information regarding the change in the resident’s skin to the next shift so they knew to monitor it. LPN #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said if she saw a dressing on a resident during her shift, it would trigger her to look at the resident’s physician’s orders for any wound care orders. LPN #3 said sometimes residents asked the nursing staff for bandages and the nursing staff applied a bandage for the resident without thinking, so she would want to look into the resident’s EMR to see why the resident had the dressing and if it needed to be changed. The IP was interviewed a second time on 3/25/26 at 3:48 p.m. The IP said she had assessed Resident #55’s skin under the dressing on her forearm and found an irritated area approximately 2 inches by 2 inches which looked similar to a psoriasis plaque (an itchy, raised, inflamed, and scaly skin patch). The IP said Resident #55’s skin assessment did not reveal any open areas or any areas which would require wound care orders. The IP said Resident #55 said she wanted to keep a bandage on the area, so another dressing was placed. The IP said she did not know who put the dressing on Resident #55’s arm or if anyone had attempted to change the bandage since it was first applied. The IP said she would have expected to see documentation in the progress notes about the bandage being placed or any attempts to replace the bandage. The WCN was interviewed a second time on 3/26/26 at 10:18 a.m. The WCN said the area under the bandage on Resident #55’s arm was a patch of dry skin, and the resident had requested the bandage herself. The WCN said she did not know when Resident #55 had requested for the bandage to be applied. The WCN said if Resident #55 wanted to continue wearing the bandage, she would put in physician’s orders so the bandage could be changed and monitored.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident’s admission to the facility, the facility failed to ensure the resident’s prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. The facility’s failure to send the resident’s prescription to the pharmacy in a timely manner, resulted in the resident not receiving the narcotic pain medication for 21 hours after leaving the hospital, resulting in severe back pain for Resident #74. Additionally, Resident #71 did not receive pain medication in a timely manner and per physician’s orders. Specifically, the facility failed to: -Ensure Resident #74’s pain medication was received and administered as ordered in a timely manner, which resulted in severe back pain for the resident; and,-Ensure Resident #71’s pain was addressed timely and pain medication was administered per physician ordered parameters. III. Resident #71A. Resident statusResident #71, age 89, was admitted on 1/1/26 and discharged to the hospital on 1/14/26. According to the January 2026 CPO, diagnoses included a displaced fracture of the left femur, need for assistance with personal care and cognitive communication deficits. The 3/15/25 MDS assessment revealed the resident had mild cognitive impairments, per the staff assessment for mental status. The resident required moderate to substantial assistance from staff for all activities of daily living (ADL). The MDS assessment documented the resident received scheduled pain medications, as needed (PRN) pain medications and non-medication interventions for pain. B. Resident #71’s representative interviewResident #71’s representative was interviewed on 3/26/26 at 1:25 p.m. The resident’s representative said Resident #71 was in pain when he was first admitted to the facility on 1/1/26. The resident’s representative said Resident #71 requested pain medications from the nurse right when he was admitted, and the nurse told him she would get his pain medications right away. The resident’s representative said Resident #71 was not administered any pain medications until later that night (1/1/26) because the nurse could not get the code she needed from the pharmacy in order to dispense the pain medication dose. C. Record reviewReview of Resident #71’s January 2026 CPO revealed the following physician’s orders:Tylenol 325 mg oral tablets, give two tablets by mouth every six hours as needed for pain, ordered 1/1/26 at 7:02 p.m. Oxycodone 5 mg oral tablets, give one tablet by mouth every four hours as needed for pain ranging from 6 to 10 on a scale of 1 to 10 and give 0.5 tablets by mouth every four hours as needed for pain ranging from 3 to 5 on a scale of 1 to 10, ordered 1/1/26 at 7:15 p.m. Non-pharmacological interventions for pain: repositioning, rest, massage, distraction, or other, ordered 1/1/26 at 2:05 p.m. A progress note, dated 1/1/26 at 5:50 p.m., revealed Resident #71 arrived at the facility from the hospital. Resident #71 had received surgery for a left femur fracture, and said his pain was a 6 out of 10. The progress note documented the nurse was notified about Resident #71’s pain. An admission pain management review assessment was completed by a member of the nursing staff on 1/1/26 at 8:05 p.m. The assessment documented Resident #71 had pain frequently over the last five days. The assessment documented Resident #71’s pain was at his incision site. The assessment documented Tylenol and oxycodone relieved Resident #71’s pain, along with rest and repositioning. The assessment documented Resident #71 would be satisfied with a pain level of 2 out of 10. The pain management review assessment documented Resident #71 had a pain of 7 out of 10 at the time of the assessment. A progress note, dated 1/1/26 at 8:17 p.m., revealed Resident #71 was administered a dose of PRN 5 mg oxycodone. Resident #71 had requested the medication for generalized pain.-However, the oxycodone was administered nearly two and a half hours after the resident admitted to the facility and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident’s PRN pain medications (see admission progress note and physician’s orders above). Review of Resident #71’s January 2026 MAR did not reveal any administered doses of the resident’s PRN Tylenol medication. Review of Resident #71’s January 2026 treatment administration record (TAR) revealed the physician’s order for non-pharmacological pain interventions was documented as completed during the evening shift on 1/1/26.-However, the specific non-pharmacological pain interventions used were not documented or assessed for effectiveness. D. Staff interviewsRegional nurse consultant #1 was interviewed on 3/25/26 at 9:41 a.m. Regional nurse consultant #1 said the facility’s expectation for the nursing staff, in the event of a pain medication order not being available for a newly admitted resident, was for the nurses to contact the pharmacy and the resident’s physician to see if there were any other pain medication options which could be administered. LPN #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said if a resident expressed they were in pain, the nursing staff attempted non-pharmacological interventions before moving to administering any PRN pain medications. LPN #3 said if a resident was in pain and did not have any pain medication options available for her to give, she would contact the resident’s physician right away. LPN #3 said she would assess the resident’s pain and try to find a way to relieve their pain so it did not get any worse, and document her steps in the resident’s EMR. LPN #3 said she would carry out the same process if a resident was just admitted to the facility. LPN #3 said the facility had an emergency medications machine where she could get an emergency dose of a PRN medication after receiving orders from the physician. The nursing home administrator (NHA), the infection preventionist (IP) and the DON were interviewed together on 3/25/26 at 4:14 p.m. The NHA said if any of the residents’ medications ran out, the nursing staff had been trained regarding who to contact. The NHA said agency staff members had access to a binder and a list of pharmacist contact information just for that event. The DON and the IP said some of the agency nurses had access to the emergency medications machine, and if the agency nurses working in the facility did not have access to the machine, someone else scheduled to be working during that time would have access. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said she tried to give residents their PRN pain medications as requested or their scheduled pain medications right on time before their pain got any worse. LPN #4 said if a medication ran out or was unavailable, she would call the pharmacy and the resident’s physician, and use the emergency medication machine to dispense a dose for the resident if needed. The DON and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 10:30 a.m. The ADON said Resident #71 was admitted to the facility on 1/1/26, and his admission pain assessment documented the resident had a pain level of 7 out of 10. She said the assessment indicated that the pain medications that had worked to relieve his pain in the past were Tylenol and oxycodone. The DON said Resident #71’s first dose of oxycodone was administered on 1/1/26 at 8:17 p.m. The DON said Resident #71’s PRN pain medications were reviewed with the resident on 1/2/26.-However, the oxycodone was administered nearly two and a half hours after the resident was admitted to the facility on 1/1/26 and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident’s PRN pain medications. -The pain assessment conducted on 1/1/26 documented Tylenol had been previously effective in alleviating pain for Resident #71, however no doses of Tylenol were documented as being administered during the resident’s stay in the facility.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 13.33%, or four errors out of 30 opportunities for error. Findings include:I. Professional referenceAccording to Stat Pearls Nursing Rights of Medication Administration, 9/4/23, retrieved on 3/30/26 from https://www.ncbi.nlm.nih.gov/books/NBK560654,“Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights’ or ‘five R’s’ of medication administration.-Right patient;-Right drug;-Right route;-Right time; and,-Right dose.”II. Facility policy and procedureThe Medication Administration policy and procedure, reviewed January 2022, was provided by the director of nursing (DON) on 3/26/26 at 1:00 p.m. It read in pertinent part,“It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration. -Right resident-identified prior to medication administration;-Right time-medications are administered within prescribed time frames;-Right medication-medications are checked against the order before they are given;-Right dose-medications are administered according to the dose prescribed;-Right route-medications are administered according to the route prescribed; and,-Right documentation-document administration or refusal of the medication after the administration or attempt and note any concerns.”III. Observations and InterviewsOn 3/24/26 at 11:40 a.m. licensed practical nurse (LPN) #2 was observed administering medications to Resident #64. LPN #2 dispensed one tablet of Guaifenesin (expectorant medication) 600 milligram (mg). -However, Resident #64’s March 2026 medication administration record (MAR) indicated the physician’s order for the resident’s Guaifenesin was 400 mg every morning. Upon prompting, LPN #2 reviewed the physician’s order, then discarded the 600 mg tablet of Guaifenesin. LPN #2 was unable to locate a 400 mg tablet of Guaifenesin. LPN #2 requested assistance from nursing management who could not locate the medication in a 400 mg dose. -Resident #64 failed to receive his Guaifenesin medication. LPN #2 said the physician would be contacted for clarification of the physician’s order. LPN #2 next gathered Resident #64’s Fluticasone (allergy anti-inflammatory medication) 50 microgram (mcg)/actuation nasal spray and Trelegy Ellipta (lung inflammation reducing medication) 100-62.5-25 mcg respiratory inhaler medications and carried them to the resident’s bedside. Resident #64 asked for applesauce for the other medications and LPN #2 left the room. While LPN #2 was out of the room, Resident #64 picked up the Trelegy Ellipta inhaler and breathed in once. The resident did not rinse his mouth with water afterward. -However, Resident #64’s March 2026 MAR indicated the resident needed to rinse his mouth after using the inhaler. -LPN #2 failed to instruct Resident #64 to rinse his mouth after using the inhaler. When LPN #2 returned to the resident’s room, Resident #64 picked up the Fluticasone nasal spray and dispensed two sprays into each nostril. -However, Resident #64’s March 2026 MAR indicated the nasal spray was to have one spray to each nostril. -LPN #2 failed to instruct Resident #64 on how many sprays of Fluticasone were ordered and the resident received the wrong dose of nasal spray. LPN #2 prepared Resident #64’s psyllium powder (laxative medication for constipation). The resident’s March 2026 MAR indicated the resident was to receive two teaspoons of the psyllium powder every morning. -However, LPN #2 did not use a measuring medication cup to administer the correct dose, but used a white plastic spoon to measure the powder instead. LPN #2 acknowledged the need to use an accurate measuring device when administering powder medications. IV. Additional interviewsThe DON and the nursing home administrator (NHA) were interviewed on 3/25/26 at 3:53 p.m. The DON and the NHA said when a nurse identified a medication that was not available to administer, the nurse should check the stat safe (emergency medications machine) to see if the medication was in the machine and if not, the nurse was to reach out to the pharmacy or nursing management staff to help locate a medication. The NHA and the DON said when there was an identified medication issue, the facility would put together a group text so communication would be among several staff members to help resolve the issue. The NHA and the DON said nursing should notify the physician if medications were missed or were unavailable to administer in order to obtain physician’s orders for alternate medications if there were options available.

Based on record review and interviews, the facility failed to ensure three (#74, #43 and #55) of eight residents reviewed for medication management were free from significant medication errors out of 32 sample residents. Specifically, the facility failed to:-Ensure Resident #74 received scheduled intravenous (IV) antibiotics as ordered; and, -Ensure Resident’s #43 and #55’s blood pressure medications were administered or held per physician ordered parameters. II. Failed to ensure Resident’s #43 and #55’s blood pressure medications were administered or held per physician ordered parametersA. Resident #431. Resident statusResident #43, age 87, was admitted on 1/19/24. According to the March 2026 CPO, diagnoses included supraventricular tachycardia (fast heart rhythm), hypertension and chronic embolism and thrombosis. According to the 12/22/25 MDS assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. 2. Record reviewThe comprehensive care plan, revised 7/30/24, revealed Resident #43 had hypertension and coronary artery disease. Pertinent interventions included giving anti-hypertensive medications as ordered and monitoring for side effects, including increased heart rate, orthostatic hypotension and effectiveness. Review of Resident #43’s March 2026 CPO revealed the following physician’s orders:Lisinopril 2.5 milligram (mg) oral tablet, give one tablet by mouth in the morning for hypertension, hold for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmHg), ordered 11/19/25 and discontinued 12/23/25. Lisinopril 2.5 mg oral tablet, give one tablet by mouth at bedtime for hypertension, ordered 12/23/25. Metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension; ordered 3/15/25. A progress note, dated 12/13/25 at 11:12 p.m., revealed Resident #43 had a physician’s order for metoprolol succinate 25 mg tablets, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 or heart rate less than 60 beats per minute(BPM).-However, the parameters to hold the medication were not included in the December 2025 CPO.A nurse practitioner’s note, dated 12/29/25 at 8:57 a.m., revealed Resident #43’s medications were reviewed and reconciled by the nurse practitioner. Resident #43’s medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM.-However, the parameters to hold the medication were not included in the December 2025 CPO.A physician’s note, dated 1/22/26 at 9:45 a.m., revealed Resident #43’s medications were reviewed and reconciled by her physician. Resident #43’s medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM.-However, the parameters to hold the medication were not included in the January 2026 CPO and did not match the physician’s orders the nursing staff were following, as documented in Resident #43’s progress notes (see below). A progress note, dated 1/23/26 at 12:03 a.m., revealed Resident #43 had a physician’s order for metoprolol succinate 25 mg tablets, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 100 mmHg or heart rate less than 60 BPM.-However, the parameters to hold the medication were not included in the January 2026 CPO.A nurse practitioner’s note, dated 2/23/26 at 1:24 p.m., revealed Resident #43’s medications were reviewed and reconciled by the nurse practitioner. Resident #43’s medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the February 2026 CPO.A nurse practitioner’s note, dated 3/13/26 at 2:00 p.m., revealed Resident #43’s medications were reviewed and reconciled by the nurse practitioner. Resident #43’s medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM.-However, the parameters to hold the medication were not included in the March 2026 CPO.Review of Resident #43’s December 2025 medication administration record (MAR), from 12/1/25 through 12/31/25, revealed the following:-On 12/2/25 the resident’s blood pressure (BP) measured 107/60 mmHg and metoprolol was marked as administered;-On 12/8/25 the resident’s BP measured 108/56 mmHg and metoprolol was marked as administered; and, -On 12/29/25 the resident’s BP measured 100/54 mmHg and metoprolol was marked as administered.-However, Resident #43’s metoprolol order had physician ordered parameters to hold the medication for any SBP below 110 mmHg (see physician’s orders and progress notes above). Medication regimen review notes, dated 12/10/25, revealed the following pharmacist’s recommendations:Resident #43 had a physician’s order to hold Lisinopril 2.5 mg tablets for low BP, however the BP was not being documented on the MAR prior to medication administration. The pharmacist recommended that the supplementary documentation be added to the physician’s order. The pharmacist requested that the facility follow the facility’s policy for documenting the following medication error: Resident #43 had an order for metoprolol 25 mg, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. However, the medication was given on the following days outside of the hold parameters: on 12/2/25 BP was 107/60 mmHg and 12/8/25 BP was 108/56 mmHg. Review of Resident #43’s January 2026 MAR, from 1/1/26 through 1/31/26, revealed the following:-On 1/3/26 the resident’s BP measured 105/62 mmHg and metoprolol was marked as held;-On 1/7/26 the resident’s BP measured 109/68 mmHg and metoprolol was marked as held:-On 1/15/26 the resident’s BP measured 107/57 mmHg and metoprolol was marked as held; and,-On 1/22/26 the resident’s BP measured 104/66 mmHg and metoprolol was marked as held. -However, Resident #43’s metoprolol order had parameters to hold the medication for a SBP lower than 100 mmHg. Medication regimen review notes, dated 1/10/26, revealed the following pharmacist recommendations:The pharmacist requested that the facility follow the facility’s policy for documenting the following medication error: Resident #43 had an order for metoprolol 25 mg, hold for systolic BP less than 100 mmHg or heart rate less than 60 BPM. However, the medication was held outside of hold parameters on the following days: on 1/3/26 BP was 105/62 mgHg, on 1/7/26 BP was 68 mmHg. The [pharmacist indicated the hold parameters for metoprolol and lisinopril were different, so maybe the nursing staff were holding the metoprolol medication because the hold parameter for Resident #43’s lisinopril medication was for systolic BP less than 110 mmHg. The pharmacist recommended the facility discuss the issue with the physician to see if the physician wanted to change the hold parameter for metoprolol to be held for systolic BP less than 110 mmHg as well. Review of Resident #43’s March 2026 blood pressure records, from 3/1/26 through 3/24/26, revealed the following:-On 3/1/26 the resident’s BP was 98/56 mmHg;-On 3/4/26 the resident’s BP was 104/60 mmHg;-On 3/5/26 the resident’s BP was 100/50 mmHg;-On 3/8/26 the resident’s BP was 99/50 mmHg;-On 3/9/26 the resident’s BP was 102/61 mmHg;-On 3/11/26 the resident’s BP was 107/58 mmHg;-On 3/14/26 the resident’s BP was 100/62 mmHg;-On 3/17/26 the resident’s BP was 94/57 mmHg;-On 3/18/26 the resident’s BP was 101/64 mmHg;-On 3/19/26 the resident’s BP was 102/55 mmHg;-On 3/23/26 the resident’s BP was 100/60 mmHg; and,-On 3/24/26 the resident’s BP was 107/60 mmHg. Review of Resident #43’s March 2026 MAR, from 3/1/26 through 3/24/26, revealed the following:-The resident’s lisinopril medication was held on 3/5/26 and 3/14/26; and,-The resident’s metoprolol medication was held on 3/5/26, 3/14/26 and 3/19/26.-However, the nursing staff failed to hold Resident #43’s hypertensive medications when the resident’s SBP was below 100 mmHg on 3/1/26, 3/8/26 and 3/17/26 or when her SBP was below 110 mmHg on 3/4/26, 3/9/26, 3/11/26, 3/18/26, 3/23/26 or 3/24/26.3. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said when she was preparing to administer blood pressure medications, she needed to measure the resident’s blood pressure first. LPN #3 said the residents’ blood pressures were measured, as the physician’s order for their medication had blood pressure parameters below which the nurse would need to hold the medication. LPN #3 said if a blood pressure medication did not have any hold parameters in the CPO, she would need to use her clinical judgement and hold the medication if the resident’s blood pressure was measured and found to be below 100/60 mmHg. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said most residents’ blood pressure medication orders had parameters to hold the medication if their SBP was measured and found to be below 110 mmHg or 100 mmHg, so she followed what the physician’s order said. LPN #4 said if a blood pressure medication order did not have any hold parameters listed, she would call the physician and consult with them to revise the order and add parameters. LPN #4 said she would not administer a blood pressure medication without any parameters in the physician’s order. The DON and clinical resource nurse #2 were interviewed together on 3/25/26 at 3:41 p.m. The DON said when the nursing staff were administering blood pressure medications, they needed to measure the resident’s BP prior to administration. The DON said if the resident’s BP was found to be outside of the hold parameters in the physician’s order, the nurse would hold the medication, contact the resident’s physician and recheck their blood pressure later. The DON said if there were no hold parameters in the physician’s order, the nurses used their clinical judgement prior to administering the blood pressure medication. The DON said the nurses assessed the resident to see if they were at their baseline and contacted the physician to see if the medication needed to be held if the resident’s SBP was lower. Clinical resource nurse #2 said with fluctuations in blood pressure measurements like those of Resident #43, parameters would be helpful to include in the physician’s order. Clinical resource nurse #2 said the facility would consult with Resident #43’s physician and have hold parameters added to her blood pressure medications’ orders. B. Resident #551. Resident statusResident #55, age greater than 65, was admitted on 3/8/26. According to the March 2026 CPO, diagnoses included hypertension, hyperlipidemia, presence of a cardiac pacemaker and atrial fibrillation. The 3/11/26 MDS assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident required supervision to maximum assistance from staff for all activities of daily living (ADL). 2. Record reviewThe cardiovascular care plan, revised 3/24/26, revealed Resident #55 had an altered cardiovascular status due to her diagnoses of hypertension, atrial fibrillation, hyperlipidemia and the presence of a pacemaker. Pertinent interventions included administering medications as ordered and assessing Resident #55’s vital signs as ordered and notifying the physician with any abnormal readings. Review of Resident #55’s March 2026 CPO revealed the following physician’s orders:Amlodipine besylate 5 mg tablet, give one tablet by mouth two times a day for hypertension, ordered 3/8/26 and discontinued 3/16/26. Isosorbide dinitrate 5 mg oral tablet, give one tablet by mouth three times a day for hypertension, ordered 3/8/26 and discontinued 3/10/26. Isosorbide dinitrate 5 mg oral tablet, give one tablet by mouth two times a day, hold for SBP less than 110, ordered 3/10/26. Sotalol 80 mg tablets, give 40 mg by mouth two times a day for hypertension, ordered 3/8/26. Review of Resident #55’s March 2026 blood pressure records, from 3/8/26 through 3/26/26, revealed the following:-On 3/8/26 at 5:58 p.m. the resident’s BP was 93/59 mmHg;-On 3/8/26 at 6:14 p.m. the resident’s BP was 93/59 mmHg;-On 3/8/26 at 10:35 p.m. the resident’s BP was 121/61 mmHg;-On 3/11/26 at 2:02 p.m. the resident’s BP was 105/62 mmHg;-On 3/16/26 at 9:44 p.m. the resident’s BP was 105/62 mmHg;-On 3/19/26 at 11:36 p.m. the resident’s BP was 107/60 mmHg;-On 3/22/26 at 8:36 p.m. the resident’s BP was 108/60 mmHg; and,-On 3/26/26 at 1:07 a.m. the resident’s BP was 103/60 mmHg. Review of Resident #55’s March 2026 MAR, from 3/8/26 through 3/26/26, revealed the following:-The resident received doses of amlodipine, isosorbide and sotalol on the evening of 3/8/26;-The resident’s isosorbide was administered on 3/11/26 during the morning shift and on 3/16/26, 3/19/26, 3/22/26 and 3/25/26 during the evening shifts; and,-The resident did not receive her scheduled dose of sotalol on 3/24/26.-However, Resident #55’s SBP was below the 110 mmHg hold parameter in the physician’s order during these medication administrations.-Review of the resident’s electronic medical record (EMR) did not reveal any documentation of the physician being contacted regarding the resident’s low blood pressure prior to administration of her hypertensive medications on 3/24/26. A progress note, dated 3/25/26 at 4:27 a.m., revealed Resident #55’s sotalol medication was not administered. The note documented the facility was waiting for the medication to be delivered. -Review of Resident #55’s progress notes did not reveal any documentation of Resident #55’s physician or the pharmacy being contacted regarding the missing medication. 3. Staff interviewsThe nursing home administrator (NHA) was interviewed on 3/25/26 at 4:14 p.m. The NHA said the nursing staff had all been trained on the facility’s procedures for when a medication ran out. The NHA said the nursing staff had been informed of who to contact at the facility’s pharmacy if they were out of medications, and any agency staff nurse had a list of pharmacy contact information available to them. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said if she ran out of a medication, she would call the pharmacy and the resident’s physician to notify them about the missing medication and document this information in the resident’s progress notes. The DON was interviewed on 3/25/26 at 3:48 p.m. The DON said when a medication was unavailable, the nurse should contact the resident’s physician and the pharmacy to notify them the medication was out of stock, and the physician would usually put the medication on hold or give further orders. The DON said the nurse would also need to monitor the resident for any changes related to the missing medication. The DON said Resident #55’s physician should have been contacted on 3/24/26 when the resident’s sotalol medication was unavailable.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of four medication storage rooms and two of four medication storage carts. Specifically, the facility failed to:-Ensure eye drops were dated with the date they were opened;-Ensure medications were contained in the original packaging; and,-Ensure expired medical supplies were discarded. Findings include:I. Professional referenceAccording to manufacturer Allergan’s Ophthalmic Medication Beyond-Use Date Guide, April 2024, retrieved on 3/30/26 from https://www.hdrxservices.com/Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024,“Thera Tears eye drops should be discarded 90 days from opening.”According to manufacturer Nephron Pharmaceutical’s, Beyond-Use Date, 2026, retrieved on 3/30/26 from https://nephronpharm.com/products/ipratropium-bromide-05-mg-and-albuterol-sulfate-3-mg,“Vials should be protected from light before use, therefore, keep unused vials in the foil pouch or carton. Vials should be used within two weeks once removed from the foil package.” According to manufacturer Hydrofera Blue’s user guide, retrieved on 3/30/26 from https://hydrofera.com/app/uploads/2022/03.pdf,“Hydrofera Blue dressings are sterile in their original, unopened packaging. However, they are not guaranteed to remain sterile after opening. Single-Use Only: The dressings are designed for single-use and should not be reused. Handling: Once the package is opened, the dressing is exposed to the environment, compromising its sterility. Do not use a Hydrofera Blue dressing if the individual package has been opened or damaged prior to use.”II. Facility policy and procedureThe Medication Access and Storage policy and procedure, revised October 2025, was provided by the director of nursing (DON) on 3/26/26 at 1:00 p.m. It read in pertinent part,“The provider pharmacy dispenses medications in containers that meet legal requirements. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist.”“Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from pharmacy.”“Any opened vial without an open date will be discarded immediately, and replaced with a new vial. Any medication that cannot be verified as to the expiration date, either due to not being dated when opened, or unclear shelf life, shall be discarded immediately and replaced.”III. Observations and interviewsOn 3/24/26 at 10:43 a.m. the 2 East medication storage cart was reviewed with licensed practical nurse (LPN) #1. The following items were found:-One small unknown yellow tablet in a medication cup in the top drawer that was not labeled with a resident’s name. LPN #1 was unaware what the tablet was or why it was in a medication cart in the drawer.-An eight ounce (oz) bottle of hand sanitizer on top of the medication cart that expired September 2022.-One bottle of Thera tears that was opened and was not dated.-One vial of thiamine (vitamin B1) injectable 200 milligram (mg)/2 milliliter (ml) lying loose in the top drawer.-One single dose tablet of potassium chloride 20 milliequivalent (meq) lying loose in the top drawer.-One single use dose of cyclosporine ophthalmic emulsion 0.05 % (antibiotic eye drop) lying loose in the top drawer.-One single use dose of Ipratropium Bromide/Albuterol Sulfate 0.5 mg/3 mg/3 ml (nebulizer inhalation solution) lying loose in the top drawer.-One package of Hydrofera Blue wound dressing that had been opened, cut in half, and was lying in the bottom drawer. On 3/25/26 at 8:05 a.m. the 1 West medication storage cart was reviewed with LPN #4. The following items were found:-Two medication cups were in the top drawer, one stacked on top of the other, with one unknown tablet in the bottom cup and four unknown tablets in the top cup. The cups were not labeled with resident identifying information. LPN #4 said the resident who the medication was for was eating and she would go give the medications to the resident. On 3/25/26 at 8:20 a.m. the medication storage room on 1 West was reviewed with LPN #4. The following items were found:-15 blue top blood collection tubes that expired 9/30/25.-15 red top blood collection tubes that expired 2/28/26.-25 yellow top blood collection tubes that expired 2/28/26.-One vanish point 3 ml syringe with a needle attached that expired 5/28/22.-Three safety glide needles that expired March 2021. IV. Additional staff interviewsLPN #4 was interviewed on 3/25/26 at 8:30 a.m. LPN #4 said the pharmacist came to the facility monthly and reviewed the medication storage carts and any medications in the medication storage room but she was unaware if the pharmacist checked for expired medical supplies. LPN #4 said the facility would only draw blood if the lab was unable to do it. The DON, the infection preventionist (IP), clinical resource nurse #2 and the nursing home administrator (NHA) were interviewed on 3/25/26 at 3:30 p.m. The DON, the IP, the clinical resource nurse and the NHA said the management staff had recently reviewed the medication storage rooms and medication storage carts for expired medications and medical supplies and missed the items identified on 3/24/26 and 3/25/26 (see observations above). The NHA said the pharmacist was in the facility the week prior (week of 3/15/26) and had reviewed the medication storage carts. The NHA said nurses did not draw blood at the facility and was unaware of the expired blood collection tubes in the 1 West medication storage room. Clinical resource nurse #2 said night shift nurses were responsible for removing expired medications and medical supplies from the medication storage rooms and medication carts. Clinical resource nurse #2 said the facility’s process for ensuring expired medications were removed from the medication carts and medication storage rooms would be addressed.

Based on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically the facility failed to ensure one of three washing machines in the facility’s laundry room was in appropriate operational condition. Findings include:I. Observations On 3/25/26 at 8:50 a.m. an observation of the facility's laundry room revealed the following:Behind washing machine #1, four floor tiles were detached with water underneath them. A portable blower (industrial dryer) was set up behind washing machine #1 and pointed towards the detached tiles. Behind washing machine #3 was a puddle of water underneath a supply hose. A rolled up blanket was tucked to the left side of washing machine #3 and another blanket was tucked in the front of washing machine #3. Underneath the blankets, water was observed. II. Staff interviewsThe laundry aide was interviewed on 3/25/26 at 9:00 a.m. The laundry aide said she had worked at the facility in the laundry room for seven months. She said the leak behind the washing machines had been going on the entire time she had worked in the facility and the maintenance director (MTD) was aware of the issue. The laundry aide said she put a new rolled up blanket in the front and the side of washing machine #3 every morning to prevent the water from coming out onto the floor and creating a fall hazard. A representative with the facility's laundry chemical supply provider was interviewed on 3/25/26 at 12:45 p.m. The representative said his company managed the laundry chemicals and any repairs to the equipment associated with the chemicals and refilling the chemicals. The representative said he had repaired the supply hose on washing machine #3 when he came out on 3/25/26 at 11:30 a.m. (during the survey) as a favor because it only needed a new washer (a simple mechanical component that is used in conjunction with a bolt, screw, or nut). He said his company was not responsible for any mechanical repairs to the washing machines, including the supply hose. He said when he came out to the facility on 1/15/26, he did observe water behind the washing machines but could not recall if he had told anyone. The MTD was interviewed on 3/26/26 at 9:40 a.m. The MTD said that he supervised the housekeepers, the laundry staff and any as needed (PRN) maintenance staff. He said he was responsible for basic inspections of the washers and dryers in the laundry room. The MTD said the technician from the facility's laundry chemical supply provider had come out on 3/25/26 (during the survey) and replaced a washer in the supply hose of washing machine #3 (where the leak was coming from). He said the laundry chemical supply provider was responsible for refilling the laundry chemicals and any service to the equipment which distributed those chemicals into the washing machines. The MTD said the supply hose maintenance was a facility responsibility. The MTD could not explain why he had not made the repairs himself prior to the survey. The MTD said he and the laundry aide had put the portable blower behind the washing machines to address the water coming from the leak in the supply hose, but he could not recall exactly when the blower had been put back there. He said he was aware of the detached tiles behind the washing machines and said the tiles had been that way since the facility's acquisition by another corporation on 6/1/24. The MTD said he conducted monthly inspections of the laundry room machines and washing machine #3 had been leaking on and off since February 2026. He said he should have gone to the home repair store and purchased supplies to repair the leaking hose but he had not done so. The MTD said that the laundry aide had put blankets around washing machine #3 to prevent water from leaking outward and causing safety and trip hazards, however, he said this was not an appropriate way to address a leak.

Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for the residents. Specifically the facility failed to:-Ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head;-Ensure resident room corridors were free of deterioration and water damage;-Ensure one of 12 resident rooms had a properly operational sink faucet; and, -Ensure two of 12 resident personal bathrooms were free of deterioration and water damage. Findings include:I. Failure to ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head A. Observations On 3/23/25 at 9:12 a.m., the facility's West One shower room was observed. The shower room had four 12 by12 inch tiles on the lowest part of the shower wall, held to the wall with six strips of vertical duck tape. The tile closest to the exit door had a gap of one half an inch with a visible black substance underneath. When light pressure was applied to the last tile, it bowed inward toward the surface underneath the tile. The corner of the shower room wall, closest to the exit door, revealed signs of warping and there was peeling paint to the wall above the baseboard. There were signs of warping and peeling paint around the door stop of the exit door. The inner doorframe of the exit door, from the bottom of the door to approximately five inches up the door, revealed discoloration, peeling paint and soft wood. The exterior door frame of the exit door (facing the exterior hallway), from the bottom of the door to approximately five inches up the door, revealed discoloration, peeled and missing paint and exposed soft wood with disintegrated wood flakes on the carpet. Additionally, the shower head in the West One shower room had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water. On 3/23/25 at 1:51 p.m. the facility's West One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water. On 3/24/26 at 8:42 a.m. the facility's West One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water. On 3/24/26 at 11:29 a.m. the facility's West One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor. B. Record reviewOn 3/24/26 at 9:45 a.m., the maintenance director (MTD) provided a typed timeline he had created showing the process of repairs to the West One shower room. The timeline revealed that staff had notified him of the loose wall tiles in the shower room on 3/4/26. The MTD began working on cleaning and replacing the tiles on 3/4/26 and had continued to work on the tile repair (between staff using the shower room for showering residents) up until the day of the survey entrance on 3/23/26. Between 3/4/26 and 3/23/26, the MTD had worked in the West One shower room seven times. On 3/25/26 at approximately 10:00 a.m. the MTD provided a print out of all the closed work orders from 1/1/26 to 3/24/26. Work order #1172, for a shower without pressure in the West One shower room, was highlighted in the work order history.-However, there was no date for when the work order was submitted or completed. On 3/25/26 at approximately 11:30 a.m. the MTD provided a print out of a supply purchase order for a shower cartridge and a new handheld shower head, which was scheduled to arrive at the facility on 3/25/26. -However, there was no date on the purchase order for when the order for the shower cartridge and a new handheld shower head was placed. C. Staff interviews and observations Certified nurse aide (CNA) #1 was interviewed on 3/24/26 at 8:42 a.m. CN! #1 said she worked on the West One hallway and she was also a shower aide. CNA #1 said the loose tiles and water damage in the shower room had been there for at least a month. CNA #1 said the leaking shower head in the shower room had been that way for at least a month. The West One shower room was observed with the MTD on 3/24/26 at 12:50 p.m. The MTD said the housekeeping staff cleaned the shower room daily and he was aware of the water damage to the tiles and walls. He said he had been working on replacing the tiles for two weeks. The MTD said he had to do the repairs between residents continuing to be showered in the West One shower room. He said he did not have documentation of his repairs to the shower room and he had not been providing documentation to the nursing home administrator (NHA) of his progress with the shower room’s repairs. The MTD said he was not aware of the shower head leak in the West One shower room. The West One shower room was observed with the NHA on 3/25/26 at 8:45 a.m. The NHA said the West One shower room would be closed and the West Two shower room would be the only shower room used on the facility’s West unit until the water damage to the interior and exterior of the West One shower room were addressed. The MTD and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m. The MTD said he started to notice the leak in the West One shower head the week prior to the survey (the week of 3/16/26). He said he had purchased a replacement shower head and installed it on 3/20/26, however, he had no documentation of the purchase, the installation or a work order. The MTD said during the survey, it was determined the West One shower head needed a cartridge (a component of the shower system that regulates water flow from the showerhead) replacement. The MTD said continuous leaks could create water damage and compromise surfaces. The MTD acknowledged that due to a leak in the shower head and the staff's use of the shower room on a daily basis, the prolonged water saturation would compromise the adhesiveness of the duct tape holding the tiles to the shower wall. He said after observing the shower room during the survey, he determined the project needed more extensive work and made his regional plant resource aware. The MTD said it was his decision to not close down the West One shower room to expedite the repairs and ensure the tiles were secured to the backing board. The MTD was unable to give a reason for this decision, but he said it was a mistake and he should have closed down the shower room. He said the West One shower room was now closed until it was fully repaired. The regional plant resource said that he was unaware of the repairs the MTD was doing in the West One shower room prior to the survey and when he came in to inspect the repairs, he said he found the surface behind the tiles to be compromised from water damage. He said the tiles had since been removed, the backing board repaired and new tiles placed. The regional plant resource said if ,while showering residents, the staff were to hit the wall with a shower chair, it would have caused the tiles to collapse inwards from the water damage. II. Failure to ensure resident room corridors were free of deterioration and water damageA. Observations On 3/23/25 at 9:12 a.m. the corridor outside the West One shower room revealed an area of the carpet below the wood frame, and running along approximately six inches of the baseboard, that was discolored, soft and damp. C. Staff interviews and observationsThe corridor outside the West One shower room was observed with the MTD on 3/24/26 at 12:55 p.m. The MTD said he was not aware of the water damage to the exterior baseboard and the carpet. He said the damage would have resulted from leaks in the shower room. The MTD was interviewed again on 3/26/26 at 9:40 a.m. The MTD said he had noticed the water damage to the exterior baseboard and carpet outside the West One shower room and had used carpet fans to attempt to dry the area. The MTD said he was waiting to finish the repairs inside the shower room first before repairing the exterior corridor and he had obtained bids on a new carpet. -However, the MTD did not provide documentation of the bids for the carpet replacement. III. Failure to ensure one of 12 resident rooms had a properly operational sink faucet. A. Observations On 3/24/26 at 11:45 a.m. resident room #104 was observed. The observation revealed a dripping bathroom sink faucet B. Staff interviews and observationsRoom #104's resident bathroom was observed with the MTD on 3/24/26 at 12:50 p.m. The MTD said he had not been made aware of the bathroom sink faucet drip and had not received a work order to repair it. The MTD said his housekeepers cleaned the residents’ bathrooms daily, to include the sinks, and he would have expected the housekeepers to submit a work order or verbally tell him about the leaking faucet in room #104’s bathroom. IV. Failure to ensure two of 12 resident personal bathrooms were free of deterioration and water damageA. ObservationsOn 3/24/26 at 11:58 a.m., two resident rooms on the facility’s West unit were observed. Room #105 had a triangular area from the resident's personal bathroom ceiling to the exhaust vent and around the vent of peeled and missing paint. The area was approximately two feet wide by six inches long. Room #108 had an area on the resident's personal bathroom wall of approximately three feet long by two feet wide of discolored, bubbled and peeling paint. B. Staff interviews and observationsRoom #105 and room #108 were observed with the MTD on 3/24/26 at 1:05 p.m. The MTD identified the damage to the bathroom walls in the rooms as being caused by water damage and said he had not been aware of the damage and the staff had not submitted a work order for the damage. He said a few months prior, there was a toilet leaking on the second floor that probably was the cause of the water damage, but he could not pull up the work order for the toilet to show when that leak was reported and repaired. The MTD and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m. The MTD said his housekeepers cleaned the residents’personal bathrooms daily but had never reported to him the water damage to the walls in room #105 and room #108. He said after observing the water damage, during the survey, he believed it resulted from the second floor’s previously leaking toilet. The regional plant resource was able to pull the work order report showing the ticket for the leaking toilet was opened on 1/17/26 and completed 1/19/26.

Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for three out of 12 residents’ personal bathrooms. Specifically, the facility failed to ensure ventilation fans were kept operational in the resident personal bathrooms. Findings include:I. Professional referenceAccording to the United States (U.S.) Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 3/30/26 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., "Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and well-being of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents.” II. Observations On 3/24/25 at 11:58 a.m. three resident personal bathrooms were observed. In room #110, room #119 and room #208, the resident personal bathroom ventilation systems revealed there was no air flow present. III. Staff interviews and observations Rooms #110, room #119 and room #208 were observed with the maintenance director (MTD) on 3/24/26 at 1:05 p.m. The MTD said he was not aware of decreased air flow in the vents in the three rooms. The MTD said the facility used a mechanical ventilation system. He said the ventilation system prevented airborne contaminants within the facility. The MTD said to ensure the ventilation system was working properly in the bathrooms, a piece of tissue paper could be put up to the vent. The MTD said if there was proper air flow, the tissue paper would be pulled to the vent. During the observation, the MTD held tissue paper up to the vents, however the tissue papers were not pulled into the vents in room #110, room #119 or room #208. In room #208, the MTD removed the vent cover and had to put his hand, up to the wrist, into the vent opening to detect any sense of air flow. The MTD said he was unable to explain the reason for the decreased air flow in the resident personal bathrooms. On 3/25/26 at approximately 10:00 a.m., the MTD provided a work history report of inspections he had completed on the exhaust fans. The work history report revealed an inspection was completed on the exhaust fans on 3/20/26. -However, the report did not reveal which specific resident personal bathroom exhaust fans were inspected.

A survey prompted by #CO2718023 was completed on 3/23/26 to 3/26/26. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident’s admission to the facility, the facility failed to ensure the resident’s prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. The facility’s failure to send the resident’s prescription to the pharmacy in a timely manner, resulted in the resident not receiving the narcotic pain medication for 21 hours after leaving the hospital, resulting in severe back pain for Resident #74. Additionally, Resident #71 did not receive pain medication in a timely manner and per physician’s orders. Specifically, the facility failed to: -Ensure Resident #74’s pain medication was received and administered as ordered in a timely manner, which resulted in severe back pain for the resident; and,-Ensure Resident #71’s pain was addressed timely and pain medication was administered per physician ordered parameters. III. Resident #71A. Resident statusResident #71, age 89, was admitted on 1/1/26 and discharged to the hospital on 1/14/26. According to the January 2026 CPO, diagnoses included a displaced fracture of the left femur, need for assistance with personal care and cognitive communication deficits. The 3/15/25 comprehensive assessment revealed the resident had mild cognitive impairments, per the staff assessment for mental status. The resident required moderate to substantial assistance from staff for all activities of daily living (ADL). The comprehensive assessment documented the resident received scheduled pain medications, as needed (PRN) pain medications and non-medication interventions for pain. B. Resident #71’s representative interviewResident #71’s representative was interviewed on 3/26/26 at 1:25 p.m. The resident’s representative said Resident #71 was in pain when he was first admitted to the facility on 1/1/26. The resident’s representative said Resident #71 requested pain medications from the nurse right when he was admitted, and the nurse told him she would get his pain medications right away. The resident’s representative said Resident #71 was not administered any pain medications until later that night (1/1/26) because the nurse could not get the code she needed from the pharmacy in order to dispense the pain medication dose. C. Record reviewReview of Resident #71’s January 2026 CPO revealed the following physician’s orders:Tylenol 325 mg oral tablets, give two tablets by mouth every six hours as needed for pain, ordered 1/1/26 at 7:02 p.m. Oxycodone 5 mg oral tablets, give one tablet by mouth every four hours as needed for pain ranging from 6 to 10 on a scale of 1 to 10 and give 0.5 tablets by mouth every four hours as needed for pain ranging from 3 to 5 on a scale of 1 to 10, ordered 1/1/26 at 7:15 p.m. Non-pharmacological interventions for pain: repositioning, rest, massage, distraction, or other, ordered 1/1/26 at 2:05 p.m. A progress note, dated 1/1/26 at 5:50 p.m., revealed Resident #71 arrived at the facility from the hospital. Resident #71 had received surgery for a left femur fracture, and said his pain was a 6 out of 10. The progress note documented the nurse was notified about Resident #71’s pain. An admission pain management review assessment was completed by a member of the nursing staff on 1/1/26 at 8:05 p.m. The assessment documented Resident #71 had pain frequently over the last five days. The assessment documented Resident #71’s pain was at his incision site. The assessment documented Tylenol and oxycodone relieved Resident #71’s pain, along with rest and repositioning. The assessment documented Resident #71 would be satisfied with a pain level of 2 out of 10. The pain management review assessment documented Resident #71 had a pain of 7 out of 10 at the time of the assessment. A progress note, dated 1/1/26 at 8:17 p.m., revealed Resident #71 was administered a dose of PRN 5 mg oxycodone. Resident #71 had requested the medication for generalized pain.-However, the oxycodone was administered nearly two and a half hours after the resident admitted to the facility and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident’s PRN pain medications (see admission progress note and physician’s orders above). Review of Resident #71’s January 2026 MAR did not reveal any administered doses of the resident’s PRN Tylenol medication. Review of Resident #71’s January 2026 treatment administration record (TAR) revealed the physician’s order for non-pharmacological pain interventions was documented as completed during the evening shift on 1/1/26.-However, the specific non-pharmacological pain interventions used were not documented or assessed for effectiveness. D. Staff interviewsRegional nurse consultant #1 was interviewed on 3/25/26 at 9:41 a.m. Regional nurse consultant #1 said the facility’s expectation for the nursing staff, in the event of a pain medication order not being available for a newly admitted resident, was for the nurses to contact the pharmacy and the resident’s physician to see if there were any other pain medication options which could be administered. LPN #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said if a resident expressed they were in pain, the nursing staff attempted non-pharmacological interventions before moving to administering any PRN pain medications. LPN #3 said if a resident was in pain and did not have any pain medication options available for her to give, she would contact the resident’s physician right away. LPN #3 said she would assess the resident’s pain and try to find a way to relieve their pain so it did not get any worse, and document her steps in the resident’s EMR. LPN #3 said she would carry out the same process if a resident was just admitted to the facility. LPN #3 said the facility had an emergency medications machine where she could get an emergency dose of a PRN medication after receiving orders from the physician. The nursing home administrator (NHA), the infection preventionist (IP) and the DON were interviewed together on 3/25/26 at 4:14 p.m. The NHA said if any of the residents’ medications ran out, the nursing staff had been trained regarding who to contact. The NHA said agency staff members had access to a binder and a list of pharmacist contact information just for that event. The DON and the IP said some of the agency nurses had access to the emergency medications machine, and if the agency nurses working in the facility did not have access to the machine, someone else scheduled to be working during that time would have access. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said she tried to give residents their PRN pain medications as requested or their scheduled pain medications right on time before their pain got any worse. LPN #4 said if a medication ran out or was unavailable, she would call the pharmacy and the resident’s physician, and use the emergency medication machine to dispense a dose for the resident if needed. The DON and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 10:30 a.m. The ADON said Resident #71 was admitted to the facility on 1/1/26, and his admission pain assessment documented the resident had a pain level of 7 out of 10. She said the assessment indicated that the pain medications that had worked to relieve his pain in the past were Tylenol and oxycodone. The DON said Resident #71’s first dose of oxycodone was administered on 1/1/26 at 8:17 p.m. The DON said Resident #71’s PRN pain medications were reviewed with the resident on 1/2/26.-However, the oxycodone was administered nearly two and a half hours after the resident was admitted to the facility on 1/1/26 and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident’s PRN pain medications. -The pain assessment conducted on 1/1/26 documented Tylenol had been previously effective in alleviating pain for Resident #71, however no doses of Tylenol were documented as being administered during the resident’s stay in the facility.

Based on observations, record review and interviews, the facility failed to ensure that the residents had a safe, clean, comfortable, and homelike environment for three out of 12 rooms. Specifically, the facility failed to ensure the facility's process of reporting and responding to repairs in the resident's rooms was being utilized to maintain three damaged closets in Resident #8, Resident #74, and Resident #33's rooms. Findings include:I. Observations and staff interviewResident #8's room was observed on 3/23/26 at 9:13 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed on 3/23/26 at 9:20 a.m. The hinge holding the resident's closet door to the frame was detached from the frame. Resident #74's room was observed on 3/23/26 at 11:45 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #8's room was observed again on 3/24/26 at 1:10 p.m. with the maintenance director (MTD). The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed again on 3/24/26 at 1:15 p.m. with the MTD. The hinge holding the resident's closet door to the frame was detached from the frame. Resident #74's room was observed again on 3/24/26 at 1:25 p.m. with the MTD. The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged. The MTD said he was not aware of the damaged closet doors in Resident #8, Resident #33 and Resident #74’s rooms and he had not received a work order to repair them. The MTD said the facility's process when things needed to be fixed was for an electronic work order to be submitted so he could repair items inside of residents’ rooms. II. Resident interviewResident #74 was interviewed on 3/23/26 at 11:45 a.m. Resident #74 said the hinge on her closet door had been loose and coming out of the door since she was admitted to the facility on 3/22/26. Resident #74 said she had complained to the staff and they told her that maintenance would repair it, but no one from maintenance had come to see her about it. III. Additional staff interviewsCertified nurse aide (CNA) #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said when something in the facility needed repair, the CNAs would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents’ rooms that was broken or needed repair. CNA #1 said work orders were submitted by CNAs and nurses. Licensed practical nurse (LPN) #4 was interviewed on 3/25/26 at 1:12 p.m. LPN #4 said when something in the facility needed repair, the nurses would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents’ rooms that was broken or needed repair, such as a bed not working, bathroom doors and or closet doors. LPN #4 said work orders were submitted by CNAs and nurses. LPN #3 was interviewed on 3/25/26 at 1:34 p.m. LPN #3 said she was an agency nurse but most facilities she had worked in used an electronic reporting system to submit work orders to their maintenance department for repairs. She said she would try to submit it that way or ask the charge nurse. The MTD was interviewed again on 3/26/26 at 11:30 a.m. The MTD said he had submitted a ticket to the electronic work order help desk in order to open up access to submitting work orders for all staff, not just CNAs and nurses. IV. Facility follow upOn 3/26/26 at approximately 11:30 a.m. the MTD provided a training in-service sheet, dated 3/26/26, on the importance of the electronic work order system, which indicated education had been completed with the 13 administrative staff, one activities assistant, two transportation drivers and one regional clinical resource. Of the facility’s six housekeeping staff, one was trained; of the facilities 28 CNAs, three were trained; of the facilities nine LPNs, none were trained and of the facility’s nine registered nurses, one was trained. -The MTD did not provide documentation of a plan to ensure all staff were trained and understood the electronic work order system.

A complaint survey, prompted by #CO1921778 was conducted on 9/15/25. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 5/14/24 for all previous deficiencies cited on 3/27/24. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 16, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (2) story, Type II (111) construction. This original facility was constructed in 2006. There is a partial basement that is used for support services and there is no resident access. There is an assisted living unit as well as an independent living unit. The assisted living and independent living are separated from the long term care facility by a two-hour fire rated wall. The facility is licensed for 58 beds and the census on the date of the survey was 36. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry pipe fire sprinkler systems. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Administrator and Maintenance Director during the exit conference conducted on April 16, 2024.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. East and West stairwell 1st and 2nd floor used for storage. 2. Exit egress path throughout the building has obstructions and impediments. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 7.9.3 and 19.2.9.1.1. Emergency lighting no annual 30 seconds inspection report available for reviewNFPA 101 7.10.1.2.1 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit accessNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1. Exit Lights no annual 30 seconds inspection report available for review 2. Blocked exit signs in the dining room. 3. Missing 2 exit signs dining room corridor 4. Exit signs do not light up. 2nd floor east and west stairwells Life Safety Code Section 19.2.10.1 to comply with 7.10Life Safety Code Section 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director during the survey and the Maintenance Director and Administrator at the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2.1. Mechanical room next to rehab no access. No key to open the Fire door. NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this CodeThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director during the survey and the Maintenance Director and Administrator at the exit conference.

Through observation and staff interview of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes in accordance with NFPA 101 Life Safety Code (2012 Edition), section 19.3.3.1 and 10.2. 1. Ceiling tiles have holes in them outside the second floor media room. 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section10.2 shall be permitted to be Class A or Class B.Through observation during the survey, it was determined that the facility failed to meet theprotection requirements in accordance with NFPA 101. This was evidenced by:This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31.119 door door doesn ' t latch2.219 door seal 3. Door 207 handle is falling off 4. Facity failed to provide an annual fire door inspection report at time of inspection. 5. Fire door front door handle no up repaired Doesn ' t latch 6. Fire door doesn ' t latch 1 west7.1 east wing fire door doesn ' t latch 8. Fire door west stairwell doesn ' t always close 9. Rehab gym fire doors won't latch east 10. Media room fire door doesn ' t latch first floorNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance team at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. Nutrition room fire caulk missing around a conduit NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.1. Exposed wires hanging from the ceiling in the rehab room. 2. Nutrition room 2 east and west curtain against electrical equipment. NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Facility missing fire drill in third and fourth quarter of the year. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6. This was evidenced by: 1) Facility has decorations outside patients rooms in 1 west corridor. Life Safety Code Section 19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:(1)They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.(2)The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.(3)The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.(4)*The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:(a)Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 19.7.5.6(b), (c), or (d).(b)Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.(c)Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.(d)Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.(5)*They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. Life Safety Code Section 19.7.5.1 Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1(see 19.3.5.11), and the following also shall apply: (1) Such curtains shall include cubicle curtains. (2) Such curtains shall not include curtains at showers and baths. (3) Such draperies and curtains shall not include draperies and curtains at windows in patient sleeping rooms in smoke compartments sprinklered in accordance with 19.3.5. (4) Such draperies and curtains shall not include draperies and curtains in other rooms or areas where the draperies and curtains comply with all of the following: (a) Individual drapery or curtain panel area does not exceed 48 ft2 (4.5 m2). (b) Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located. © Smoke compartment in which draperies or curtains are located is sprinklered in accordance with 19.3.5. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the maintenance director during the survey and the Maintenance Director and Administrator at the exit conference.

Based on observation and staff interview it was determined that the facility failed to maintain a fire safe environment within the facility Life Safety Code, Section 19.7.81. Portable space heater used in Rooms (front reception area, HR office, rehab room, ) 2. Fireplace outside the dining room is a non permitted portable space heater. Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1. Fridge into power strip business office 2. Fridge in from lobby needs to be plugged into extension cord through receptionFlexible cords and cables in accordance with Chapter 4 of NFPA 70, Section 400.8(1), in part, flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."This deficiency has the potential to affect the occupants, who might include the resident, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

A recertification survey was conducted from 3/25/24 to 3/27/24. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/25/24 to 3/27/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#25) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #25. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."II. Facility policy and procedureThe Administering Medications policy and procedure, revised in April 2019, was received from the executive director (ED) on 3/27/24 at 7:22 a.m. It revealed in pertinent part,"Medications were administered in a safe and timely manner and as prescribed."Medication administration times were determined by resident need and benefit, not staff convenience. Factors to consider include: enhancing optimal therapeutic effect of the medication; honoring resident choices and preferences, consistent with his or her care plan."Medications were administered within one hour of their prescribed time."As required or indicated for a medication, the individual administering the medication records in the resident's medical record: date and time the medication was administered."III. Resident #25A. Resident statusResident #25, older than 65, admitted on 5/9/23. According to the March 2024 computerized physician orders (CPO), diagnoses include congestive heart failure (excessive fluid), chronic kidney disease (decrease in kidney function), hypertension (increased blood pressure) and atrial fibrillation (abnormal heat function). The 2/16/24 minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He required one person's assistance with transfers and dressing. He required set up assistance for eating and personal hygiene. B. Resident interviewResident #25 was interviewed on 3/25/24 at 1:14 p.m. Resident #25 said his medications were late and he was afraid it would affect his health. C. Record reviewThe March 2024 CPO documented the following medication orders:Metoprolol succinate (used for blood pressure control) 50 milligrams (mg) two times daily at 8:00 a.m. and 8:00 p.m. ordered on 10/26/23. Trazadone (used for insomnia) 50 mg once daily at bedtime at 8:00 p.m. ordered on 9/15/23. Genteal ophthalmic gel 0.25-0.3% instill one drop in both eyes for cataracts at bedtime 8:00 p.m. ordered on 5/17/23. Finasteride 5 mg (used to treat enlarged prostate) at bedtime 8:00 p.m. ordered on 6/12/23. Furosemide 10 mg (used to remove excess fluid in the body) every morning at 8:00 a.m. ordered on 8/19/23. Review of the medication administration record (MAR) from 3/12/24 to 3/26/24 revealed the following:The Metoprolol succinate 8:00 a.m. dose was not administered timely on the following days:-3/12/24, the medication was administered at 10:21 a.m (one hour and 21 minutes after the allowed administration time);-3/15/24, the medication was administered at 11:22 a.m. (two hours and 22 minutes after the allowed administration time);-3/16/24, the medication was administered at 11:15 a.m. (two hours and 15 minutes after the allowed administration time);-3/17/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time);-3/18/24, the medication was administered at 10:56 a.m. (one hour and 56 minutes after the allowed administration time);-3/24/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time); and-3/25/24, the medication was administered at 10:34 a.m. (one hour and 34 minutes after the allowed administration time). The Metoprolol succinate 8:00 p.m. dose was not administered timely on the following days:-3/12/24, the medication was administered at 10:26 p.m. (one hour and 26 minutes after the allowed administration time);-3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time);-3/16/24, the medication was administered at 11:56 p.m. (two hours and 56 minutes after the allowed administration time);-3/21/24, the medication was administered at 10:22 p.m. (one hour and 22 minutes after the allowed administration time); and-3/15/24, the medication was administered at 12:07 a.m. on 3/26/24 (three hours and seven minutes after the allowed administration time). The Trazadone 8:00 p.m. dose was not administered timely on the following days:-3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); and-3/21/24, the medication was administered at 10:45 p.m. (one hour and 45 minutes after the allowed administration time). The Genteal ophthalmic gel 8:00 p.m. dose was not administered timely on the following days:-3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); -3/19/24, the medication was administered at 11:10 p.m. (two hours and 10 minutes after the allowed administration time);-3/21/24, the medication was administered at 10:49 p.m. (one hour and 49 minutes after the allowed administration time)The Finasteride 8:00 p.m. dose was not administered timely on the following days:-3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); and-3/21/24, the medication was administered at 10:43 p.m.(one hour and 43 minutes after the allowed administration time). The Furosemide 8:00 a.m. dose was not administered time on the following days:-3/12/24, the medication was administered at 10:21 a.m. (one hour and 21 minutes after the allowed administration time);-3/15/24, the medication was administered at 9:39 a.m. (39 minutes after the allowed administration time);-3/16/24, the medication was administered at 11:15 a.m. (two hours and 15 minutes after the allowed administration time);-3/17/24, the medication was administered at 10:12 a.m. (one hour and 12 minutes after the allowed administration time);-3/18/24, the medication was administered at 10:55 a.m. (one hour and 55 minutes after the allowed administration time);-3/24/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time); and-3/25/24, the medication was administered at 10:34 a.m. (one hour and 34 minutes after the allowed administration time).-There were no progress notes documenting the reason the medications were administered late. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/27/24 at 8:10 a.m. LPN #1 said medications were to be administered in one hour before or after the medication scheduled time. LPN #1 said if a medication was not administered timely it could affect the resident's health, could be given too close to the next dose compromising the resident. LPN #1 said sometimes medications were given late due to an emergency with other residents. The director of nursing (DON) was interviewed on 3/27/24 at 8:21 a.m. The DON said resident medications should be administered timely to ensure the effectiveness of a medication purpose for the resident. The DON said the nurses should administer medications within the one hour window before and after the scheduled time. The DON said the administration of medications being timely was part of the seven rights of medication administration. The DON said it was up to the nurse to add a progress note to state why a medication was administered late. The DON said medication could be documented late if the nurse did not sign them out at time of administration but that was not best practice.

Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the outcome of the reviews for three out of five CNAs reviewed for annual reviews and training. Specifically, failed to provide performance reviews annually and training based on the outcome of the individual reviews for CNA #1, CNA #2 and CNA #3. Findings include:I. Facility policy and procedureThe Performance Evaluations policy, revised September 2020, was provided by the executive director (ED) on 3/27/24 at 12:27 p.m. It documented in pertinent part, "The job performance of each employee shall be reviewed and evaluated at least annually. Performance evaluations may be used in determining employee promotion, shift/position transfers, demotion, terminations, wage increases and to improve the quality of the employee's work performance. The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training) and goals."II. Record reviewThe 2/8/24 facility assessment was provided by the social services director (SSD) on 3/26/24 at 12:07 p.m. It revealed the facility average census was 35 residents. The common diseases the facility provided care to were psychiatric/mood disorders, circulatory system, neurological system, vision and hearing, musculoskeletal system, metabolic disorders, respiratory systems, genitourinary system, diseases of blood, digestive system, integumentary system and infectious diseases. Performance evaluations for CNAs were reviewed. -However, the facility was unable to provide annual performance evaluations and reviews for CNA #1, CNA #2 and CNA #3 during the survey process. III. Staff interviewsThe human resources director (HRD) was interviewed on 3/27/24 at 9:18 a.m. She said the facility had a new administration team that came together in 2023. She said performance reviews were not a priority for the past administration team. She said the current administration team had made it a priority to complete the performance reviews timely. The director of nursing (DON) was interviewed on 3/27/24 at 11:06 a.m. She said performance evaluations should have been completed annually. She said she completed the performance evaluations for CNA #1, CNA #2 and CNA #3 on 3/26/24 during the survey. She said going forward the performance evaluations would be completed on the CNAs anniversary date.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of three medication storage rooms and one of three medication carts. Specifically the facility failed to:-Ensure expired medications were not stored with current medications in the medication storage rooms;-Ensure medications were stored at correct temperatures in medication storage refrigerators;-Ensure medications were not stored in a dormitory style refrigerator/freezer combination; and, -Ensure used medication vials were not stored in the medication cart. Findings include:I. Professional reference According to the Vaccine Storage and Temperature Monitoring Equipment (January 2023), retrieved on 3/18/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf,"It is important the facility has proper storage and monitoring equipment that was set up correctly, maintained appropriately and repaired as needed. The equipment protects patients from inadvertently receiving compromised vaccines."Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in the freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage."Temperature ranges for refrigerators should maintain temperatures between 36 and 46 degrees fahrenheit (F)."II. Facility policy and procedureThe Medication Labeling and Storage policy and procedure, revised February 2023, was received from the executive director (ED) on 3/27/24 at 7:22 a.m. It revealed in pertinent part "The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls."If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items."Medications requiring refrigeration were stored in the refrigerator located in the medication room at the nurses station."III. Observations and staff interviewsOn 3/26/24 at 1:40 p.m. the first floor east wing medication cart was observed with RN #1. The following item was found: -One open and used vial of ceftriaxone 1 gram injection (an antibiotic medication used for infections).-The vial had no resident name or date on it. Registered nurse (RN) #1 said it was the responsibility of each nurse working the medication cart to ensure the cart was clean. She said the empty vial should have been disposed of after the medication was drawn up from the vial. RN #1 said the vial did not have a resident name on it but it could have been removed from the facility's emergency medication supply. On 3/26/24 at 1:47 p.m., the east wing medication storage room was observed with RN #1. The following items were found:-One opened bottle of vitamin D3 5000 units that expired 11/2023; -One unopened bottle of Iron 325 milligrams (mg) expired 12/2023; and,-Two unopened bottles of Senokot (aids in relieving constipation) 8.6 mg that expired 11/2023. Additionally, the temperature in the medication storage refrigerator in the medication storage room was 33 degrees F which was confirmed by RN #1. The refrigerator had a single door and had a freezer compartment which had about six inches of ice build up in the freezer section. The ice build up would not allow for anything to be stored in the freezer section. The refrigerator had the following vaccines and medications stored in it:-Three Basaglar insulin pens (used for blood glucose management);-One bottle of liquid Lorazepam (anti-anxiety medication);-One Fluad quadrivalent flu vaccine for residents over 65 years old;-One quadrivalent flu vaccine for residents younger than 64 year olds;-One open vial of tuberculin (used to test for tuberculosis);-One unopened vial of tuberculin; and, -One box ofBisacodyl suppositories (used for constipation). RN #1 said the medication storage refrigerator was not within the correct temperature range per the facility's log and the medications or vaccines in the refrigerator could be compromised if they were not stored at the correct temperatures. RN #1 said the expired medication bottles should have been placed in the cabinet labeled expired medications which was at the other end of the medication storage room to ensure a nurse did not collect them to be used for a resident. On 3/26/24 at 2:02 p.m., the second floor medication room was observed with licensed practical nurse (LPN) #1. The medication storage refrigerator in the medication storage room was a dormitory style refrigerator where the freezer was in the same compartment as the refrigerator. The freezer had two inches of ice build up. The following medications were observed to be stored in the refrigerator:-One open vial of Tuberculin; and,-One novolog insulin vial. LPN #1 said she did not know medications could not be stored in a dormitory style fridge. LPN #1 said she did not think the medications in the refrigerator were compromised as the temperature log for the fridge did not have any temperatures out of the safe range. IV. Additional staff interviewsThe director of nursing (DON) was interviewed on 3/26/24 at 2:20 p.m. The DON said medications and vaccines should be stored per the recommendations of the medication manufacturers to ensure medications were effective at the time administered. The DON was not aware the facility could not use the dormitory style refrigerators because of increased risks of temperature fluctuations. The DON observed the ice build up in the first floor east wing medication room and said the facility did not use the freezer section to store medications. The DON said the medications stored in the refrigerator would be destroyed and new ones would be ordered from the pharmacy to ensure medications were not given to residents because they might have been compromised. The DON said expired medications were to be stored in the medication room in the cabinet labeled expired medications to ensure the nurses did not accidentally give a resident a medication that was expired. The DON said the expired medications should not have been in the cabinet labeled medication cart supplies. The DON said the empty vial of antibiotics should have been disposed of at the time the injection was given and should not have been stored in the medication cart. The DON said all nurses working the medication cart were to keep the carts clean. The DON said she completed random medication cart checks monthly and the pharmacy consultant also completed checks monthly.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for one of two units. Specifically, the facility failed to:-Ensure resident rooms and bathrooms were cleaned in a sanitary manner;-Ensure surface disinfectants were used for the appropriate dwell time (amount of time surface must remain visibly wet);-Ensure appropriate hand hygiene was performed by housekeeping staff; and,-Ensure high touch surfaces were cleaned. Findings include:I. Professional reference According to the Environmental Cleaning procedures (reviewed 5/4/23) retrieved on 3/28/24 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, "Common high touch surfaces include: sink handles, bedside tables, call bells, door knobs, and light switches."High touch surfaces and floors should be cleaned at least once daily (24 hour period)."At least once daily or every 24 hours high touch surfaces are to be cleaned."According to the List N tool: Covid 19 disinfectants retrieved on 4/1/24 from: https://cfpub.epa.gov/wizards/disinfectants/ "Fabuloso requires a 10 minute contact time (surface must remain visibly wet for the duration of the contact time)."II. Facility policyThe Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was received from the executive director (ED) on 3/27/24 at 12:14 p.m. It revealed in pertinent part "The purpose of this procedure is to provide guidelines and disinfecting residents' rooms."Environmental surfaces will be disinfected (or cleaned) on a regular basis."Disinfecting solutions will be prepared as needed and replaced with fresh solutions frequently."Perform hand hygiene after removing gloves."The environmental service director and administrator, in conjunction with the infection preventionist will select appropriate facility disinfectants."Change cleaning clothes when they become soiled."Clean personal use items lights, phones, call bells with disinfectant solution."III. ObservationsOn 3/26/24 at 9:36 a.m., housekeeper (HSK) #1 was cleaning room #110, a private resident room. HSK #1 grabbed a wet rag from a bucket on her cleaning cart, wrung it out and picked up a spray bottle with a purple solution in it. HSK #1 entered room #110, sprayed the purple solution from the bottle onto the bedside table and immediately wiped the table top and the legs of the bedside table with the rag. -HSK #1 did not allow the cleaning solution to remain wet on the surface of the bedside table for the manufacturer recommended dwell time of 10 minutes. HSK #1 proceeded to move into the bathroom, sprayed the purple solution on the sink and wiped it off immediately with the rag.-HSK #1 did not allow the cleaning solution to remain wet on the surface of the sink for the manufacturer recommended dwell time of 10 minutes. At 9:41 a.m., HSK #1 sprayed the toilet and brushed the toilet bowl with a toilet brush.. HSK#1 wiped the rim of the toilet, bottom of the toilet seat, then the top of toilet seat and lastly the toilet lid was wiped. HSK #1 used the same rag to wipe the toilet tank and the outside of the toilet down to the floor.-HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the toilet for the manufacturer recommended dwell time of 10 minutes.-HSK #1 did not clean the toilet from cleaner areas to dirtier areas. At 9:42 a.m., HSK #1 sprayed and immediately wiped off the grab bars in the bathroom using the same rag she cleaned the toilet with.-HSK #1 did not allow the cleaning solution to remain wet on the surface of the grab bars for the manufacturer recommended dwell time of 10 minutes. HSK#1 returned to her cleaning cart and retrieved a broom to sweep the room. As she was sweeping, she touched the resident's recliner, pillow, bedside table, desk chair, shoes, toilet riser and themain door handle with the same gloves she had used to clean the bathroom with.-HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before she touched multiple items in the resident's room while sweeping the floor..HSK #1 returned to her cart and grabbed a mop pad from a bucket with cleaning solution on her cleaning cart. -HSK #1 did not remove her gloves and perform hand hygiene before reaching into the bucket of solution for the mop pad. HSK #1 wrung out the mop pad with the same gloves she had been wearing throughout the entire cleaning process of the resident's room. She allowed the excess cleaning solution to drip back into the container and returned to the resident's room to mop the floor. HSK #1 mopped the resident's room from the window towards the bathroom. HSK #1 proceeded to mop the floor of the bathroom with the same mop pad before she finished mopping the resident's room to the main doorway. While HSK #1 was mopping the resident's room, she touched the call light, desk chair, shoes, bedside table, toilet riser and a package of adult briefs. -HSK #1 failed to change her mop pad after mopping the bathroom floor before she finished mopping the remainder of the resident's room.-HSK #1 continued to wear the same gloves she had worn throughout the cleaning process of the resident's room and again touched multiple items in the resident's room during the mopping process. On 3/26/24 at 9:54 a.m., HSK #1 began cleaning room #108, a private resident room. HSK #1 grabbed a rag from the bucket with the cleaning solution on her cart and the spray bottle containing the purple cleaning solution before entering the resident's room. With her gloved hands, which had cleaning solution on them from grabbing the rag, HSK #1 moved several personal items, including the resident's drinking cup which she grabbed by the rim of the cup, from the resident's bedside table and nightstand to the resident's recliner. HSK #1 proceeded to spray the bedside table and nightstand with the purple solution. After spraying the cleaning solution, she immediately wiped off the bedside table and nightstand. HSK #1 then wiped the bedside table and night stand immediately after spraying. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the bedside table and nightstand for the manufacturer recommended dwell time of 10 minutes. At 9:57 a.m., HSK #1 sprayed and immediately wiped off the dresser.-HSK #1 did not allow the cleaning solution to remain wet on the surface of the dresser for the manufacturer recommended dwell time of 10 minutes. At 9:58 a.m., HSK #1 entered the bathroom where she proceeded to spray the sink with the purple solution and immediately wiped the faucet and sink bowl before wiping the faucet handles. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the sink area for the manufacturer recommended dwell time of 10 minutes. HSK #1 sprayed the bathroom cabinet, toilet bowl and toilet riser. HSK #1 moved the toilet riser out of the way and used the toilet bowl brush to scrub the visible brown residue in the toilet bowl. At 10:00 a.m., HSK #1 sprayed more purple solution on the toilet seat, tank and outside of the toilet. HSK #1 immediately wiped the toilet seat, tank, flushing handle, toilet seat (which had visible brown residue on top and underneath) and the rim of the toilet bowl. HSK #1 placed the dirty rag on the toilet riser and moved the toilet riser back over the toilet.-HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the toilet for the manufacturer recommended dwell time of 10 minutes.-HSK #1 failed to clean the toilet from a cleaner area to a dirtier area. HSK #1 returned to her cart, changed her gloves without performing hand hygiene, grabbed a new rag from the bucket on the cleaning cart and returned to the bathroom to clean the toilet riser and the toilet again as there was still brown residue on them. -HSK #1 failed to perform hand hygiene between gloves changes. HSK #1 returned to her cart and retrieved the broom from the cleaning cart to sweep the room.-HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before using the broom to sweep the floor. After sweeping the room with the broom, HSK #1 retrieved a mop pad from the bucket on her cleaning cart wearing the same gloves she had worn to clean the bathroom. She wrung out the mop pad allowing the excess solution to drip back into the bucket. -HSK #1 did not remove her gloves and perform hand hygiene before reaching into the bucket of solution for the mop pad. HSK #1 returned to the room and mopped from the window to the bathroom and then to the main doorway of the room. While mopping the resident's room, HSK #1 touched the residents oxygen tubing, portable oxygen tank, wheelchair pedals, walker, shoes, bedside table, toilet riser and collected the trash from the trash can, all while wearing the same gloves she had been wearing to clean the bathroom.-HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before she touched multiple items in the resident's room while she was mopping the floor.-HSK #1 failed to use a separate mop pad after mopping the bathroom floor before she finished mopping the remainder of the resident's room. III. Staff interviewsHSK #1 was interviewed on 3/26/24 at 10:15 a.m. HSK #1's primary language was French and a translating service was used during the interview. HSK #1 said the purple solution in the bottle was used to make it smell good. HSK #1 did not know the name of the solution but showed a bottle with the name of Fabuloso on the label. HSK #1 said she mixed the solution with water but was unable to say how much water to solution was used. HSK #1 identified the cleaning solution, the rags and mop pads were in a heavy duty tub and tile cleaner from the housekeeping closet dispensing system. HSK #1 identified the following areas as high touch areas which should be cleaned daily: bathroom, tables and the floors. HSK #1 said the call light and light switches were only cleaned twice a week. HSK #1 said she only needed to change gloves if they looked dirty or in between rooms. HSK #1 did not know if the cleaning products she was using were disinfectants or if they had a dwell time. The human resource director (HRD), who was also the housekeeping manager, was interviewed on 3/27/24 at 9:25 a.m. The HRD said she was overseeing housekeeping for ordering the supplies they needed and advising housekeepers when there was a discharge or new admission. The HRD said she was not involved in the training process of housekeepers. The HRD did not know if HSK #1 was provided training in her preferred language. The HRD said HSK #2 was the lead housekeeper and was in charge of training new housekeepers. The HRD said Fabuloso was not one of the approved cleaning chemicals for the facility and she did not know where it came from as it was not a product she had ordered for the facility. HSK #2, who was in charge of training new housekeepers, was interviewed via telephone on 3/27/24 at 10:10 a.m. HSK #2 said high touch items in resident rooms were doors, tables and call lights and should be cleaned daily. HSK #2 said Fabuloso was used to sanitize the rooms. HSK #2 said she used the dispenser in the housekeeping closet for the mopping solution and the solution for the rags. -However HSK #2 was not able to say the name of the chemical as she indicated the writing was too small for her to read on the labels. HSK #2 said she had trained two other housekeepers for the facility. HSK #2 was not able to confirm that HSK #1 was trained in her preferred language. The director of nursing (DON), who was also the facility's infection preventionist (IP), was interviewed on 3/27/24 at 10:29 a.m. The DON said she did not know what chemicals were being used for cleaning of resident rooms. The DON identified the following as high touch areas in a room which should be cleaned daily: television remote, light switches, bedside tables and call lights. The DON said she did not complete any specialized training to housekeepers and it was HSK #2's responsibility to train new housekeepers as she had been working at the facility the longest. The DON said she did not know if the training/education was provided to HSK #1 in her preferred language of French. The DON said she did not know the facility was using Fabuloso for cleaning resident rooms nor did she know what the dwell time of the cleaner was. The ED was interviewed on 3/27/24 at 11:23 a.m. The ED said the facility initially had a dual HRD/housekeeper who would complete inservice and training with the housekeepers. The ED said the facility relied currently on HSK #2 to complete training with new housekeepers. The ED was not aware the housekeeping staff was using an unapproved chemical (Fabuloso) for cleaning. The ED said housekeeping staff were to change their gloves and perform hand hygiene between cleaning the bathroom and the resident rooms to prevent contamination. The ED said high touch areas like call lights, television remotes, bedside tables and light switches should be cleaned daily.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training to ensure continued competence. Specifically, the facility failed to ensure 23 of 24 CNAs received 12 hours of annual training. Findings include:I. Facility policy and procedureThe In-Service Training policy, revised August 2022, was provided by the executive director (ED) on 3/27/24 at 12:25 p.m. It documented in pertinent part, "The primary objective of the in-service training was to ensure that staff were able to interact in a manner that enhanced the resident's quality of life and quality of care and could demonstrate competence in the topic areas of the training." II. Training reviewCNAs were reviewed for the required annual 12 hours of continued education units (CEUs). -Training records revealed only one out of 24 CNAs had completed the required training. III. Staff interviewsThe human resources director (HRD) was interviewed on 3/27/24 at 10:45 a.m. The HRD said the facility did not employ a staff development coordinator. She said it was not communicated to her that the CNAs were required to have the 12 hours of annual in-service training. She said only one CNA had their 12 hour CEUs completed. The director of nursing (DON) was interviewed on 3/27/24 at 11:06 a.m. The DON said all CNAs should have completed their 12 hours of CEUs. She said the HRD should have a tracking system in place to track the amount of hours completed. The ED was interviewed on 3/27/24 at 11:22 a.m. The ED said all CNAs should have completed their 12 hours of CEUs. She said the HRD had initiated a tracking form (during the survey) to ensure CNAs were completing their required CEUs annually.

A focused infection control survey was conducted on 9/27/23. No deficiencies were cited.

An Emergency Preparedness focused infection control survey was conducted on 9/27/23. No deficiencies were cited.

A complaint survey, prompted by #CO31770 was conducted on 4/25/23. No deficiencies were cited.