Every finding on record at Advanced Health Care of Glendale

Based on observations, staff and resident interviews, and a review of facility documentation, policies, and procedures, the facility failed to follow the manufacturer's guidelines for the use of a mechanical lift for one resident (#1). Staff used a manual-operated mechanical lift that did not fit under the resident's bed. As a result, the lift tilted forward and struck the resident's right leg, causing a laceration that required sutures. This deficient practice resulted in physical harm to the resident and could place other residents at risk of injury.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, pyelonephritis, encounter for fitting and adjustment of urinary device, and hypertensive heart disease with heart failure.The Resident's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 9.0, indicating that the Resident's cognition was moderately impaired. The MDS assessment did not code for the resident using a mechanical lift prior to admission. The assessment also included that the resident had a wheelchair as a mobility device in the last 7 days; and, was dependent on staff for sit to lying and chair/bed-to-chair transfer.A care plan initiated on June 3, 2026, revealed the following areas of focus: ADLs (activity of daily living) functional status/rehabilitation potential: Resident requires/receives staff assist with ADL completion related to limited mobility and generalized weakness. On admission the resident required total assist with bed mobility; transfers, non-ambulatory x 2 person stand pivot transfer with gait belt/wheelchair. Interventions included that staff will assist as needed with all ADL completion and to assist with ambulation or wheelchair mobility as needed. Falls, at risk for falls with interventions that included 1 person stand pivot transfer with gait belt/wheelchair, assist with transfers and ambulation as needed. The clinical record revealed no evidence that the resident has orders to or was care planned for use of mechanical lift during transfers. An Event Report dated June 16, 2026, revealed that the nurse was notified of a skin injury to the resident's right lower extremity by CNAs. A review of the nursing progress notes dated June 16, 2026, revealed that at approximately 6:20 PM, the nurse was made aware of a new skin tear and the nurse entered the Resident's room and observed the Certified Nursing Assistant (CNA/Staff #91 and CNA/Staff #49) at the Resident's bedside. The progress note described the resident having a large laceration to right lateral anterior leg. The note relayed that the nurse instructed the CNA (Staff #91) and CNA (Staff #49) to reapply pressure while she gets more supplies. The progress note further revealed that an image and description of the wound were sent to the Nurse Practitioner (NP) per the Nurse Practitioner's request, and a pressure dressing was applied to the wound. The note relayed that 911 was called, and the Resident was sent to the emergency room (ER) for further evaluation and treatment, and that the Director of Nursing (DON/Staff #13) and the Resident's family member were notified of the laceration to Resident #1's right leg during a mechanical lift transfer, and the resident's injury required a higher level of treatment. The note included that the resident stated that she was being transferred from her wheelchair to her bed via the mechanical lift device when the device fell sideways onto her leg. The note also revealed that CNA (Staff #91) and CNA (Staff #49) stated that after Resident #1 had been lifted over the bed, the mechanical lift device fell sideways onto the resident's leg.Another nursing progress note dated June 16, 2026 revealed that the resident sustained a laceration to the leg during a mechanical lift device transfer and that the injury resulted in active bleeding which required nursing intervention and emergency medical services (EMS) transport to the ER.On June 16, 2026, the resident's care plan was updated and revealed that the resident sustained a laceration to her leg while using a manually operated mechanical lift device for transfer. The care plan also revealed that the resident was sent to the ER and returned to the facility on the same day with sutures. The interventions included to monitor the Resident's skin for signs and symptoms of infection.A physician's order dated June 17, 2026, revealed an order for suture removal from the right lower extremity, cleanse with iodine, remove every other suture at a time, and notify the provider of any concerns.An interview was conducted on June 18, 2026, with CNA (Staff #33), who stated that during her 2 days of orientation, she was following a CNA, and was shown how to answer call lights, how the residents' meals work, passing water for the residents, and how to operate the residents' bed. Regarding her training with a mechanical transfer lift device, she stated that 2 people were needed to safely transfer a resident using a mechanical lift device. The CNA also stated that a mechanical transfer lift device is a machine that she can push, the machine had a hook for the sling, and the sling was a barrier placed under a resident to be lifted up, and the sling comes in green, red and yellow. She further stated that she does not know what the colors meant.On June 18, 2026, at 10:22 AM, a CNA (Staff #32) was observed pushing a battery-operated mechanical transfer lift device from one hall to another hall. An interview was conducted with Staff #32 who stated that he was on his way to use the mechanical transfer lift device on a resident sitting in a shower chair. He also stated that he needed 2 people to use the battery-operated mechanical transfer lift device during a resident transfer. While interviewing Staff #32, another CNA (Staff #78) joined the interview and she stated that she would be assisting Staff #32 with the transfer using the battery-operated mechanical transfer lift device.On June 18, 2026, at 10:39 AM, a battery-operated mechanical transfer lift device transfer observation was conducted with two CNAs (Staff #32 and Staff #78) for Resident #2. During the observation, Staff #78 was pushing the battery-operated mechanical transfer lift device towards Resident #2's bed. The battery-operated mechanical transfer lift device that holds the sling was raised up so it can go over the bed and the base of the device was pushed under Resident #2's bed. CNA (Staff #32) was on the opposite side of the bed guiding the device. While Resident #2 was lying in her bed with the sling under her, CNA (Staff #32) assisted with placing the straps of the sling in the hooks of the battery-operated mechanical transfer lift device. Once the straps of the sling were placed in the hooks, the sling with the Resident on it was lifted up from her bed, and the Resident was transferred from her bed to her wheelchair.After the observation of transferring Resident #2 using a mechanical transfer lift device, an additional interview was conducted with CNA (Staff #32) and CNA (Staff #78). The CNA (Staff #78) stated that for her to know how a resident should be transferred, the physical therapist or the occupational therapist would write on the whiteboard in the resident's room, which would include how a Resident should be transferred. The CNA (Staff #78) stated that she would ask the resident how he/she want to be transferred, either by using their wheelchair or a mechanical transfer lift device. The CNA (Staff #78) stated that she would ask for help or get a partner to assist with the use of a mechanical transfer lift device. The CNA (Staff #78) stated that the other person who would be assisting with the transfer would grab the resident's wheelchair, while the other CNA would be operating the mechanical transfer lift device. The CNA (Staff #78) further stated that she would open the lift device's legs using the lift control device so that the Resident's wheelchair could go in between the mechanical transfer lift device's legs, and that after the mechanical transfer leg device was in between the wheelchair, the resident could then be lowered on the wheelchair. The CNA (Staff #78) stated that a mechanical transfer lift device would work when the battery was charged. The CNA (Staff #78) also stated that the other department in the facility would also check the mechanical transfer lift device to make sure that it was operating properly. The CNA (Staff #78) stated that when a mechanical transfer lift device was not working properly, she would notify the maintenance department or she would go directly to the administrator. The CNA (Staff #78) also stated that if the maintenance staff was not available, she would write the work order in the maintenance work order binder located at the nurses' station. Further, the CNA (Staff #78) stated that she was trained using a mechanical transfer lift device during her CNA training program, from her previous job, and that she did not remember receiving mechanical transfer lift device training when she started at the facility because she already knew how to use it.Further interview was conducted on June 18, 2026, at 10:39 AM with CNA (Staff #32) in conjunction with CNA (Staff #78). The CNA (Staff #32) stated that he heard about an incident involving a resident that occurred while using a manually operated mechanical transfer lift device but was not aware of the specifics of the incident. The CNA (Staff #32) stated that other than the battery-operated mechanical transfer lift device, the facility also had a manually operated mechanical transfer lift device. The CNA (Staff #32) also stated that the manually operated mechanical transfer lift device was being used because it would be available if the battery-operated mechanical transfer lift device might not be available. Further, the CNA (Staff #32) also stated that he was trained using a mechanical transfer lift device during his CNA training program and during his first week of work at the facility.On June 18, 2026, at 11:08 AM, a call was placed to CNA (Staff #91), who stated that she had already made a statement to the Director of Nursing (DON/Staff #13) about the incident that occurred on June 16, 2026, involving Resident #1 and the manually operated mechanical transfer lift. The CNA further stated that she did not want to continue with the interview because she did not know who she was talking to.On June 18, 2026, at 11:15 AM, a phone interview was conducted with CNA (Staff #49), who stated that right after dinner, Resident #1 requested to be put back in bed. The CNA (Staff #49) stated that on June 16, 2026, she and another CNA (Staff #91) assisted Resident #1 back in bed using the manually operated mechanical transfer lift device, and that during the transfer, the device tilted to the side. The CNA further stated that she un-tilted the device, removed the sling, and then she noticed a skin tear on Resident #1's right leg after the transfer. The CNA (Staff #49) stated that she called for the night nurse to inform her of the incident. The CNA (Staff #49) stated that she believed that a part of the manually operated mechanical transfer lift device touched the Resident, but she could not tell how it happened because it happened so fast. The CNA (Staff #49) also stated that she was told not to come to work the next day while the investigation of the incident was happening. Further, CNA (Staff #49) stated that she knows how to use a manually operated mechanical transfer lift device.A review of the CNAs' June 14, 2026 through June 20, 2026, staff schedule revealed that CNA (Staff #91) and CNA (Staff #49) were scheduled on June 16, 2026, from 7:00 AM to 7:00 PM.During an interview with Resident #1 on June 18, 2026, at 11:44 AM, the resident stated that the staff used an old hand pump mechanical transfer lift device, that the CNAs put her on it and pushed her over the bed while on the transfer lift, but the transfer lift would not go over the bed. Resident #1 stated that the mechanical transfer lift device tilted, and one of the CNAs assisting with the transfer went to the other side of her bed and pulled or touched the mechanical transfer lift device to move it, because the mechanical transfer lift device's legs did not want to go under the bed, and that's when the handle of the manually operated mechanical transfer lift device hit her leg. Resident #1 stated that it was the CNAs' first time to use the manually operated mechanical transfer lift device for transfer. Resident #1 stated that since she had been in the facility, the CNAs had been using the battery operated mechanical transfer lift device for her transfers. During the interview, Resident #1's representative was at bedside, and stated that staff called 911 because it was gushing blood. Further, Resident #1 stated that she was sent out to the hospital, and the hospital told her that she received 23 stitches.During the interview, Resident #1 was observed to have her lower right leg above the ankle wrapped in white bandage.On June 18, 2026, employee records for Staff #49 and Staff #91 were requested for review.Regarding Staff #49's employee record, the document revealed that Staff #49 received a mechanical transfer lift device competency skill check on November 2024 and December 2025. Per the November 2024 Nursing Assistant Competency Checklist, the mechanical transfer lift device checklist contained the following return demonstration: weight limit, 2-staff members at all times, sling placement under the resident, sling placement on attachment points, base legs and positioning, locking of the wheels, and remote-control use and the moving of the resident. Regarding Staff #91's employee record, the document revealed that Staff #91 received a mechanical transfer lift device competency skill check on December 2025.An interview was conducted on June 18, 2026, at 1:02 PM with the Maintenance/Housekeeping Supervisor (Staff #10), who stated that her responsibilities included life safety, housekeeping, maintaining the building, handling of work orders such as call light issues, air condition issues, bathroom plumbing, bed or bed controls not working, and any mechanical transfer lift device issues, which she stated that mechanical transfer lift device issues were rarely a problem. The Maintenance Supervisor stated that regarding the mechanical transfer lift device maintenance, she would check the hooks, battery, and cable connections. The Maintenance Supervisor stated that the facility had two mechanical transfer lift devices, one was battery operated and the other was a manually operated lift device. She stated that the manual device was available in case the battery device was not working. The Maintenance Supervisor stated that the manually operated mechanical transfer lift device was recently used for Resident #1. She also stated that the manually operated mechanical transfer lift device was locked away after the incident occurred with Resident #1, to make sure that there would not be another incident with that lift device. The Maintenance Supervisor also stated that after the incident involving Resident #1, she checked the manually operated mechanical transfer lift device, it was 100% fine, in good condition and there was nothing loose.At 1:12 PM, on June 18, 2026, the Maintenance Supervisor (Staff #10) went to the locked storage room where the manually operated mechanical transfer lift device was kept. While inside the storage room, the transfer lift device revealed a weight capacity of 400 pounds posted on the lift's vertical metal bar. The Maintenance Supervisor used the hand pump to raise the lift's horizontal bar that had the hooks. At 1:16 PM, the Maintenance Supervisor asked the Case Manager (Staff #59) to demonstrate how a mechanical transfer lift device would work because the Maintenance Supervisor stated that she did not know how to operate the device.At that time, an observation was conducted while the Case Manager (Staff #59) demonstrated on how to use the manually operated mechanical transfer list. The Case Manager raised the mechanical transfer lift device manually using a handle connected from the lift transfer device to crank it up. The Case Manager used another lever connected from the lift transfer device to make the device's legs move outward and back, and demonstrated how to lock the transfer lift device wheels. The Case Manager stated that the hooks can swivel to position the resident, and the hooks could go down all the way to the bed, but the Case Manager did not demonstrate the hook swiveling. The Case Manager stated that a mechanical transfer lift device can tilt if the device's legs were not spread because it needed the balance between the resident on the sling and the machine. The Case Manager further stated you need to know when to open the legs, when a mechanical transfer lift device goes under the bed, the legs should be opened to balance. The Case Manager also stated that anytime that the staff unload or load a resident on the manually operated mechanical transfer lift device, the device's legs must be opened, and always have 2 staff to operate and guide the transfer lift device, one person would be guiding the machine by holding the handle, while the other person would be positioning the resident with the swivel.An interview was conducted on June 18, 2026, at 2:04 PM with the DON (Staff #13), who stated that she conducts huddles, staff meetings and in-services for her staff to provide training. The DON stated that regarding mechanical transfer lift devices, the Director of Rehabilitation (Staff #76) was responsible for the yearly CNA competency skills checks during annual skills fair. The DON stated that the Director of Rehabilitation (Staff #76) demonstrated to the staff how to use a mechanical transfer lift device during the skills fair. The DON stated that regarding the incident involving Resident #1 with the manually operated mechanical transfer lift device, she received a message that Resident #1 obtained a laceration on her leg during the transfer. The DON stated that Resident #1 was sent out to the emergency room. The DON stated that one of the CNAs reported to her that it was from the handle of the mechanical lift device that could have hit Resident #1's leg, but that the CNA did not see the handle hit the Resident's leg. The DON stated that the handle of the transfer lift device was not removable and it had rubber ends. The DON stated that according to CNA (Staff #49), the handle of the mechanical transfer device caused the laceration. The DON stated that the mechanical transfer lift device tipped while Resident #1 was still in the sling, and the handle of the lift device touched the resident's leg, because the handle of the mechanical transfer lift device was lined up to where the resident leg would have been while Resident #1 was still in the sling. The DON stated that CNA (Staff #49) was controlling the mechanical transfer lift device and CNA (Staff #91) was on the opposite side of the bed controlling the sling. The DON stated that the manually operated mechanical transfer lift device may have tilted because the CNAs may not have had the mechanical transfer lift device's legs spread out enough. The DON stated that the purpose of the manually operated mechanical transfer lift device's legs were to stabilize the machine. The DON stated that the CNAs stated that they did not have the mechanical transfer lift device legs spread enough. The DON also stated that if she would use the mechanical transfer lift device, the steps she would follow included the following: she would keep the transfer lift device legs spread; she would lower the transfer lift device arm down enough to remove the strap once the resident was over the bed so to remove the weight from the hook; once the resident is on the bed, she would remove the sling under the resident; and she would pull the mechanical transfer lift device away from the bed. The DON also stated that the CNAs were trying to put the Resident #1 quickly in bed. The DON also stated that the CNAs knew exactly what they were supposed to be doing, it was just that the CNAs did not take their time. Further, the DON stated that she expects her staff to spread the mechanical transfer lift device legs. She also stated that she would clarify what the mechanical transfer lift device manual relayed about spreading the mechanical transfer lift device legs.An interview was conducted on June 18, 2026, at 2:40 PM with the Director of Rehabilitation (Staff #76), who stated that he facilitates the in-services for the new hire on transfer training, gait belt and the use of mechanical transfer lift device. The Director of Rehabilitation stated that the training of the mechanical transfer lift device involved the use of visuals, handouts, watching videos, and the trainings were conducted quarterly and during monthly meetings. The Director of Rehabilitation stated that during the mechanical transfer lift device training, the base legs of the mechanical transfer lift device would be wide open as possible to have a nice base of support, to keep the resident steady and safe so that the weight would be distributed safely. He stated that if not widely open, he would not know what would happen, but the best way was to have the legs opened widely to distribute the weight evenly. He also stated that he could not tell how a mechanical transfer lift device would tilt during a transfer. The Director of Rehabilitation provided a copy of a handout that he uses when training the staff, titled How to Safely Lift A Patient Into A Patient Lift/Hoyer Lift, Tri-State Nursing Professionals with Pride.A request was made to observe a demonstration using the manually operated mechanical lift device on a similar bed frame that Resident #1 used at the time of the incident. At 3:03 PM on June 18, 2026, an unoccupied room was used, and the unoccupied room had the same bed frame used by Resident #1. At 3:11 PM, the manually operated mechanical device was brought inside the unoccupied room by the Administrator (Staff #55) and the DON (Staff #13) to conduct a transfer demonstration using the manually operated mechanical lift device. During the observation, the manually operated mechanical device was being operated by the DON while the Administrator was at the other side of the bed. During the observation, the manually operated mechanical lift device's base legs could not go under the bed because it was hitting the horizontal base of the bed. The manually operated mechanical device stayed side by side parallel with the bed, and the hook part of the lift device could not go over the surface of the bed. The DON stated that she would not use the manually operated lift because it would be unsafe for transfer, the hook for the sling was not over the bed, the hook could not be moved, and she was not sure how to move the resident on the bed while the mechanical lift device sling was not over the bed. The DON stated that she would not recommend anybody using it if the sling did not go over the bed. The Medline Hydraulic Patient Lift Low Base User Manual with a revised date of May 12, 2017, revealed on page 9 of the manual on how to use a patient lifter during a Transfer to Bed:Raise the lifter until the patient's gluteus maximus (butt area) is above the surface of the bed. You may need to lower the height of the bed. If the patient cannot be lifted above the bed, do not push or pull the patient onto the bed. This can cause in a tip over and serious injury to the patient and assistant!Move the lifter so that the open end of the U-base is safe as far under the bed as possible.After the patient has been centered on the bed, rotate the patient so that the patient faces the foot of the bed.Carefully lower the patient onto the bed.Remove the chains or straps from the sling.The instructions from the Hydraulic Patient Lift Low Base User Manual were to raise the lifter until the patient's butt area was above the surface of the bed. If the patient cannot be lifted above the bed, do not push or pull the patient onto the bed. This can result in a tip over and serious injury to the patient and assistant! And, to move the lifter so that the open end of the U-base is safe as far under the bed as possible. However, during the transfer lift demonstration observation by the DON (Staff #13) and the Administrator (Staff #55) using the manually operated mechanical lift device with the same bed frame as what Resident #1 was on, the mechanical lift hook could not get above the surface of the bed, the mechanical lift base legs could not go under the bed, and the mechanical lift transfer device stayed side by side or parallel with the bed because the mechanical lift's base legs could not go under the bed.A facility document titled How to Safely Lift A Patient Into A Patient Lift/Hoyer Lift, by Tri-State Nursing Professionals with Pride, provided by Staff #76 revealed under (9) Lower the Patient:Use gentle pressure when maneuvering and guiding the patient towards the receiving surfaceLower patient in lift slowly and make sure the patient is in the correct position before releasing the patient's weight from the liftCarefully remove sling from the patient's body after detaching the sling from the bar.A policy titled, Activities of Daily Living (ADLs), Version F1222, revealed that ADLs include bathing, dressing, grooming, mobility and transferring. The policy included that staff encourage residents to participate in activities of daily living to the greatest extent possible while providing necessary support to prevent injury.A policy titled, Resident Rights, version A0717, revealed the resident has a right to safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety.A policy titled, Staff Education, version A0717, revealed that all employees will be oriented to facility operation and job responsibilities and the facility will provide employees with annual in-service education to facilitate proper training and implementation of knowledge and skills necessary to adequately perform duties and responsibilities. The policy further revealed that the facility shall maintain current reference material related to the care that is provided in the facility for use by all personnel.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) regarding end of insurance coverage and discharge for one resident (#69) was provided timely according to regulation and facility policy. The deficient practice could lead to inadequate notice for a resident or resident representative to appeal the decision.Findings include:Resident #69 admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, metabolic encephalopathy, type 2 diabetes mellitus without complications, and other abnormalities of gait and mobility.Review of the clinical record revealed no evidence that a NOMNC was delivered to the beneficiary/representative at least two (2) days before the Medicare covered services ended.An admission Nursing Observation assessment dated [DATE], revealed Resident #69's preferred language was a language other than English, and the document revealed unable to determine whether the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Additionally, the resident had unclear speech-slurred or mumbled words, was sometimes understood, and sometimes could understand others' verbal communication.A Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 1, indicating severe cognitive impairment.A baseline care plan dated January 9, 2026, revealed Resident #69 had an alteration in communication, with a goal that the resident's needs would be met daily. The care plan revealed that the resident had a language barrier, and had aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult. The care plan revealed that the check boxes for a communication board, written communication, and/or translation application were not checked.A Provider Notification progress note dated January 10, 2026, revealed Resident #69 would not take any medications or allow her blood sugar to be checked that morning. A language communication board was used but the resident pushed medications away from her and tried to wheel herself away from nursing staff with one arm. The note revealed that staff attempted to provide education on risks / benefits to the resident, but unable to verify understanding due to language barrier. There was no evidence of attempts to use an interpreter or a translator application.An Occupational Therapy (OT) Evaluation and Plan of Treatment dated January 10, 2026, revealed Resident #69 primarily spoke a foreign language other than English, and that the resident was pleasant, cooperative, and attentive. The document revealed Resident #69 required maximum assistance to perform lower body dressing and toileting, and required moderate assistance to perform upper body dressing and bathing. The goals of the plan of care included for the resident to reach an independent level of functioning in these tasks, and the frequency of the plan of care included 3-7 times per week for 4 weeks.An OT Service Log revealed on January 10, 2026, Resident #69 participated in 15 minutes of OT evaluation, 20 minutes of therapeutic activity, and 25 minutes of self-care management training.A Nursing note dated January 11, 2026, revealed Resident #69 was alert and uncooperative, and had an unwitnessed fall. The note revealed a certified nursing assistant (CNA) found the resident on the ground next to her bed sitting upright while holding her call light in her hand. The documentation revealed the resident was asked what happened but was unable to provide any information about the fall.An OT Service Log revealed on January 11, 2026, Resident #69 participated in 21 minutes of therapeutic activity. The Service Log included that the resident refused treatment on January 13, 14, and 15, 2026, with the same male therapist.A Physical Therapist (PT) Evaluation and Plan of Treatment dated January 12, 2026, revealed the reason for referral included that Resident #69 presented to the hospital with increased dizziness, confusion, and right sided weakness, and was diagnosed with a cerebral vascular accident (CVA / stroke). The evaluation revealed the resident's primary language was a foreign language other than English. The evaluation included that the resident required partial assistance to perform bed mobility and transfers with a hemiwalker, and required moderate assistance to be able to propel 30 feet in a wheelchair, with therapy goals to improve mobility to an independent level. The plan included for a frequency of 3 to 5 times per week, for 6 weeks.A PT Service Log included that on January 12, 2026, Resident #69 participated in 15 minutes of PT evaluation and 25 minutes of therapeutic activity.A Speech Therapy (ST) Evaluation and Plan of Treatment dated January 12, 2026, but signed January 16, 2026, revealed the resident predominantly spoke a foreign language other than English, was alert and oriented only to herself, and was pleasantly confused and impulsive. The evaluation revealed the resident had a diagnosis of dysphagia, and had goals for safe swallowing. The evaluation included it should be noted that (the resident) would not cooperate with attempts to assess her cognitive linguistic skills. The evaluation included no evidence of any attempts to use a language board, a translator application, or interpreter.An ST Service Log included that on January 12, 2026, Resident #69 participate in 10 minutes of ST evaluation, and 45 minutes of treatment of swallowing dysfunction and/or oral function for feeding.A Nursing note dated January 13, 2026, revealed the resident had a fall, and was found next to the bed on the floor, and was unable to describe the event. The note included that the provider was notified of the resident's fall.A PT Treatment Encounter Note dated January 13, 2026, revealed that resident #69 was refusing, pushing therapist away and holding onto a rail from her wheelchair, and refusing to leave her room. Regarding a pain assessment, the documentation included unable to communicate pain. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.An ST Service Log revealed that on January 13, 2026, Resident #69 participated in 55 minutes of treatment of swallowing dysfunction and/or oral function for feeding. The ST Treatment Encounter Note for January 13, 2026, included that Resident #69 was alert to herself only and confused, and required maximum verbal cues and gestures to increase her participation. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.An ST Service Log revealed on January 14, 2026, that Resident #69 participated in 57 minutes of treatment of swallowing dysfunction and / or oral function for feeding. The ST Treatment Encounter Note for January 14, 2026, included the resident was oriented only to herself and pleasantly confused, and willing to comply / cooperate with the treatment only if it took place in her room. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.A Nursing note dated January 14, 2026, revealed at 6:15 a.m., two CNAs attempted to change the resident, and the resident was observed screaming, kicking, scratching staff, and refusing medications and blood sugar checks at times. The documentation revealed the resident was redirected, and was changed. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 12:10 p.m., revealed Resident #69 was observed attempting to get out of bed and stand by herself without assistance, and when staff tried to assist the resident, the resident smacked staff's arm and gestured with her hand to move and get out. The note revealed that additional staff were able to assist the resident into the wheelchair. The note included that the resident started throwing things onto the floor and into the trash, including the resident's leg brace, sensor pad, and wheelchair pad. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 9:38 p.m., revealed Resident #26 remained combative and refused all care and medications. There was no evidence of notification to the provider of the resident's continued behaviors.A Nursing note dated January 14, 2026, at 9:52 p.m. revealed Resident #60 had 3 unwitnessed fall events that evening alone. The note revealed that the resident would not allow any staff to touch her and continued to be very distressed and seemed unable to be safe at that time, and that the provider was notified.A care plan initiated January 14, 2026, included a problem that the resident had behavioral symptoms of noncompliant with medications and treatments and occasionally combative with caregivers. The approaches / interventions dated January 14, 2026, included to administer medications per physician orders, aid in avoiding stressful situations, allow resident adequate time to complete task on own, if able, allow quiet, calm environment during acute phase, anticipate resident's needs, approach resident calmly and introduce self during encounters or cares, consult with physician regarding drug regimen as needed, encourage independence in activities of daily living (ADLs) as resident is safely able, encourage positive expressions of concerns, anxieties, and fears, gently explain all cares before processing, keep pathway clear of clutter, labs as ordered, and validate positive expressions of concerns, anxieties, and fears.The care plan was reviewed and revealed no evidence of updates to the care plan regarding communication with the resident whose primary language was a foreign language other than English, and no evidence of any interventions to include attempts to use a translator application or interpreter.A Nursing note dated January 14, 2026, at 9:59 p.m. revealed that a psychiatric consult was ordered for Resident #69. The note included that the resident's family was contacted and urged to sit bedside with her or hire someone to sit bedside with her 24/7 for the resident's safety. The note revealed that the resident's family stated that they are not in the city and unable to hire someone that evening. The note included that the family was informed to speak with management tomorrow for a plan of action. Additionally, the note revealed that the resident was refusing all medications that evening, was sitting on the floor and refusing to get back in bed, refusing staff to come near her, was not receptive to redirection, and appeared comfortable at that time. The documentation revealed no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Nursing note dated January 14, 2026, at 10:10 p.m. revealed that the physician ordered to send the resident to the hospital.A Nursing note dated January 14, 2026, at 10:26 p.m. revealed Resident #69 had barricaded herself in the room, and that staff were attempting to get into the room in order to check on her, and that the physician was aware.A physician order dated January 14, 2026, included for a psychiatric consult, and to discharge the order when completed.A Nursing note dated January 15, 2026, at 1:05 a.m., revealed transportation arrived to take the resident to the hospital at 10:45 p.m., and that due to it being an all male crew, it was requested per their supervisor to wait to exchange care with a female crew, and that an all female crew arrived at 12:05 p.m.An Acute Care Transfer nursing progress note dated January 15, 2026, at 1:05 a.m., revealed the resident was transferred to the hospital due to having 3 unwitnessed fall events on evening shift, and the resident was unable to answer questions.A Nursing progress note dated January 15, 2026, at 4:27 a.m. revealed Resident #69 returned to the facility with no findings per the hospital Emergency Department (ED), and had no injury and no evidence of urinary tract infection (UTI) or other abnormal lab results. Additionally, the documentation revealed the resident was resting comfortably in bed.A Social Services progress note dated January 15, 2026, at 9:48 a.m., signed by the administrator (Staff #81), revealed that the administrator spoke with the resident's son and stated concerns about the resident's safety and need for a caregiver with her from 4:00 p.m. to 6:00 a.m. The note revealed that the son stated he will plan to take her home with him or have her stay with her brother for safety reasons, but revealed no evidence of a timeframe for a planned discharge. The note revealed that the administrator shared with the resident's son information for a private caregiver company for hire in case the son needed it for that night. The note revealed that the son stated at worst, he would be at the facility by tomorrow to take Resident #69 home.An ST Service Log dated January 15, 2026, revealed Resident #69 participated in 45 minutes of treatment of swallowing dysfunction and/or oral function for feeding. The ST Treatment Encounter Note dated January 15, 2026, included that the resident was treated in her room as she refuses to leave the room, and cooperated with treatment. The note included a recommendation to continue the plan of care.Despite the recommendation to continue the plan of care, an ST Discharge summary revealed dates of service included January 12 - 15, 2026, and the Discharge Summary was signed on January 18, 2026. The Discharge Summary included that the resident had made minimal progress and was discharged home with her son.A PT Treatment Encounter Note dated January 15, 2026, included that Resident #69 was waving her left upper extremity indicating no. The note revealed education was provided that the resident could stay in her room, and the resident appeared to accept and sat quietly, and demonstrated an increased quiet demeanor. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application. The note revealed the response to the session was nonparticipative.A PT Discharge Summary revealed the dates of service included January 12 - 15, 2026, and signed on January 17, 2026. The documentation included no evidence that the resident met her goals, and no evidence of attempts to use a language communication board, or an interpreter, or a translator application. The documentation revealed the resident was refusing.A Nursing progress note dated January 15, 2026, at 9:54 p.m., revealed Resident #69 had direct 1 to 1 supervision with a private sitter, and that the resident refused medications, blood glucose checks, and a skin check. The note revealed that the resident was calm and not calling out. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Discharge Planning note dated January 15, 2026, revealed the resident was discharging home with the resident's son on January 16, 2026, and that communication was with Resident #69's son, and the discharge location and discharge letter were discussed, and the Notice of Medicare Non-Coverage (NOMNC) was signed. The documentation revealed no evidence that the NOMNC timeframe was waived, or that information regarding appeal was given to the son, or that the discharge was driven by the resident or family, or that the discharge was due to the facility not able to meet the resident's needs, or due to safety concerns.A Discharge BIMS assessment dated [DATE], revealed the Resident had a score of 4, indicating severe cognitive impairment.Despite the order for psychiatric evaluation, the clinical record revealed no evidence that either an emergency or standard psychiatric consult were provided to Resident #69 at any time during her stay at the facility.A Discharge Instructions and Summary document, dated January 16, 2026, signed by the discharge nurse (Staff #88) on January 15, 2026, and also signed by the resident's son on January 16, 2026, revealed that the resident was discharged to home, and the reason for discharge was completed skilled services, and the recapitulation of stay, included that the resident participated in therapy sessions as tolerated.Despite the documentation that the reason for discharge was due to completion of skilled services, a Notice of Transfer or Discharge document, revealed the reason for discharge was the resident's needs cannot be met in the facility. The documentation revealed information to appeal the discharge decision, and information to contact the Long-Term Care Ombudsman. The document revealed conflicting information; the first page of the document revealed the notice was given on January 15, 2026, however, the second page of the document revealed the notice was given on January 16, 2026. The document was signed by the resident's son on January 16, 2026.The clinical record was reviewed, and revealed no evidence of a physician note stating that the resident was not safe to remain in the facility or that the resident's needs could not be met in the facility.Additionally, despite the Discharge Planning note revealing that the NOMNC was signed on January 15, 2026, the Notice of Medicare Non-Coverage (NOMNC) document revealed that the Medicare coverage of your current skilled nursing services will end on January 15, 2026. The document was signed by Resident #69's son on January 16, 2026. The document revealed information regarding the right to appeal the decision.A Discharge progress note dated January 16, 2026, revealed Resident #69 left the facility at 11:20 a.m. to discharge home and that transportation was provided by the resident's son, and the resident's family was made aware of the resident's continued refusal of medications.A telephonic interview was conducted with Resident #69's son on February 4, 2026, at 8:45 a.m. who stated that he was called by facility staff on January 15, 2026, informing him that Resident #69 could no longer stay at the facility because she was resisting staff and was difficult at night. The son stated that the facility staff stated that the only condition that the resident could stay in the facility the night of January 15, 2026, was if the resident had a family member who could stay overnight with the resident or if the resident's family hired a private sitter to come to the facility overnight with the resident. The son stated he was panicking because he lived out of town and could not be there, and stated that he did not want the facility to kick her out to the curb, so he hired a private caregiver / sitter to stay with the resident overnight on the night of January 15, 2026. The son stated that he had to pay for the sitter out of pocket, because the facility staff had told him that the facility could not provide that level of one to one care. The son stated that the facility did not give him 48 hours' notice for the end of coverage or discharge, or information to appeal the decision, and that he found out about Resident #69's discharge on the January 15, and had to come to the facility the morning of January 16, 2026, to pick her up.An interview was conducted on February 5, 2026, at 9:59 a.m. with a licensed practical nurse / discharge nurse (LPN / Staff #88) who stated that the facility's discharge process included that the interdisciplinary team (IDT) meets to determine a discharge, and that there is a notification process that typically requires 48 hours' notice to be given to a resident or a resident's responsible party before end of Medicare coverage prior to discharge. Staff #88 stated that the importance of the 48-hour advanced notice is because there is an appeal process that patients or their representative or family can initiate, and the advanced notice of end of coverage or discharge allows time for the appeal process. Additionally, Staff #88 stated that the advanced notice also keeps the discharge process from being rushed, so residents and families can reduce stress surrounding the discharge process. Staff #88 stated that Resident #69 had met her therapy goals, and completed her skilled stay. The clinical record was reviewed, and Staff #88 stated that Resident #69's son was called and notified on January 15, 2026 of the planned discharge on [DATE], and the son was going to come to the facility on January 16, 2026, to transport the resident home. Staff #88 stated that the resident's NOMNC and notice for discharge were signed on January 16, 2026 by the resident's representative, who was her son. Despite his previous statements, Staff #88 then stated that Resident #69 was given the NOMNC and notice of discharge on [DATE], and that the resident was alert, of sound mind, and could make her own decisions. Additionally, Staff #88 stated that Resident #69 had a rushed discharge because of safety concerns, because the resident was combative, was refusing therapy, and the resident needed a caregiver/sitter between the hours of 4:00 p.m. to 6:00 a.m.An interview was conducted with a licensed practical nurse (LPN / Staff #10) who stated that he had cared for Resident #69, and that the resident could understand very basic things, but did not speak English, and would have bouts of confusion and was impulsive and very forgetful. Staff #10 stated that from his experience, the resident's behaviors never became too much for staff to handle, and that she was able to calm down with staff interventions.An interview was conducted with the Rehab Service Manager and Activities Director (Staff #5) on February 5, 2026, at 9:24 a.m., who stated that typically residents are scheduled for physical therapy 5 times per week, and occupational therapy 5 times per week, and speech therapy as needed. Staff #5 stated that if a resident were to miss or refuse a session, that therapy staff have a general practice to try 2-3 times during the day to get the resident to participate in therapy, and if still missed or refused, then the session would be attempted to be made up on the weekend. Regarding Resident #69, Staff #5 stated that the resident primarily spoke a foreign language other than English, and that he did not know of a language interpreter service or translator service that the facility had. Staff #5 stated that the resident was hit or miss whether she would participate in therapy, that some days the resident would participate, and other days the resident was really upset and would refuse. Staff #5 reviewed the clinical record and stated that regarding physical therapy (PT), Resident #69 was evaluated by PT on January 12, 2026, and had a PT treatment session on January 13, refused the session on January 14, and then had a physical therapy session on January 15, and was discharged by PT services later that day on January 15, 2026. Regarding occupational therapy (OT), Staff #69 was evaluated by OT on January 10, 2026, and then was discharged by OT services on January 12, 2026. Staff #5 stated that he did not believe the resident was being treated by speech therapy.An interview was conducted with the administrator (Staff #81) on February 5, 2026, at 10:17 a.m. who stated that the facility is equipped to care for residents with cognitive impairments, dementia, and/or behaviors by first pre-screening residents prior to admission to ensure the residents are appropriate for the facility, and additionally by discussing possible interventions with resident's family, physicians, and care team members to ensure the appropriate interventions are in place for those residents. Regarding Resident #69, the administrator stated he remembered the resident. The administrator stated the resident became progressively more confused over the course of her stay at the facility, and reverted back to speaking her native foreign language other than English, and that with that came the challenges of her participation in therapy. The administrator stated that Resident #69 was discharged because she met her goals physically, and could get around, but there was no cognitive carryover. Additionally, the administrator stated he was aware there was a requirement for notice of discharge, and requirement for the NOMNC to be issued 48 hours prior to end of coverage of a resident, and he believed that the resident's son was given 48 hours advanced notification.An interview was conducted with a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #85) on February 5, 2026, at 10:33 a.m. who stated if a resident had impaired cognition or dementia and had behaviors, then staff would re-orient the resident to the room, perform additional safety checks, ask the resident's family for assistance and to provide re-assurance to the resident, and if needed, refer the resident and the family to an outside caregiving company for additional caregiver support. Additionally, Staff #85 stated that a resident with behaviors could be referred for a psychiatric consult, which would provide the resident with additional interventions such as activities or medications to assist with managing the resident's behaviors. Regarding Resident #69, Staff #85 stated that she remembered the resident primarily spoke a foreign language other than English, and that the resident could understand some English. Staff #85 stated that she was not aware that the facility had a translator or interpreter service, but that there was a sign with some pictures on it to help identify basic wants or needs of a resident. The clinical record was reviewed, and Staff #85 stated that the reason the resident was discharged was because she refused everything, including therapy, and that she did not meet her therapy goals. Staff #85 stated that a psychiatric consult was ordered on January 14, 2026, but that the resident did not receive it before she was discharged on January 16, 2026.A telephonic interview was conducted with a registered nurse (RN / Staff #146) on February 5, 2026, at 12:00 p.m. who stated that she recalled Resident #69, and that she received report from the previous shift staff that the resident had some aggressive behaviors, and that during her shift, the resident had some episodes of refusing some care, and that she observed the resident throw some of her equipment onto the floor. Staff #146 stated that the resident was able to be calmed down and redirected, and that she felt the resident was appropriate for the facility. Staff #146 also stated that she did not know the extent of the resident's language barrier or how much of the communication the resident could understand.An interview was conducted on February 5, 2026, at 12:20 p.m. with the Director of Nursing (DON / Staff #86), who stated that the discharge planning process includes that the discharge nurse (Staff #88) starts communicating with families early in the resident's stay to determine the appropriate and planned discharge setting. The DON stated that every week, the interdisciplinary team (IDT) meets to decide if residents are ready for discharge and safe to go home. Regarding the NOMNC, the DON stated that it is required to give 48 hours advanced notice from the termination of services. The DON stated that the risk to a resident if not given the 48 hours advanced notice of a resident's termination of services, with the information on how to appeal the decision would be that the resident or resident's family may not have enough time to appeal the decision. The DON stated that resident's and their families should be given notice and made aware that they have the right to appeal the decision. Regarding behavioral services, the DON stated that the facility has two psychiatrist providers and a psychologist to assist residents who are having behavioral problems. The DON stated that including a psychiatric provider can be beneficial to a behavioral resident because the provider would discuss additional interventions, recommendations, or medications if necessary, and that would be added to the resident's care plan. Additionally, the DON stated that the psychiatric provider can perform emergency visits if needed. Regarding Resident #69, the DON stated that she was not very familiar with the resident, and that prior to the day the resident was discharged , the DON stated she received a call from the nurse that the resident had barricaded herself in her room, and the nurse had to walk around the outside of the building to look into the resident's window to ensure the resident was safe. The DON stated that she believed it was the resident's son who wanted the resident to discharge home, and she was not sure where she had heard that information.An interview was conducted with a regional corporate resource (Staff #15) on February 5, 2026, at approximately 12:25 p.m. who stated the NOMNC should be given 72 hours before a resident's discharge.Review of the facility policy titled Notice of Medicare Non-Coverage (NOMNC), version A0717 (undated), revealed that the facility will deliver a NOMNC for all beneficiaries eligible for the expedited process, even if the resident agrees with the termination of services. The NOMNC must be prepared using the OMB approved for (CMS-10123) by either typing or writing in the appropriate fields the following information:The resident's nameThe Medicare patient number or unique medical record numberThe type of coverageThe effective date (last date of coverage)The NOMNC will be delivered to the beneficiary at least two (2) days before the Medicare covered services end. The beneficiary must sign and date the NOMNC to demonstrate that they received the notice and understand the termination decision can be appealed or disputed. If the beneficiary refuses to sign the NOMNC, annotate the notice to that effect and indicate the date of refusal on the notice. The date of refusal is considered to be the date of notice receipt. The NOMNC may be delivered to a beneficiary authorized representative who has been appointed to act on behalf of the beneficiary during the appeal process. Whenever possible, delivery of the NOMNC should occur in person; however, the following alternative means of delivery are acceptable:TelephoneIf contact by telephone is necessary, the date you communicate the information is considered the NOMNC's receipt date.Annotate the NOMNC to document the telephone contact on the day that you make the telephone contact, reflecting that all of the required information was included in the communication.The annotation should include the name of that staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.Place a dated copy of the annotated NOMNC in the beneficiary's medical file and mail a NOMNC to the representative the day the telephone contact is made.Retain the original signed document in the beneficiary's file, and provide the beneficiary copies of all notices that include all of the required information such as the effective date and covered service at issue.

Based on review of observations, staff interviews, and policy and procedures the facility failed to ensure that one resident (#78) had documentation and orders in place for dressings to the wrists and elbow. The universe was 52 and the sample size was 16. The deficient practice could impact the doctors available information on the resident, improper documentation/ communication among staff and potential for infection and worsening of the wound.Findings include:Resident #78 was admitted with pleural effusion, acute respiratory failure with hypoxia, syncope and collapse, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, sick sinus syndrome, left bundle branch block, endocarditis, metabolic encephalopathy, acute embolism and thrombosis of the left peroneal vein, long term (current use) of anticoagulants and presence of a cardiac pacemaker.A review of the 5-day MDS (minimum data set) dated 01/31/2026 revealed no observed BIMS (brief interview of mental status) score.A review of the admission assessment dated [DATE] revealed that the resident was alert, cooperative and oriented to person, place, time and situation, and affirmed that the resident had clear comprehension. The admission assessment revealed no evidence of wounds to the wrists or elbow.A review of the care plan revealed no evidence of the presence of wounds to the wrists or elbow or corresponding wound care.An observation was conducted on February 3, 2026 at 9:13 AM which revealed the resident seated in his wheelchair with his daughter present in the room. The resident was further observed with bandages/ dressings to both the left and right wrist as well as the left elbow. None of the bandages were dated or initialed by staff. The daughter stated that the bandage to the right wrist was coming off, but that the resident was getting ready to leave for a medical appointment. The staff #2, RN (registered nurse) was advised of the lose bandage to the right wrist.A review of the physician's orders on February 3, 2026 at 9:20 AM revealed no evidence of documented wound care orders to the left wrist and elbow or the right wrist. A subsequent physician order entry revealed an initial order of wound care to the right wrist on February 3, 2026.A review of the progress notes on February 3, 2026 revealed no documentation regarding any wounds to the wrist(s) or left elbow.An observation was conducted on February 4, 2026 at 8:12 AM. Resident #78 was observed seated in his wheelchair. The dressing to his right wrist was observed to be securely in place with a date and initial displayed on the bandaging; however, the dressing to the left wrist and elbow showed no evidence of a date or staff initial.A follow-up review of the physician orders revealed an order dated February 4, 2026 noting wound care to the right wrist, left elbow and left wrist area. Indicating that the areas should be cleaned with wound cleanser, patted dry and a foam dressing applied twice a day as needed.An interview was conducted on February 4, 2026 at 8:01 AM with staff #43 RN (registered nurse). Staff #43 stated that the wound team rounds every Wednesday and that orders outside of Wednesday, regarding wound care, are addressed by the nursing staff. Staff #43 stated that post ordered wound care, all bandages are required to be dated and initialed. Staff #43 stated that if they are not dated and initialed, you would not know when the dressing was last changed or who changed it. Staff #43 stated that for each wound site an order needs to be in place. The RN stated that if wound care is conducted during an outside appointment, nursing staff review the documentation from the appointment and conduct a head to toe assessment when the resident returns from the appointment. The RN stated that that if orders for wound care were not in place for each wound, the risk could include a wound not being cared for and a potential for infection.An interview was conducted on February 4, 2026 at 8:30 AM with staff #2 RN. Staff #2 stated that wound care orders are required for each wound. Staff #2 stated that if orders were not in place for each wound, that there could be a chance for infection, since the wound care would not be addressed. Staff #2 stated that all wounds need to be looked at, including those that a resident may have been admitted with. Staff #2 further stated that all dressings should have a date and the initial of the nurse who conducted the wound care. Staff #2 pulled up the electronic health record for resident #78 and stated that she had asked the doctor yesterday for wound care orders for the right wrist, after she was notified of the lose bandage. She stated that she did not know why the dressing was not dated or initialed, but stated that it should have been. Staff #2 further stated that this morning she had noticed a few more areas, but stated that she wasn't sure how long these dressings had been in place. Staff #2 reviewed the record again and stated that there were no orders in place for the left wrist or left elbow. Staff #2 stated that the risk for not having orders in place can include the doctor not being aware of the wound, improper monitoring of the wound and the risk of infection.A telephone call was placed on February 4, 2026 at 8:45 AM to staff #73 LPN (licensed practical nurse), who conducted the initial admission assessment. A message was left on the voicemail, but no return call was received.An interview was conducted on February 4, 2026 at 9:09 AM with staff #85 ADON (assistance director of nursing). Staff #85 stated that if a resident has a wound on admission, then it would be identified in the admission assessment and orders would need to be put in place. Staff #85 stated that if wound care was conducted during an offsite appointment, then nursing staff would confirm that orders were put in place. Staff #85 stated that any bandaging/ dressings have to be documented in the electronic health record and have corresponding orders. Staff #85 further stated that per facility policy all dressings are required to have a date and initial of the staff who completed the wound care or observation. The ADON stated that if dates and initials on the dressing were not in place that the risk could include a worsening of the wound, progression or regression of the wound and or infection. Staff #85 pulled up resident #78 in the electronic health record and confirmed the new orders for the right wrist but stated that she did not see any orders for the left wrist and elbow. She further reviewed the electronic health record and stated that she did not see any entries indicating when the dressings were applied and by who. Staff #85 stated that this did not meet her expectations and stated that the risks wound include the wound(s) not being monitored, not healing and the risk for infection. Staff #85 further stated that orders always need to be in place to provide treatment/ services. An interview was conducted on February 4, 2026 at 10:00 AM with staff #75 (Wound Care Nurse). Staff #75 stated that she was not aware when the injuries to the wrist(s) and elbow occurred. She stated that the nurse, staff #2, had made her aware of the missing orders, dates and initials and that she was in the process of creating education for staff regarding wound dressings. She stated that the expectation would be to have orders in place, documentation of the wound and that dressings are dated and initialed. She stated that the risk would include not knowing what happened, who provided the care and what was done.A review of the facility policy titled Documentation of Wounds, version F1008, revealed that the licensed nurse assigned to each individual patient will be responsible for completing all daily monitoring, treatments and weekly skin assessments on the day and shift indicated. The policy further noted that eh licensed nurse will sign that he/ she has completed the assigned daily monitoring and treatment. A review of the facility policy titled Standards of Professional Nursing Practice, version A0717, revealed the American Nurses Association standards of practice documented as 1-16, noting that registered nurses collect comprehensive data pertinent to the healthcare consumer's health or situation, implements coordination of care, evaluates progress towards attainment of outcomes, contributes to quality of nursing practice.A review of the facility policy titled Charting Requirements, version E0325, revealed that all new admits will be charted on every shift for the first 72 hours and daily thereafter. Charting for new admissions noted a head to toe assessment. The policy further documented that daily charting will include a thorough head to toe assessment, in addition to alert charting including any incident or acute medical issues and that treatment nurses will be responsible for charting on each treatment they complete including condition of site.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure sufficient staffing regarding provision of a caregiver / sitter to meet a resident's (#69) needs. The deficient practice could place the resident at risk for physical or psychosocial harm, or place a resident at risk of undue financial burden of having to provide the staffing out-of-pocket for themselves.Findings include:Resident #69 admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, metabolic encephalopathy, type 2 diabetes mellitus without complications, and other abnormalities of gait and mobility.An admission Nursing Observation assessment dated [DATE], revealed Resident #69's preferred language was a language other than English, and the document revealed unable to determine whether the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Additionally, the resident had unclear speech-slurred or mumbled words, was sometimes understood, and sometimes could understand others' verbal communication.A Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 1, indicating severe cognitive impairment.A baseline care plan dated January 9, 2026, revealed Resident #69 had an alteration in communication, with a goal that the resident's needs would be met daily. The care plan revealed that the resident had a language barrier, and had aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult. The care plan revealed that the check boxes for a communication board, written communication, and/or translation application were not checked.A Provider Notification progress note dated January 10, 2026, revealed Resident #69 would not take any medications or allow her blood sugar to be checked that morning. A language communication board was used but the resident pushed medications away from her and tried to wheel herself away from nursing staff with one arm. The note revealed that staff attempted to provide education on risks / benefits to the resident, but unable to verify understanding due to language barrier. There was no evidence of attempts to use an interpreter or a translator application.A Nursing note dated January 11, 2026, revealed Resident #69 was alert and uncooperative, and had an unwitnessed fall. The note revealed a certified nursing assistant (CNA) found the resident on the ground next to her bed sitting upright while holding her call light in her hand. The documentation revealed the resident was asked what happened but was unable to provide any information about the fall.The care plan revealed no evidence of updates or added interventions to address the resident's fall on January 11, 2026.A Nursing note dated January 13, 2026, revealed the resident had a fall, and was found next to the bed on the floor, and was unable to describe the event. The note included that the provider was notified of the resident's fall.The care plan revealed no evidence of updates or added interventions to address the resident's fall on January 13, 2026.A Nursing note dated January 14, 2026, revealed at 6:15 a.m., two CNAs attempted to change the resident, and the resident was observed screaming, kicking, scratching staff, and refusing medications and blood sugar checks at times. The documentation revealed the resident was redirected, and was changed. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 12:10 p.m., revealed Resident #69 was observed attempting to get out of bed and stand by herself without assistance, and when staff tried to assist the resident, the resident smacked staff's arm and gestured with her hand to move and get out. The note revealed that additional staff were able to assist the resident into the wheelchair. The note included that the resident started throwing things onto the floor and into the trash, including the resident's leg brace, sensor pad, and wheelchair pad. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 9:38 p.m., revealed Resident #26 remained combative and refused all care and medications. There was no evidence of notification to the provider of the resident's continued behaviors.A Nursing note dated January 14, 2026, at 9:52 p.m. revealed Resident #60 had 3 unwitnessed fall events that evening alone. The note revealed that the resident would not allow any staff to touch her and continued to be very distressed and seemed unable to be safe at that time, and that the provider was notified.The care plan was reviewed and revealed no evidence of updates to the care plan regarding communication with the resident whose primary language was a foreign language other than English, and no evidence of any interventions to include attempts to use a translator application or interpreter.A Nursing note dated January 14, 2026, at 9:59 p.m. revealed that a psychiatric consult was ordered for Resident #69. The note included that the resident's family was contacted and urged to sit bedside with her or hire someone to sit bedside with her 24/7 for the resident's safety. The note revealed that the resident's family stated that they were located out of town and unable to hire someone that evening. The note included that the family was informed to speak with management tomorrow for a plan of action. Additionally, the note revealed that the resident was refusing all medications that evening, was sitting on the floor and refusing to get back in bed, refusing staff to come near her, was not receptive to redirection, and appeared comfortable at that time. The documentation revealed no evidence of attempts to use a language communication board, or an interpreter, or a translator application.The care plan was reviewed and revealed no evidence of a revision or added intervention specifying the need for 1 to 1 sitter or caregiver 24/7.A Nursing note dated January 14, 2026, at 10:10 p.m. revealed that the physician ordered to send the resident to the hospital.A Nursing note dated January 14, 2026, at 10:26 p.m. revealed Resident #69 had barricaded herself in the room, and that staff were attempting to get into the room in order to check on her, and that the physician was aware. There was no evidence that the facility had provided a sitter or caregiver as was previously recommended 24/7.A physician order dated January 14, 2026, included for a psychiatric consult, and to discharge the order when completed.A Nursing note dated January 15, 2026, at 1:05 a.m., revealed transportation arrived to take the resident to the hospital at 10:45 p.m., and that due to it being an all male crew, it was requested per their supervisor to wait to exchange care with a female crew, and that an all female crew arrived at 12:05 p.m.An Acute Care Transfer nursing progress note dated January 15, 2026, at 1:05 a.m., revealed the resident was transferred to the hospital due to having 3 unwitnessed fall events on evening shift, and the resident was unable to answer questions.A Nursing progress note dated January 15, 2026, at 4:27 a.m. revealed Resident #69 returned to the facility with no findings per the hospital Emergency Department (ED), and had no injury and no evidence of urinary tract infection (UTI) or other abnormal lab results. Additionally, the documentation revealed the resident was resting comfortably in bed.A Social Services progress note dated January 15, 2026, at 9:48 a.m., signed by the administrator (Staff #81), revealed that the administrator spoke with the resident's son and stated concerns about the resident's safety and need for a caregiver with her from 4:00 p.m. to 6:00 a.m. The note revealed that the son stated he will plan to take her home with him or have her stay with her brother for safety reasons, but revealed no evidence of a timeframe for a planned discharge. The note revealed that the administrator shared with the resident's son information for a private caregiver company for hire in case the son needed it for that night. The note revealed that the son stated at worst, he would be at the facility by tomorrow to take Resident #69 home.The care plan was reviewed and revealed no evidence of a revision or added intervention specifying the need for 1 to 1 sitter or caregiver between the hours of 4:00 p.m. to 6:00 a.m.A Nursing progress note dated January 15, 2026, at 9:54 p.m., revealed Resident #69 had direct 1 to 1 supervision with a private sitter, and that the resident refused medications, blood glucose checks, and a skin check. The note revealed that the resident was calm and not calling out. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Discharge BIMS assessment dated [DATE], revealed the Resident had a score of 4, indicating severe cognitive impairment.A Notice of Transfer or Discharge document, revealed the reason for discharge was the resident's needs cannot be met in the facility.The clinical record was reviewed, and revealed no evidence of a physician note stating that the resident was not safe to remain in the facility or that the resident's needs could not be met in the facility.A Discharge progress note dated January 16, 2026, revealed Resident #69 left the facility at 11:20 a.m. to discharge home and that transportation was provided by the resident's son, and the resident's family was made aware of the resident's continued refusal of medications.A telephonic interview was conducted with Resident #69's son on February 4, 2026, at 8:45 a.m. who stated that he was called by facility staff on January 15, 2026, informing him that Resident #69 could no longer stay at the facility because she was resisting staff and was difficult at night. The son stated that the facility staff stated that the only condition that the resident could stay in the facility the night of January 15, 2026, was if the resident had a family member who could stay overnight with the resident or if the resident's family hired a private sitter to come to the facility overnight with the resident. The son stated he was panicking because he lived out of town and could not be there, and stated that he did not want the facility to kick her out to the curb, so he hired a private caregiver / sitter to stay with the resident overnight on the night of January 15, 2026. The son stated that he had to pay for the sitter out of pocket, because the facility staff had told him that the facility could not provide that level of one to one care. The son stated he found out about Resident #69's discharge on [DATE], and had to come to the facility the morning of January 16, 2026, to pick her up.An interview was conducted on February 5, 2026, at 9:59 a.m. with a licensed practical nurse / discharge nurse (LPN / Staff #88) who stated that Resident #69 had met her therapy goals, and completed her skilled stay. The clinical record was reviewed, and Staff #88 then stated that Resident #69 was given notice of discharge on [DATE], and that the resident was alert, of sound mind, and could make her own decisions. Additionally, Staff #88 stated that Resident #69 had a rushed discharge because of safety concerns, because the resident was combative, was refusing therapy, and the resident needed a caregiver/sitter between the hours of 4:00 p.m. to 6:00 a.m. Staff #88 stated that the facility administrator (Staff #81) had informed the resident's son that there needed to be a sitter in the facility with the resident from 4:00 p.m. to 6:00 a.m., and that there was not a facility staff who could sit with the resident then, and that the resident's son could not provide the sitter in order for the resident to stay longer in the facility.An interview was conducted with a licensed practical nurse (LPN / Staff #10) who stated that he had cared for Resident #69, and that the resident could understand very basic things, but did not speak English, and would have bouts of confusion and was impulsive and very forgetful. Staff #10 stated that from his experience, the resident's behaviors never became too much for staff to handle, and that she was able to calm down with staff interventions.An interview was conducted with the Rehab Service Manager and Activities Director (Staff #5) on February 5, 2026, at 9:24 a.m., who stated that Resident #69 primarily spoke a foreign language other than English, and that he did not know of a language interpreter service or translator service that the facility had.An interview was conducted with the administrator (Staff #81) on February 5, 2026, at 10:17 a.m. who stated that the facility is equipped to care for residents with cognitive impairments, dementia, and/or behaviors by first pre-screening residents prior to admission to ensure the residents are appropriate for the facility, and additionally by discussing possible interventions with resident's family, physicians, and care team members to ensure the appropriate interventions are in place for those residents. The administrator stated that the facility staff can provide more frequent checks on a resident, such as every 30 minutes, however if the resident required one on one care, that would be above the scope of the facility. In the case that a resident would require one on one supervision for safety, the administrator stated that the facility could provide a sitter for a very short period of time, up to a few hours, but if a sitter were needed longer than that, then a pamphlet for caregivers for hire is then provided to a resident's family, so that the family could hire a sitter to stay with the resident at the facility. The administrator stated that ultimately, he is responsible for ensuring sufficient and competent staff to meet the needs of the residents. Regarding Resident #69, the administrator stated he remembered the resident. The administrator stated the resident became progressively more confused over the course of her stay at the facility, and reverted back to speaking her native foreign language other than English, and that with that came the challenges of her participation in therapy. The administrator stated he contacted the resident's son, who lived out of town in another city, and informed the resident's son that the resident required above what we are able to care for and informed the son that Resident #69 needed a sitter / caregiver for safety. The administrator stated that the son stated that he could not come to the facility, and the administrator stated that he informed the resident's son that the facility could not provide a sitter, and then gave the son information for a private caregiver company to hire a sitter. The administrator stated that he believed the son hired a private caregiver for Resident #69 just during the night hours, for the two days prior to the resident's discharge.An interview was conducted with a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #85) on February 5, 2026, at 10:33 a.m. who stated if a resident had impaired cognition or dementia and had behaviors, then staff would re-orient the resident to the room, perform additional safety checks, ask the resident's family for assistance and to provide re-assurance to the resident, and if needed, refer the resident and the family to an outside caregiving company for additional caregiver support. Staff #85 stated that the facility did have staff who could act as a sitter for a resident who needed one, however the additional staffing would have to be approved through the administrator first. Additionally, Staff #85 stated that a resident with behaviors could be referred for a psychiatric consult, which would provide the resident with additional interventions such as activities or medications to assist with managing the resident's behaviors. Regarding Resident #69, Staff #85 stated that she remembered the resident primarily spoke a foreign language other than English, and that the resident could understand some English. Staff #85 stated that the facility did not have a translator or interpreter service, but that there was a sign with some pictures on it to help identify basic wants or needs of a resident. The clinical record was reviewed, and Staff #85 stated that a psychiatric consult was ordered on January 14, 2026, but that the resident did not receive it before she was discharged on January 16, 2026. Staff #85 stated based on reviewing the clinical record, that Resident #69 needed a sitter. Additionally, Staff #85 stated that when the resident returned from the hospital on January 15, 2026, that it appeared that the resident had calmed down and was resting comfortably in bed with no behaviors.A telephonic interview was conducted with a registered nurse (RN / Staff #146) on February 5, 2026, at 12:00 p.m. who stated that she recalled Resident #69, and that she received report from the previous shift staff that the resident had some aggressive behaviors, and that during her shift, the resident had some episodes of refusing some care, and that she observed the resident throw some of her equipment onto the floor. Staff #146 stated that the resident was able to be calmed down and redirected, and that she felt the resident was appropriate for the facility. Staff #146 also stated that she did not know the extent of the resident's language barrier or how much of the communication the resident could understand.An interview was conducted on January 5, 2026, at 12:20 p.m. with the Director of Nursing (DON / Staff #86), who stated that regarding behavioral services, the facility has two psychiatrist providers and a psychologist to assist residents who are having behavioral problems. The DON stated that including a psychiatric provider can be beneficial to a behavioral resident because the provider would discuss additional interventions, recommendations, or medications if necessary, and that would be added to the resident's care plan. Additionally, the DON stated that the psychiatric provider can perform emergency visits if needed. Regarding Resident #69, the DON stated that she was not very familiar with the resident, and that prior to the day the resident was discharged , the DON stated she received a call from the nurse that the resident had barricaded herself in her room, and the nurse had to walk around the outside of the building to look into the resident's window to ensure the resident was safe.Review of the facility policy on staffing (undated and untitled) revealed that the facility does not adjust staffing based on fluctuation in census. The facility considers both census and acuity levels that impact staffing needs and staff accordingly. Census and patient acuity are discussed daily in stand-up meeting. If the resident population contains higher acuity residents, additional staff are added. The facility has the ability to hire sitters as needed. Additionally, the policy revealed if the facility experiences an event that requires additional resources but does not require activation of the Emergency Plan, off-duty staff will be called in to provide additional support as needed. If necessary, the facility has contracts in place for temporary agency personnel. The facility is also able to use resources from sister facilities as needed. The policy revealed a re-statement that the facility has the ability to hire sitters as needed.

Based on review of observations, staff interviews, and policy and procedures the facility failed to ensure that one resident's (#86) medication/treatments were not left at bedside. The universe was 52 and the sample was 16. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include:An observation of Resident #86's room was conducted on February 3, 2026 at 11:45 AM. Two containers of ZAL cream were observed on the counter next to the sink, in the resident's room. The containers were observed with pharmacy label attached. When interviewed the resident stated that she applied the ZAL cream herself on her buttocks and labia. The resident stated that she had been cleared to use the cream, and that staff knew that she was using the cream since her admission. The resident also stated that one of the containers was empty. There was no evidence of a lockbox for medications at the bedside.Resident #86 was admitted on [DATE] with diagnoses that included Sjogren syndrome, urinary tract infection, Type 2 diabetes mellitus.An admission Observation assessment form dated January 28, 2026 revealed that the resident was alert/oriented to person, place, time, situation.Orders dated January 28, 2026 through February 3, 2026 revealed no evidence of provider orders regarding medication/treatment self-administration.Further review of provider orders revealed no evidence of an order for ZAL cream from January 28, 2026 through February 3, 2026.Review of the clinical record revealed that the admission Minimum Data Set assessment had been submitted, and was still in process. However, a Brief Interview of Mental Status (BIMS) form dated January 28, 2026 revealed a score of 13, which indicated that the resident was cognitively intact.A care plan revealed evidence of the following areas of focus:Altered skin integrityIndwelling catheterThe care plan revealed no evidence of a focus or interventions regarding self-administration of medication/treatments.Provider orders dated February 4, 2026 were written for:4 ounces of equal parts topical lidocaine 3%, zinc oxide 20% ointment, Vitamin A/D ointment; sparingly topical, 1 application twice a day; preventative per patient request.ZAL topical cream (zinc oxide/A&D/Lidocaine), twice a day.Another observation of the resident's room was conducted on February 5, 2026 at 7:45 AM. A container of ZAL ointment was observed on the counter next to the sink, along with a box of Baqsimi (glucagon), and there was no evidence of a lockbox for medication storage at the bedside. An interview was conducted on February 2, 2026 at 3:53 PM with a Certified Nursing Assistant (CNA/staff #57), who stated that it is not ok for medications or treatments (creams/ointments) to be left in the resident's room at bedside, and if she observed this she would immediately tell the nurse. The CNA further stated that residents are not supposed to have any medications/creams unattended at the bedside, and staff should also report to the nurse when a family member/visitor/resident brings any medications/creams/ointments into the facility. An interview was conducted on February 5, 2026 at 8:08 AM with a Licensed Practical Nurse (LPN/staff #10), who stated that residents can have ointments left unattended at the bedside, but a nurse would apply the ointment, unless there was a provider order that the resident may self-administer. He reviewed the resident's clinical record and stated that there were no orders for medication/treatment self-administration. The LPN entered the resident's room along with the surveyor and stated that there was a box of Baqsimi nasal spray (glucagon) sitting on the counter, next to the sink, unattended. The LPN stated that this is generally kept in the medication cart and should not have been left in the resident's room unattended. He also stated that he observed a container of ZAL (zinc oxide, vitamin A & D cream, topical BID (twice a day), and the label on the container was from the acute care hospital. The LPN stated that he did not know that these medications were in the resident's room, and that neither of the medications should have been left unattended in the resident's room without a provider order. The nurse stated he talked to provider about the ZAL cream yesterday, February 4, 2026, and received an order for 4% lidocaine, zinc oxide and A & D ointment. The LPN reviewed the resident's provider order and stated that there was no evidence of a physician order for ZAL ointment, and that 4% lidocaine was ordered by the provider on February 4, 2026, or orders for Baqsimi nasal spray or [NAME] cream to be self-administered. The LPN stated that leaving medication/ointments unattended at the bedside did not meet the facility standard, and the risk could result in medication error.An interview was conducted on February 5, 2026 at 8:25 AM with the Director of Nursing (DON/staff #86), who stated that when residents request to self-administer medications/ointments, nurses are expected to conduct an observation to determine if the resident knows how to administer the mediation, the medication/ointment needs to be kept in a lock box. The DON stated that the observation would be documented on a form that is found the observation tab on a form titled AHC Self Medication Administration observation. The DON also stated that a provider order would be required prior leaving any medications/creams/ointments in a resident's room for medication self-administration. The DON reviewed the resident's clinical record and stated that there was no evidence of a nursing administration observation form for medication self-administration at the bedside. The DON stated that there was a standing order to administer glucagon, but there was no order to store the medications/cream at bedside, and there was evidence of a provider order for ZAL cream dated February 4, 2026. However, the DON stated that there was no provider order for ZAL cream to be left at the bedside. The DON stated that she would have expected that staff would have noticed the Baqsimi and ZAL cream unattended in the resident's room. She stated that this did not meet her expectations and could result in another resident taking the medications.An interview was conducted on February 5, 2026 at 8:44 AM with CNA (staff #38), who stated that the resident was assigned to him for care today, but he had not observed any medications on the residents sink counter when he was providing care this morning.A policy titled, Administration of Medication, Version F0505, revealed that licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. A Policy titled, Self-Medication Administration, version A1014, revealed that patients may self-administer medications if it is determined that they are capable of doing so in a safe and consistent manner. As part of their overall evaluation, staff will assess each patient's mental and physical abilities to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, staff will perform a more specific skill assessment utilizing the Self-Medication Administration Assessment form which includes the patient's ability to read and understand medications labels, comprehension of the purpose/proper dosage and administration time for his/her medications. the Self-Medication Administration Assessment form will be maintained in the medical record. Patients requesting to self-administer medications will be assessed as above. Staff shall identify and remove any medications found at the bedside that are not authorized for bedside storage, for proper storage or return to the family or responsible party.A policy titled, Medication Orders, Version B0113, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338). Findings include: Resident #338 was admitted on [DATE] with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. A review of clinical record Minimum Data Set (MDS) is still in process. During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking. A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand. During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea. An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas. An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation. The facility's policy Resident Rights included that (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338). Findings include: Resident #338 was admitted on [DATE] with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. A review of clinical record Minimum Data Set (MDS) is still in process. During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking. A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand. During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea. An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas. An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation. The facility's policy Resident Rights included that (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observations, staff interview, and policy review, the facility failed to ensure opioid medication regimen was administered according to physician's ordered parameters for one patient (#8). The deficient practice could result in the side effects of exacerbated respiratory failure or cause life-threatening breathing problems. Findings: The subacute rehab patient (#8) was admitted on [DATE] with diagnoses of GLF-ground level fall, acute respiratory failure with hypoxia, lobar pneumonia, single subsegmental thrombotic pulmonary embolism, gastrostomy, acute embolism and thrombosis of right distal lower extremity, edema, acute post hemorrhagic anemia, adult failure to thrive, dementia. History of breast cancer. An Admission 5-day Minimum Data Set (MDS) included the patient's Brief Interview for Mental status (BIM) score of 12 out of 15 which indicated the resident was moderately impaired. The MDS also included the resident experienced frequent pain and was receiving (PRN) as needed pain medication. A physician's order dated September 03, 2024 included oxycodone 5 mg tablet every 6 Hours PRN 5 mg, gastric tube, Every 6 Hours - PRN, Pain parameters 8-10/10 Review of the Medication Administration Record (MAR) and the opioid oxycodone PRN pain management treatment was administered to patient outside of the provider's ordered pain level parameters of 8-10 of a pain scale 1-10. There is no evidence or documentation within the clinical records that the physician had been notified when oxycodone was administered outside of ordered perimeters on dates: 9/04/2024 at 19:09 for pain level 7 9/11/2024 at 19:41 for pain level 7 9/12/2024 at 19:33 for pain level 6 9/16/2024 at 21:04 for pain level 5 9/18/2024 at 19:14 for pain level 7 9/19/2024 at 02:16 for pain level 7 An interview was conducted on September 26, 2024 12:51 PM with nurse (#28) who stated about pain management opioid treatment, that if a patient has an order for pain medication, the patient has a related pain scale with parameters, and it is the facility policy and procedures to follow physician orders as written including parameters. Nurse referred to patient #8's oxycodone order having the pain scale of 1-10, and she stated that the opioid is prescribed for 8-10 pain level treatment on patient provider's order and that the floor nurse would only administer that opioid treatment if the patient's pain is within that range of 8-10 parameters. But, if the patient requested the opioid medication and their pain level is not within the prescribed 8-10 perimeters, then the nurse would call the patient's physician for clarification, then put in a new order or parameter change and document the change in either the MAR or progress note, or both locations. Nurse #28 stated patient #8's oxycodone, that the oxycodone was given outside of provider's 8-10 pain level perimeters order and she counted six times this occurred from 9/4/24-9/19/24. She stated that the order is written for the pain scale of 8-10 and the medication should have been administered only for the pain levels in that range. She further stated, that when a medication is administered outside of provider's orders, the physician would be notified, and if a new one-time order was received, there should be documentation of a change in the current order or parameter. Nurse #28 reviewed the progress notes on patient #8 and stated there were no related notes that the physician had been notified nor a note of a change in orders. The Nurse (#28) expressed that the risk of administering an opioid outside of the ordered parameters could result in the resident becoming lethargic, respiratory distress, and the doctor would not know or beaware. Interview was conducted September 27, 2024 08:15 AM with the Director of Nursing (DON staff #119) who stated, the facility's expectation of opioid oxycodone being dispersed to patient would be to follow the MD's (Medical Doctor's) orders, including parameters. The Director of Nursing expressed that the facility has a policy in place, that pain medication at times can be administer outside of parameters with documentations in place, or note that the opioid medication was requested by the patient and the MD is informed. Furthermore, that documentation should be in nursing progress note or within the patient's MAR, and it is expected that the nurses document in progress notes all MD order changes or parameter changes. Director of Nursing stated, the orders are changed to patient's needs by the physician. DON mentioned that she did talk to nurse #28 on September 26, 2024 and they reviewed patient #8's MAR of the six times oxycodone medication that were given to patient outside of parameters. DON stated she did not see any orders to change those parameters, nor identified any nursing progress note of a nurse calling MD to change parameters nor change the order. DON stated, she expects the nursing to notified the physician and document, and that the risk of not following the MD administration order, is that the MD would not be aware. Review of facility's policy Pain Management revealed that patients will be assessed for intensity of pain by utilizing a standard pain scale of 0-10 and the physician will be notified for further orders/interventions and asked to clarify parameters based upon pain intensity. Documentation of PRN medications will be documented on the EMAR. Additionally, the EMAR will prompt the administering nurse to include the reason given, location, and intensity of pain as per the 0-10 scale or FLACC numerical score prior to administration. The policy notes, it is not the purpose of this policy to neither dictate physician orders nor contradict current standards of care. Optimal pain control shall be determined with respect to patient goals in collaboration with the interdisciplinary team and the patient's physician.

Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect. The deficient practice could lead to residents suffering from psychosocial harm. Findings include: Resident #4 was admitted to the facility on [DATE] with a diagnosis of orthostatic hypotension and fracture of vertebrae. Resident #20 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease. Resident #60 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia. An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied you're dry and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, if you don't do things at his pace then he just does if for you. Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over. There really isn't any compassion from him and that is a real problem. Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care. An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's, Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway. When asked if she had personally interviewed the resident, she stated no, I didn't have to because my nurse reported it to me. When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said that's what I get paid to do. Resident didn't like that he said it and he didn't want the CNA in his room anymore, so we made sure of this. When this author asked if it was the same CNA in both incidents,. Staff #101 stated Actually, yes, it was now that I think about it. An interview was conducted on September 10, 2024 at 6:40 PM with Resident #4. She stated Well, I don't want to get anyone in trouble but I don't like Staff #42. He's rude, uncaring and full of himself. He's good looking and he knows it type attitude. I need help getting up because I have orthostatic blood pressure and he had an attitude and said to me why don't you have a fall bracelet on? Staff #42 said you should have a fall bracelet on if you need help getting up. So, I asked one of the nurses here about it and she said they don't even have fall bracelets here, so what is that guy talking about! He's never been inappropriate with me but I'd prefer he does not come into my room. An interview was conducted on September 10, 2024 at 7:00 PM with Resident #60. When asked why he filed a grievance on September 9, 2024, he stated well, he (Staff 342) came in here because I rang the call bell because my commode needed emptied. He came in and said it's a win-win, I get paid and you get taken care of. What kind of a statement is that? He's very uncaring, he's rude and I think all he cares about is money. I mean we are people that are having a hard time right now and need some help and someone is here and just cares about money. Actually, he took my commode out of the room, which I though was weird but when he returned it he said I was rude to him. So I said I was sorry if he misunderstood anything I said, but I apologized to him! Can you believe that? So, the next day I spoke with what's his name, the big boss (Staff #101) and told him what happened and that I did not want him back in my room. I just don't trust him and I'm not sure what he is really capable of. An interview was conducted, via phone, on September 11, 2024 at 11:40 AM with RN, (Registered Nurse), Staff #108. When asked if she received any complaints from any residents on the night of September 5th and 6th, she stated yes. Resident #20 said that the CNA, (Staff #42), changed his brief and did not do peri-care. Then on the 6th, in the morning, the same CNA at about 4:00 AM came into the room and did not wake him and just checked his brief. He woke up and said what are you doing?' and the CNA said I'm checking your brief. Resident #20 said it was more of an attitude problem. When asked if Resident #20 told her that he felt like he was groped, she stated what is groped? It was explained that groped means when someone grabs your genital area without permission and feels you in an inappropriate manner. She then stated oh no, he did not say that. Afterwards I talked to the management team, Staff #105, about the incident. Staff #105 told me to talk to the CNA and she would hold a class so this does not happen again. That's all I know. The facilities policy on Resident Rights, Version A0717, states Respect and Dignity-The resident has a right to be treated with respect and dignity.

Based on closed clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#15) with low oxygen level was monitored and treated. The deficient practice could result in residents not receiving the care needed and development of complications. Findings include: Resident #15 was admitted on [DATE] with diagnoses of aftercare following joint replacement surgery, paroxysmal atrial fibrillation, and personal history of other venous thrombosis and embolism. The baseline care plan dated February 10, 2023 included the resident was alert and oriented x 3 and had alterations in comfort. Approaches included medications as ordered. The brief interview for mental status (BIMS) dated February 10, 2023 revealed a score of 15 indicating the resident was cognitively intact. The nursing note dated February 12, 2023 included the resident was alert and oriented x 4. A physician order dated February 14, 2023 included for oxygen (O2) per nasal cannula (NC) to maintain O2 saturation >90%, to document liters per minute (LPM) every shift and may titrate/discontinue O2 LPM as tolerated while maintaining O2 saturation >90% every shift. Review of the resident's documented O2 levels on February 14, 2023 from 3:33 a.m. to 4:37 p.m. revealed that at 1:33 p.m., the O2 level was 85%. The documentation also included that the oxygen was last at 4:37 p.m. was documented at 92%. A progress note dated February 14, 2023 at 4:41 p.m. written by a registered nurse (RN/staff #13) revealed the resident's left lower extremities were swollen; and that, an X-ray was done and the results were pending. Per the documentation the resident and the RN called her surgeon who instructed to send the resident to the hospital for an evaluation related to a recent hypoxia episode. The documentation also included the resident had no signs of distress; and that, transportation gave an estimated time of arrival of 4 hours. The chest X-ray dated February 14, 2023 revealed the heart was mildly enlarged, mediastinum was normal without adenopathy and there was marked pulmonary venous congestion. Impression included mild cardiomegaly with marked congestive heart failure. A progress note dated February 14, 2023 at 7:10 p.m. written by a (RN/staff #13) included that the lab and chest X-ray results were reported to the nurse practitioner (NP) and copies were placed in the resident's paperwork for transport to the hospital. An interview was conducted on February 25, 2023 at 12:30 p.m. with a certified nursing assistant (CNA/staff #5) who stated that she and another CNA worked with the resident #15 who seemed agitated and was concerned about her breathing. The CNA stated that she took the resident's vitals and reported them to the nurse; and that, the resident was sent out to the hospital. In interview conducted with the RN (staff #13) conducted on February 25, 2023 at 12:54 p.m. the RN stated the resident was a nurse and complained about her breathing to the CNA. The RN said she instructed the resident to take deep breaths, gave the resident O2 and the O2 level changed from 88% to 96%. She stated the resident called the surgeon who wanted the resident sent to the emergency room . The RN also said that she called the surgeon who told her if the facility provider agreed to send the resident to the emergency room . She stated that she explained to the resident that the resident would be transported to the emergency room as non-emergent transfer; and that, if her condition changed, the facility would respond appropriately by calling 911. An interview was conducted on February 25, 2023 at 1:23 p.m. with resident #15 who stated that she was a nurse; and that, she went into heart failure and knew she needed to go to the hospital. She stated she called her physician who wanted her to go to the hospital. She said that she was hypoxic and was having trouble breathing; however, she does not remember if her O2 level was low. Resident #15 stated that her O2 level which was taken by transportation was 88% at that time. An interview was conducted on February 25, 2023 at 1:53 p.m. with the Director of Nursing (DON/staff #7) and the licensed practical nurse (LPN/staff #42). The DON stated that based on the clinical record, the resident was transported to the hospital on February 14, 2023 at 9:00 p.m. The LPN (staff #42) said at the time of the incident, her shift began at 6:00 p.m. and the resident was transported to the hospital between 9:30 p.m. to 10:00 p.m. The LPN stated that the CNA took the resident's vitals and it should have been documented under the vitals section of the clinical record. The DON said that the resident was on O2 at 1 liter for comfort and it was continued until transport arrived. During the interview, a review of the clinical record was conducted with the DON who stated that the oxygen order was for O2 level to be kept above 90% and may titrate. The DON also stated that based on the clinical record, the resident's O2 was last checked at 4:37 p.m. on February 14, 2023; and that, the night shift staff should have checked the resident's pulse oximetry because the resident had a change of condition. The DON also said that the clinical record revealed documentation that the staff checked the resident's O2 level after 4:37 p.m.; and that, the resident's O2 level could have dropped and gone into respiratory distress. The DON reviewed the X-ray results and stated that the results showed mild cardiomegaly with congestive heart failure and the resident's low O2 level could be a symptom. The facility policy on Oxygen Administration, dated September 28, 2022 included that only qualified personnel administer oxygen in accordance with a physician's order. Appropriate safety precautions are utilized to provide safe administration and storage of oxygen. It also included that before administering oxygen, and while the patient is receiving oxygen therapy, assess for the following: -Signs or symptoms of cyanosis, hypoxia, and/or toxicity; -Vital signs; -Lung sounds; -Oxygen saturation; and -Other laboratory results, if applicable. Continued review of the policy included that after completing the oxygen set-up or adjustment, document the following: -Date and time the procedure was performed; -The name/title of individual who performed the procedure; -The rate of oxygen flow, route, and rationale; -The frequency and duration of the treatment; -All assessment data obtained before, during and after the procedure; and -How the patient tolerated the procedure.

Based on observations, clinical record reviews, staff interviews, review of medication administration pharmacy directions, and review of facility policies, the facility failed to ensure medications were administered per professional standards of care for four residents (#23, #149, #105, and #96). The deficient practice could result in medication errors, adverse effects, and decreased effectiveness of medication treatments for residents. Findings include: -Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders revealed an order dated July 27, 2022 for [MEDICATION(S)] (an anti-diabetic medication) tablet 1000 milligrams (mg) twice a day. Review of the medication card included a red sticker that directed to take this medication with a meal. Review of the August 2, 2022 admission Minimum Data Set (MDS) assessment included a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The assessment included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A medication administration observation was conducted on August 16, 2022 at 7:19 a.m. of a Registered Nurse (RN/staff #52) administering medication to resident #23. The RN was noted to administer [MEDICATION(S)] 1000 mg to the resident. The resident did not have food present and the nurse did not offer food. An interview was conducted on August 16, 2022 at 7:25 a.m. with resident #23 who stated he had not had breakfast yet. An interview was conducted on August 16, 2022 at 1:41 p.m. with the RN (staff #52). She stated she was expected to follow pharmacy directions during medication administration. She acknowledged that the [MEDICATION(S)] medication card for resident #23 indicated that the medication was to be taken with a meal and that she did not follow the pharmacy direction. She stated that she could have encouraged the resident to have a cracker or an ensure. She stated the risk of taking [MEDICATION(S)] without food was low blood sugar. An interview was conducted on August 16, 2022 at 2:11 p.m. with the Director of Nursing (DON/staff #40). She stated she expected staff to follow pharmacy directions during medication administration. She stated if the medications included the direction to be given with food, and were not, staff did not follow her expectations and as a result the resident could experience side effects including upset stomach or altered absorption. -Resident #149 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE] included a BIMS score of 14, which indicated the resident had intact cognition. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August 2022 recapitulation of physician's orders revealed the following orders: -[MEDICATION(S)] (to treat high blood pressure and chest pain) 5 mg once a day -[MEDICATION(S)] (anti-diabetic medication) 500 mg tablet twice a day for DM type 2 -Vilazodone (and antidepressant medication) 10 mg tablet, give 30 mg for depression. -Omeprazole 40 mg once a day -Aspirin delayed release 81 mg twice a day -[MEDICATION(S)] (anticonvulsant) 25 mg once a day A medication administration observation was conducted on August 16, 2022 at 7:41 a.m. of a RN (staff #52) administering medication to resident #149. The RN was noted to fill a medication cup with the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] [MEDICATION(S)] 5 mg -Aspirin 81 mg [MEDICATION(S)] coated -[MEDICATION(S)] 25 mg -[MEDICATION(S)] [MEDICATION(S)] extended release 500 mg -Omeprazole delayed release 40 mg capsule -Three vilazodone [MEDICATION(S)] 10 mg tablets. Upon continued observation, the nurse gave the resident the cup containing the medications and left the room before the resident took the medications. The resident took the medications while the nurse was out of the room. The resident did not have a meal present. The nurse provided ensure (nutrition drink) with the medication administration, however, the resident was not noted to begin drinking the ensure prior to/or with the medication administration or throughout the observation. Review of the medication card for [MEDICATION(S)] included a red sticker that directed to take this medication with a meal. Review of the card for vilazodone included a red sticker that directed to take medication with food. An interview was conducted on August 16, 2022 at 7:49 a.m. with resident #149. She stated that she had not had breakfast yet. She had not consumed the ensure that the nurse had given her. During an interview conducted on August 16, 2022 at 1:41 p.m. with the RN (staff #52), she acknowledged the pharmacy directions to take the [MEDICATION(S)] and vilazodone with food/meal. She stated that she did not follow the pharmacy directions as the resident had not had breakfast yet and she did not provide food with the medications. She stated that giving the [MEDICATION(S)] without food put the resident at risk of decreased blood sugar and giving the vilazodone without food could effect the resident's stomach or medication absorption. She acknowledged that she left the resident with the medications and did not observe the resident taking the medications. She stated that she was expected to stay with the resident and make sure the resident takes all their medications. She stated there was a risk of choking or that the resident may drop the medications, and stated that the facility sometimes had residents that wandered and/or had dementia. She stated she would not know for sure that a resident took all of their medications unless she saw the resident take them. An interview was conducted on August 16, 2022 at 2:11 p.m. with the DON (staff #40). She stated she expected the nurse to stay and make sure the resident took their medications before leaving the room. She stated the facility had to have an order to leave medications at the bedside and that the resident would have to be assessed for self medication and the facility would provide a lockbox and key to secure the medications. She stated the risks included the resident not taking the medications and experiencing adverse effects or a wandering resident entering the room and taking another resident's medications. She also stated she expected staff to follow pharmacy directions during medication administration. She stated if the medications included the direction to be given with food, and were not, staff did not follow her expectations and as a result the resident could experience side effects including upset stomach or altered absorption. -Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding blood pressure medication administration: A physician's order dated August 11, 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's cardiac care plan, dated August 12, 2022, revealed a goal to have no acute cardiac episodes and that the resident's condition remain stable. The interventions included providing medication as ordered, monitor vital signs and heart sounds, and report abnormalities to the physician. A medication administration observation was conducted on August 16, 2022 at 8:01 a.m. of a Licensed Practical Nurse (LPN/staff #52) administering medication to resident #105. The nurse stated the resident's blood pressure was 132/64 mm Hg and heart rate was 84 bpm. The medication administration included three [MEDICATION(S)] 25 mg tablets. The directions on the medication card included to hold for a SBP under 140 mm Hg or heart rate under 60. The nurse administered the medication despite the resident's systolic blood pressure reading of 132 mm Hg. Review of the August 16, 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on August 16, 2022 at 1:58 p.m. with the LPN (staff #64). He stated he was expected to follow the physician's orders as written, including ordered parameters. He stated that he did not follow the physician's orders because he should not have administered the [MEDICATION(S)] when the resident's blood pressure was below the ordered parameters. He stated there was a risk that the resident's blood pressure would go lower and that he would need to monitor the resident and notify the provider of the medication error. An interview was conducted on August 16, 2022 at 2:11 p.m. with the DON (staff #40). She stated she expected the nurses to follow the physician's medication orders, including parameters. She stated a medication given outside of blood pressure parameters could cause the resident to become hypotensive or effect other vital signs. Regarding insulin administration: Review of the resident's diabetes care plan, dated August 12, 2022, revealed a goal that the resident would receive treatment and/or medication per physician's orders without adverse effects. Interventions included to monitor blood glucose levels and to provide medication and/or treatment per physician's orders. Review of a physician's order dated August 15, 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The sliding scale included to administer no units for a Blood Glucose (BG) of 120 milligrams per deciliter (mg/dL) or less, 2 units for a BG of 121 to 150 mg/dL, 5 units for a BG of 151 to 200 mg/dL, 10 units for a BG of 201-250 mg/dL, 15 units for a BG of 251-300 mg/dL, 20 units for a BG of 301-350 mg/dL, 25 units for a BG of 351-400 mg/dL, and for any BG greater than 400 mg/dL to notify the physician immediately for further instructions. Review of the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation included that the medication was not administered as the medication was not available. An interview was conducted on August 16, 2022 at 1:58 p.m. with the LPN (staff #64). He stated that he needed to re-do the [MEDICATION(S)] order because there was no place to document a blood sugar on the MAR. He stated that his notes included that the resident's blood sugar was 176 mg/dL before breakfast. He stated that, based on the ordered sliding scale, the resident would have required 5 units of insulin at that time. He stated if the resident should have had insulin coverage and the medication was not available he could have notified the doctor. He stated that under 200 mg/dL was not a bad blood sugar and that he used his nursing judgement and felt the doctor did not need a call. An interview was conducted on August 16, 2022 at 2:11 p.m. with the DON (staff #40). She stated she expected the nurses to follow the physician's medication orders. She stated the nurse needed to notify the doctor if the insulin required to treat a blood sugar, based off of the ordered sliding scale, was not available. She stated the nurse should then follow the physician's directions. She stated she expected the nurse to call the pharmacy as well to determine when the medication would be delivered. She stated the risk to the resident was [CONDITION(S)] (high blood sugar). Review of a progress note written on August 16, 2022 at 2:53 p.m., after the interview with the LPN (staff #64) and DON (staff #40), included that the [MEDICATION(S)] was unavailable this morning before breakfast. The note included that pharmacy was notified and the medication was in route. The physician was notified and there were no new orders. Review of the insulin administration policy revealed that the nurse will ensure, prior to administering each dose of insulin that both the correct type and dose of insulin and number of units ordered are checked against the physician's orders, the insulin vial, and syringe before the patient receives the medication. The policy included that a resident who is prescribed insulin can expect that the medication be administered in the correct form and dosage, at the correct time, with the correct injection technique with concurrent observation of benefit and potential side effects of drug interactions. -Resident #96 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders revealed an order dated May 8, 2021 for [MEDICATION(S)] (an antibiotic) 2 grams (gm) via IV every 4 hours; 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. for a lumbar incision and drainage infection. Review of the May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -May 9, 2021 8:00 p.m. scheduled dose was administered late, documented at 9:27 p.m. -May 10, 2021 12:00 a.m. scheduled dose was administered late, documented at 1:21 a.m. -May 10, 2021 4:00 a.m. scheduled dose was administered late: done at 5:40 a.m. The resident was discharged from the facility on May 11, 2021. An interview was conducted on August 17, 2022 at 9:29 a.m. with a LPN (staff #49). She stated if a medication was scheduled to be administered every 4 hours the medication administration time period was up to one hour before and no later than an hour after the specific scheduled time. She stated it was important for an antibiotic to be given as scheduled to prevent delay of care so the medication would treat the identified infection. She stated staff were expected to give the medications as scheduled. On review of the resident's MAR, she stated there were three instances where medications were given late, and stated that the nurse did not follow facility expectations for medication administration. An interview was conducted on August 17, 2022 at 9:55 a.m. with the Director of Nursing (DON/staff #40). She stated she expected medication to be administered within one hour before, to one hour after the scheduled time. She stated for an IV antibiotic that was scheduled to be administered every 4 hours the nurse would have the hour before, and up to the the hour after the scheduled time to administer the medication. She stated timely administration of antibiotic medication was important to keep the medication at therapeutic levels and to prevent delay of the healing process. On review of the resident's MAR, she stated staff did not follow expectations when the antibiotic was administered late. Review of the facility policy for medication administration included that medications are administered in accordance with a physician's written orders. Review of the administration of medication policy revealed that licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. The policy included to identify the medication on the MAR, identify the bubble pack, bottle etc. in the medication cart, and to compare the prescription label to the order on the MAR. The policy included to verify the 6 medication administration rights which include: right patient, right drug, right dose, right dosage form, right route, and right time. The policy also included to stay with the resident until all medications have been ingested and ensure that ancillary tasks such as blood pressure, apical pulse, etc. are performed with applicable medications. Review of the medication error policy revealed a policy statement to safeguard the resident against and provide emergency care as necessary related to medication errors. The policy included that medication errors are minimized by following the six rights of medication administration including: right patient, right medication, right dosage, right dosage form, right route, and right time.

Based on clinical record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure one resident (#97) was provided adequate showers to maintain good grooming. The sample size was one resident. The deficient practice could result in altered skin and adverse psychosocial impact. Findings include: Resident #97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility shower schedule revealed that residents were scheduled for showers two times a week by room number. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderated cognitive impairment. The resident received total assist with bathing. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) included a hospital stay for a fractured right hip and hematuria and that he was at the facility for rehabilitation. He had physical limitations and decreased mobility of his right leg and a decline in ADLs due to weakness and decreased mobility. Review of the resident's ADL care plan, dated March 12, 2021, revealed the resident required staff assist with ADL completion related to limited mobility and generalized weakness due to a right hip fracture. The goal included that the resident would present a clean and neat appearance. An intervention included staff to assist the resident with showers twice weekly and as needed per the resident's preference. Review of the facility's shower documentation for March 5 through 29, 2021 revealed the resident received a bed bath on March 11, 2021. Also noted, the resident refused a shower on March 25, 2021. There was no other documentation to show that the resident received any further bathing or bathing opportunities. The resident was discharged from the facility on March 29, 2021. An interview was conducted on August 16, 2022 at 1:41 p.m. with a Registered Nurse (RN/staff #52). She stated that showers are done based off of a shower schedule and that residents were scheduled to have a shower two times a week. She stated that residents could have more that two showers if needed. An interview was conducted on August 17, 2022 at 2:26 p.m. with a Certified Nursing Assistant (CNA/staff #33). She stated that residents are offered a shower twice a week and that staff had a schedule that is listed by room number. She stated she would document provision of the shower in the electronic ADL documentation for the resident and on a shower sheet. She stated if a resident refused the shower, there was a refusal form for staff to fill out on which the resident would sign and say why the shower was refused. She stated if the shower was not documented as given or refused, the facility would not be able to show that a shower was offered. She stated if the resident did not get assistance with ADLs, they may not have good hygiene and may be at increased risk for skin issues. An interview was conducted on August 18, 2022 at 10:41 a.m. with the Director of Nursing (DON/staff #40). She stated the residents are offered showers based on the shower schedule which includes providing residents with two showers per week (Sunday to Saturday). She stated if a resident refused a shower the staff is supposed to fill out a refusal form for the resident to sign. She stated the shower would be documented in the task documentation and on a shower sheer. On review of the shower documentation for resident #97, she stated that staff did not meet her expectations for provision of showers and stated there was a risk that the resident did not have proper hygiene. She stated if unable to find documentation of showers, there was no other way to show the showers were offered/given. Review of a facility policy for Shower/Bath, dated February 23, 2021, included that showers/baths are scheduled two times per week. Residents will be educated on shower/bath schedule on admission. If a different schedule is requested, arrangements will be made. The policy included that the facility will follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included to document the shower/bath in the clinical record.

Based on clinical record review, staff interviews, and review of facility policies, the facility failed to ensure one resident's (#97) skin was assessed and treated timely. The sample size was one resident. The deficient practice could result in late identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Resident #97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission skin assessment, dated March 5, 2021, revealed the resident had a pink, blanchable area to the coccyx/sacrum area. A Braden Risk Assessment, dated March 5, 2021, included that the resident was at low risk for pressure ulcers. Documented interventions included weekly skin assessment completion by a licensed nurse and barrier ointment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Barrier cream to perineal area every shift or after each incontinent episode. The schedule for administration included on the day shift and the night shift. -Weekly skin assessment to be completed once a day on Thursdays. The order included that + (altered skin) results are to be documented in the nurses notes. The March 2021 Treatment Administration Record (TAR) revealed that the barrier cream was provided as ordered. Review of Physical Therapy (PT) and Occupational Therapy (OT) notes dated March 10, 2021 revealed that the resident had red skin and a leaking catheter and a red rash between his legs and on the inner thighs. The nurse was notified of the red skin and the leaking catheter. A Certified Nursing Assistant (CNA) skin monitoring and shower review sheet dated March 11, 2021 included that the resident had redness to his upper thigh/perineal area in the front and the back. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderated cognitive impairment. The documentation included a risk of skin breakdown, bowel incontinence, and Moisture Associated Skin Damage (MASD). The pressure ulcer Care Area Assessment (CAA) included to monitor the skin weekly for change and if a change was noted to inform the physician and the nurse manager for treatment. Despite documentation of redness and a rash on the resident, review of the clinical record revealed no evidence that a skin assessment had been completed by a nurse. The March 2021 TAR documented a - for the scheduled skin assessment for March 11, 2021. Review of the resident's skin care plan, dated March 12, 2021, revealed the resident was at risk for altered skin integrity related to impaired mobility. Interventions included barrier ointment as needed, monitor skin daily during care and report changes to the nurse, and weekly skin assessments by the licensed nurses. A CNA skin monitoring and shower review sheet dated March 14, 2021 included that the resident had raw, peeling skin to his upper thigh/perineal area. Despite documentation of raw, peeling skin to his upper thigh/perineal area, there was no evidence that a nurse assessment was conducted of the resident's skin. Review of the March 2021 TAR revealed nurse initials and a - for the scheduled skin assessment on March 18, 2021. Review of an OT note dated March 19, 2021 included that perineal care was completed to assist the resident with cleaning his rash area. Review of the clinical record did not reveal nursing documentation of assessment of a rash. Review of the March 2021 TAR revealed nurse initials and a - for the scheduled skin assessment on March 25, 2021. A CNA skin monitoring and shower review sheet dated March 28, 2021 included a rash to the resident's perineal area. Review of the clinical record did not reveal any nurse assessment documentation of the CNA documented rash. The resident was discharged from the facility on March 29, 2021. An interview was conducted on August 17, 2022 at 2:26 p.m. with a CNA (staff #33). She stated if she noticed a change in a resident's skin, she would report it to the nurse or the wound care nurse and they would assess the area. She stated that she observes residents' skin when she provides showers and when she changes residents. She stated that when she provides a shower, she completes a shower sheet skin observation and she documents any skin alterations. She said this form then goes to the nurse who will sign it. An interview was conducted on August 17, 2022 at 3:14 p.m. with a Licensed Practical Nurse (LPN/staff #58). He stated that the admission nurse conducts a skin assessment and that the nurses complete weekly skin assessments. He stated ongoing assessment for skin changes included the CNA shower sheet on which the CNAs are very detailed on the skin observation portion. He stated the CNA would turn the shower sheet into him and he would act on any issue and follow-up on any skin changes. He stated his signature on a shower sheet indicates that he saw the form, not the resident's skin. He stated anything out of the ordinary would be reported to the nurse by the CNA and he would assess the concern. He said this may include notifying the wound nurse or the physician, depending on the situation. He stated that if a resident develops altered skin, this should be indicated on the nursing skin assessment. He stated that he thought there was supposed to be a skin assessment form done each week in addition to initialing the TAR that the skin assessment was done. On review of the clinical record for resident #97, he stated that unfortunately the nurse did not do the weekly head to toe skin assessment documentation, which could cause a risk for skin breakdown. He said that the record indicated that the resident developed altered skin integrity and that he would have expected to see nurse assessment documentation, but did not. An interview was conducted on August 17, 2022 at 4:21 p.m. with a Registered Nurse (RN/staff #52). She stated that when she signed the CNA shower sheet, it just indicates that she acknowledged the form. She stated that if a resident had a new skin issue, she would address it by assessing the area and documenting in the clinical record. She stated that any skin alteration should be assessed by a nurse and documented. She stated that the weekly skin assessment on the TAR would have a - if there was no new skin changes, all existing skin alterations should already have documentation of assessment. She stated a + sign for the skin assessment would indicate a new skin alteration and should have a comment and documentation of assessment of the altered skin condition. An interview was conducted on August 18, 2022 at 10:29 a.m. with the Director of Nursing (DON/staff #40). She stated a nurse conducts a head to toe skin assessment on admission then a head to toe skin assessment would be done weekly by a licensed nurse. She stated the nurse would sign off on the administration record that the skin assessment was done and that there should be a corresponding skin assessment sheet completed or a skin assessment nursing note. She stated the CNAs conduct skin observations on the shower sheets, which are then given to the nurse who would look for any changes. She stated that nurse would follow-up on any noted altered skin/skin changes and that she expected the nurse to do an assessment, document findings, and notify the physician and the responsible party. She stated the CNA shower sheet documentation are CNA observations and not a nurse assessment. On review of the documentation for resident #97, she stated that rashes, redness, and peeling skin were noted on the CNA observations and she would have expected to see nurse follow up and documentation of the assessments and she did not. She also stated that she did not see any documentation of the head to toe skin assessments that were initialed as completed on the administration record. She stated if a nurse did not do the weekly skin assessments, or follow up on the CNA observations, it could cause delayed treatments, infection, and worsening of wounds. Review of the shower/bath policy, dated February 23, 2021, included to report any findings to the nurse. Review of a facility policy for skin assessment, management, and documentation, dated August 10, 2020, included that the admission nurse or designee will perform a complete skin check or assessment on admission and document it in the clinical record. The policy included that the licensed nurse assigned to each resident will be responsible for completing all daily monitoring, treatments, and weekly skin assessments on the date and shift indicated. The licensed nurse will initial the appropriate box indicating that he/she has completed the assigned daily monitoring, treatment and/or weekly skin assessment. A narrative description of all wounds, treatments, and interventions will be recorded in the clinical record. Weekly skin assessments should be entered separately from other notes. The policy included that appropriate protective measures and interventions will be initiated and addressed on a care plan update.

Based on an observation, staff interviews, and facility documentation and policies, the facility failed to maintain infection control standards during medication administration. The deficient practice could lead to transmission of infections including COVID-19. Findings include: A medication administration observation was conducted on August 16, 2022 at 8:01 a.m. of a Licensed Practical Nurse (LPN/staff #52) administering medication to a resident. By the resident's door, there was a sign that said the resident was on standard, droplet, and contact isolation and this included clean hands and use of a gown, mask, eye protection, and gloves. The door frame had a green magnet on it. The nurse donned Personal Protective Equipments (PPE) including a gown, gloves, N95 mask and the nurse was already wearing eye protection. The nurse did not secure the gown at his waist leaving his back partially exposed and the gown fell forward from the nurse's shoulders approximately 3 times during medication administration exposing the nurse's full back, shoulders, and parts of his upper arms. The nurse went into the bathroom to empty the resident's urinal. After doing this, he did not perform hand hygiene or change his gloves and then proceeded to touch the bedside table, the countertop by the resident's sink, and the thermostat to adjust the room temperature. The nurse then doffed and disposed of his PPE to exit the room and performed hand hygiene. At 8:06 a.m. the nurse re-entered the resident's room after donning PPE and again did not secure the gown at the waist. An interview was conducted on August 16, 2022 at 1:58 p.m. with the LPN (staff #64). He stated the facility provided education on infection control including the donning and doffing of PPE and hand washing. He stated when donning a gown he was supposed to secure the neck and waist ties. He stated if the gown was not secured there was a risk of contamination and the spread of infection. He stated that he should have done a glove change and hand hygiene after handling and emptying the urinal and before touching anything in the environment. He stated that there was a risk of spreading infection by not doing this. An interview was conducted on August 16, 2022 at 2:11 p.m. with the Director of Nursing (DON/staff #40). She stated all nurses had been educated on donning and doffing PPE and that she expected staff to don and doff PPE correctly. She stated she would hope that the staff would tie the gown at the neck and waist. She stated that donning the gown securely was important to eliminate cross contamination and that an unsecured gown in a room on transmission based precautions would not give the required protection. She stated that if gloves became contaminated, the staff member should remove the gloves, do hand hygiene, and put on new gloves. She stated after staff touched and emptied a urinal, they would need to change their gloves and do hand hygiene before touching any other surface. She stated that it was important to prevent cross contamination. Review of facility documentation, dated May 2, 2022, revealed that residents will have magnets on their door, and depending on the color of the magnet, this will determine what PPE is required prior to entering the room. The form included that a green magnet=quarantine. The patient will be on this isolation until their 7th day in the facility, if they test negative for COVID-19. The form included to wear goggles or a faceshield, an N95 mask, a cloth gown, and gloves at all times when in the room. Review of facility documentation regarding donning PPE included to fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back of neck and waist. Review of the facility's standard precautions policy revealed that standard precautions are the minimum precautions utilized on all residents when there is potential or actual contact with body fluids which may or may not contain blood and/or infectious organisms. The policy included to wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. The policy included to wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. The policy included that it may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. The policy included to wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other patients or environments. The facility's contact precautions policy included that in addition to standard precautions, use contact precautions for specific residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. Gloves and hand washing, in addition to wearing gloves as outlined under standard precautions; wear gloves when entering the room. During the course of providing care for a resident, change gloves after having contact with material that may contain high concentrations of microorganisms. Review of the droplet precautions policy revealed: In addition to standard precautions, use droplet precautions, or the equivalent, for patients know or suspected to be infected with microorganisms transmitted by droplets that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures.

Based on observations, staff interviews, facility policy review, and Centers for Disease Control (CDC) guidelines, the facility failed to don appropriate Personal Protective Equipment (PPE) when caring for a resident on isolation; and, the facility failed to ensure staff cleaned and disinfected noncritical resident-care equipment prior to its use. The deficient practice could result in the spread of COVID-19. Findings included: An interview was conducted with the administrator (staff #42) on December 10, 2020 at 8:40 am. He stated any resident testing positive with COVID-19 is transferred to their sister facility and the hall where the resident resided will be turned into a lock down unit. He stated all of the newly admitted residents and those residents being ruled out and awaiting COVID-19 testing results were on hallway 2 which was designated as the lock down unit at this time. An observation was conducted on hallway 2 on December 10, 2020 at 9:00 am. The entrance to hallway 2 had two doors that were closed. These two doors had a signage posted to explain the different required PPE for each individual room. Each room either had a colored magnet or no magnet indicating staff the specific PPE to use prior to entry. The white magnet is posted for all new admission and the required PPE included a face shield, surgical mask, cloth gown (Do Not Reuse), gloves prior to entrance and at all times when in the room. Per the instruction, on day 4 after admission, the resident will be tested for COVID-19 and once test is negative the resident will be transitioned to a green magnet. The green magnet is used for quarantine of the resident for 14 days after testing negative and before transferring to the general population. The required PPE included goggles or face shield, surgical mask, cloth gown (Do Not Reuse) and gloves prior to entrance and at all times when in the room. The rooms with no magnet are for residents who was taken off quarantine after 14 days and the PPE required included wearing a mask. Per the signage, there are no other PPE required. At 9:18 a.m. on December 10, 2020, a certified nurse assistant (CNA/staff #35) entered a resident room with a Green magnet. Staff #35 had google/face shield, masks and gloves on. However, she was wearing a lab coat turned backward which was open and not buttoned up. At 9:25 a.m. on December 10, 2020, another CNA (staff #21) entered the same resident room wearing a gown, gloves, and prescription glasses. However, she was not wearing a face shield or goggles. -At 10:19 am, both staff #35 and #21 entered the same resident room. Staff #21 was wearing a gown, had a mask and gloves on. However, she did not have googles or face shield on. Staff #35 was wearing a gown, had a mask, gloves and googles on but she had her goggles on top of her head. When staff #35 was standing in front of the resident, she realized the goggles was on top of her head and made up and down motions with her head and neck that forced the goggles to move from her head to her face. During the process of moving her goggles, staff #35 dropped the pulse oximeter onto the floor. She then bent down, picked up the pulse oximeter, and placed it directly on the resident's right index finger without cleaning or disinfecting it. An interview was conducted with the Director of Nursing (DON/staff #6) on December 10, 2020 at 10:40 a.m. She stated the required PPE is designated on all of the doors with the color magnets in hallway 2. She stated each door has a sign explaining the PPE required when staff enters the room. An interview was conducted with a Registered Nurse (RN/staff #54) on December 10, 2020 at 12:10 p.m. She stated the resident in a room with a green magnet requires staff to wear a mask, face shield, gloves and a gown prior to entry into the room. She stated the residents with a green magnet have tested negative but are on a 14-day quarantine. An interview was conducted with a CNA (staff #35) on December 10, 2020 at 12:40 p.m. She stated when a resident has a Green magnet on their door she is required to wear a mask, gown, goggles or face shield and gloves. She stated the jacket with the buttons on the back are harder to close and she cannot do it by yourself. She stated all PPE should be on prior to entering the resident's room and resident-care equipment such as the pulse oximeter used on residents need to be cleaned with bleach wipes before each use. She stated she does not know why she did not clean and disinfect the pulse oximeter after it fell on the floor and prior to placing it on the resident's finger. Further, she stated she should have done so. An interview was conducted with another CNA (staff #21) on December 10, 2020 at 1:10 pm. She stated she wears a face shield, gloves, gowns, and masks for any resident with a green magnet. She stated she does not recall that she was not wearing a face shield when caring for the resident on hallway 2. An interview was conducted with a Licensed Practical Nurse/Infection Preventionist (IP/staff #44) on December 10, 2020 at 2:30 p.m. She stated all staff have been trained on the required PPE following the magnet protocol. She stated the lock down unit is in hallway 2 and is a mix of different isolation levels. However, she did not specify the different levels. She stated the staff have access to the sign on the door to identify what PPE is required for each room based on the color of magnet. She further stated staff and residents would be at risk if staff did not use the appropriate PPE. Regarding the resident care equipment, staff #44 stated the resident care equipment such as the thermometers or pulse oximeter has to be disinfected prior to and after each use. She stated the residents share the thermometer and pulse oximeter in hallway 2 and cleaned and disinfected with a bleach wipe before and after each use. She said that if the pulse oximeter was dropped on the floor, it should have been wiped down and allowed to dry prior to use on a resident. A facility policy titled COVID-19 Emergency Plan included a subtitle of Preventing Spread of COVID-19 in the Facility. The core principles are consistent with the CDC guidance for nursing homes, and should be adhered to at all times. These principals included the staff use of appropriate PPE. Patients without symptoms for confirmed COVID-19 should be placed on quarantine isolation for 14 days even with negative tests. Continued review of the plan included that all non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected with an EPA (Environmental Protection Agency) N listed chemical prior to use on another patient. Review of the CDC guidance titled, Interim Infection Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 dated July 15, 2020, revealed that dedicated medical equipment should be used when caring for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer's instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g. using cleaners and water to pre-clean surfaces prior to applying an EPA-registered hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that professional standards of quality were maintained by failing to ensure that a physician's orders [REDACTED].#277) peripheral Intravenous (IV) site and failed to ensure that medication parameters were ordered and implemented for two residents (#29 and #25). The facility census was 31 residents. The deficient practice could result in negative health outcomes for residents. Findings include: Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed no orders for the placement or care of an IV. Review of the resident's baseline care plan revealed a section for IV therapy. The section was crossed out and did not indicate that the resident had an IV. A skin assessment dated [DATE] revealed no indication that the resident had an IV. Further review of the clinical record revealed no other documentation regarding an IV site including that an IV site existed, that IV medications had been provided, that routine flushes had been performed, or that the site was dressed and cared for. An observation was conducted on 10/21/2020 at 2:00 p.m. The resident had an IV site on her right hand. There was no date or initials on the dressing that covered the site. In an interview with a Licensed Practical Nurse (LPN/staff #85) on 10/21/2020 at 2:20 p.m., she stated that the nurses follow standing orders that the facility uses for IV care. She said that these orders tell her the nurse when to change the dressing on the site and when to flush the IV. During an interview with the resident on 10/22/2020 at 12:46 p.m. she stated that the facility had removed the IV yesterday (10/21/2020) and she was told that she did not need it any longer. A physician's orders [REDACTED]. Review of the resident's admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 11 on the Brief Interview for Mental Status (BIMS) indicating mild cognitive impairment. The resident was coded to have received IV medications while a resident in the facility. An interview was conducted with a Registered Nurse (RN/staff #89) on 10/23/2020 at 8:37 a.m. She stated that there needs to be a physician's orders [REDACTED]. She said that the order should include why the resident needs the IV and specifics regarding the IV such as the size of the IV catheter. She stated that there is a lot of care required when a resident has an IV including flushing the IV and dressing the IV site. She said that once the IV was established, the nurse should dress the site as per the physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #73) on 10/23/2020 at 11:10 a.m. She stated that her expectation is that the nurses need to verify that the doctor provided an order for [REDACTED]. She said that the staff also use standing orders for the care and maintenance of the IV site. She said this would include dressing changes and flushes. She said these orders should show up in the clinical record and should be documented as completed in the electronic health record. She stated that the nurses should also be creating progress notes regarding the status of the resident's IV site. She stated that if the information is not documented, then it was not completed. Review of facility policy titled Intravenous Access Device indicated that purpose of the policy was to appropriately maintain IV access devices. The procedure included that upon receipt of physician's orders [REDACTED]. If the physician's orders [REDACTED]. -Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the baseline careplan dated 09/17/2020 revealed a problem with alteration in comfort with a goal of adequate pain control. The listed approaches to meet this goal included administration of medications as ordered, monitor for signs and symptoms of pain and medicate per order, evaluate pain for cause, site, and intensity before and after administration of pain medication, and to notify the physician if regimen is not effective. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS noted that the resident had received as needed pain medication within the last five days. Review of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the clinical record revealed the resident passed away in the facility on 9/29/2020. During an interview on 10/22/2020 at 10:45 a.m., with a Registered Nurse (RN/staff #90), she stated that if there are multiple orders for pain medication there should be pain parameters for use included in the order. She said that this is done so that the nurse knows which medication to give the resident. She said if there are two orders for two different as needed pain medications or different dosages of the same pain medication without parameters for use, she would call the provider to clarify. An interview was conducted with the Director of Nursing (DON/staff #73) on 10/23/2020 at 8:32 a.m. She stated that the expectation for as needed pain medication is for the physician to include a pain scale in the order and if there is not one, to clarify with the physician. She said this can be challenging if there are multiple pain medications and the dose differs based on the pain threshold of the resident. She said the nurse should have clarified the orders for pain medication for this resident since the orders do not indicate when to give each medication. Review of the facility's pain management policy revealed that the intention of the policy is for residents to have appropriate pain control measures to optimize comfort and well-being. Pain levels shall be controlled at acceptable levels to maximize recovery and facilitate participation in daily treatments and activities of daily living. Prescribed medications that include dosing options such as 1-2 tabs or 10-20 mg shall be clarified to include parameters based upon pain intensity as per the 0-10 scale or Face, Legs, Activity, Cry, Consolability (FLACC) numerical score. -Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -10/8/2020 Obtain resident's blood pressure prior to medication administration. -10/8/2020 Hold blood pressure medications if resident's blood pressure is less than 100 millimeters of Mercury (mmHg) Systolic Blood Pressure (SBP) or less than 65 mmHg Diastolic Blood Pressure (DBP). -10/10/2020 [MEDICATION NAME] (a high blood pressure medication) 10 mg per day. The order included to hold the medication if the resident's SBP was under 100 mmHg. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed a score of 13 on the Brief Interview for Mental Status (BIMS), which indicates she was cognitively intact. Review of the resident's cardiac careplan dated 10/15/2020 revealed an alteration in cardiac function related to [MEDICAL CONDITIONS]. The short term goal for the resident was to have no acute cardiac episodes throughout the next 90 days and to remain stable. Interventions included to administer medications, monitor vital signs, and monitor labs according to the physician's orders [REDACTED]. The vital sign report was reviewed from 10/10/2020 to 10/18/2020. There were several times when the resident's blood pressure was recorded to be below 65 mmHg for the DBP reading. Review of the Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. However, the order from 10/8/2020 to hold blood pressure medications for pressures lower than 100 mmHG SBP or less than 65 mmHg DBP was still an active order. The [MEDICATION NAME] order with the parameter to hold for blood pressure less than 65 mmHg was also still an active order. The vital sign report was reviewed from 10/18/2020 to 10/22/2020. There were several times when the resident's blood pressure was recorded to be below 65 mmHg for the DBP reading. There was one time when the resident's SBP was below 100 mmHg. Review of the MAR from 10/18/2020 to 10/22/2020 revealed that [MEDICATION NAME] was administered once and [MEDICATION NAME] was administered to the resident several times despite documentation that the resident's DBP was below the ordered parameter of 65 mmHg. There was also one occasion when [MEDICATION NAME] was administered despite documentation that the SBP was below the ordered parameter of 100 mmHg. An interview was conducted on 10/23/2020 at 11:29 a.m. with a RN (staff #90). She said that the Certified Nursing Assistants (CNA) are the ones who complete and document resident blood pressures. She said that if a resident's blood pressure was low during the CNAs reading, she would recheck it prior to giving any blood pressure medications and document the reading in the MAR. She said that when she administers blood pressure medications, she checks the order for any parameters for use. She said that each physician is a bit different and will order different parameters for different residents. She said that in general, the typical parameters include to hold the medications when the resident's SBP is under 100 mmHg and/or their pulse is under 60 beats per minute. She said that she has never seen DBP parameters included as part of the orders. She said she was not aware of a specific separate order for parameters to hold blood pressure medications for this resident as she could not see one during medication administration. She said the only parameter she was aware of was the one on the [MEDICATION NAME] order which indicated to hold the medication if the SBP was below 100 mmHg. An interview was conducted on 10/23/2020 at 12:41 p.m. with the DON (staff #73). She said that her expectation is that the nurses review physician's orders [REDACTED]. She said there are no specific standing orders in the facility for holding blood pressure medications because they are typically specific to the resident and determined by the resident's physician. When speaking of this specific resident, she said that the order for parameters was not attached to the medication orders and the nurses likely did not see it when administering medications. She said that she was surprised that the [MEDICATION NAME] was ordered for hypertension and she wondered if this was accurate because often the medication is used for [MEDICAL CONDITION] and this resident does have that diagnosis. She said if this was the case, then the separate blood pressure parameter order would not apply to the medication. She said that the facility has a policy regarding medication orders but there is no specific policy addressing blood pressure parameters. Review of the facility's medication orders policy revealed that medications are only to be administered upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The policy included that medication orders will include required parameters if applicable.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident's (#29) physician's orders were accurate regarding advance directives. The sample size was one resident. The deficient practice could result in resident's wishes not being honored in an emergency medical situation. Findings include: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 9/16/2020 revealed the resident's code status as a full code. Review of advance directives paperwork dated 9/16/2020 revealed the resident's code status was full code. The form was signed by the resident's representative. Despite the physician's order and the advance directive paperwork showing that the resident was full code status, the baseline care plan dated 9/16/2020 documented that the resident's code status was Do Not Resuscitate (DNR). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Advance directives paperwork dated 9/27/2020 revealed the resident's code status had changed to a DNR. The form was signed by the resident's representative. In the Electronic Health Record (EHR), there was a advance directive indicator which indicated that the resident's advance directive status was DNR. Review of the physician's orders revealed no evidence that the order was updated to reflect the resident's DNR status. Review of the clinical record revealed the resident passed away in the facility on 9/29/2020. An interview was conducted with a Registered Nurse (RN/staff #90) at 10:45 a.m. on 10/22/2020. She stated that when a resident is admitted to the facility, the resident or their representative will complete advance directive paperwork and that once this is completed, a physician's order will be obtained. She said the paperwork will be filed, and the advance directive indicator on the Electronic Health Record (EHR) will be updated to reflect the resident's code status. She said that if a resident changes their advance directive, the order should be updated as well as the indicator on the EHR. She said that it is important that all sources of advance directives match to avoid confusion in the case of an emergency. She said that if a resident were to need resuscitation, she would look at the indicator on the EHR and then check the advance directive paperwork to determine the resident's wishes. During the interview, the indicator on the EHR showed that the resident's code status was DNR. In an interview with the Director of Nursing (DON/staff #73) at 8:32 a.m. on 10/23/2020, she stated that upon admission, the nurse will explain advance directives to the resident to ensure their wishes are upheld. She said that once the paperwork is complete, the nurse would then ensure that a physician's order was obtained. She said that there is a third place that shows the resident's advance directive and that is the EHR code status indicator which is visible to the nurse when she views the resident in the EHR. She said that all three areas should show the same advance directive wishes to avoid any confusion. She said that sometimes residents change their advance directive wishes and that when this occurs, the nurse should also update the EHR code status indicator and the physician's orders. She said that some of the nurses are not aware of this process. She reviewed this resident's record and said the order should have matched the paperwork and the EHR code status indicator. She said that advance directives should be on the baseline care plan which is completed upon admit. She said she did not know why the baseline care plan showed a DNR status when the resident would have been a full code at that time. Review of the facility's advance directives policy revealed a policy statement that prior to or on admission to the facility, information will be provided to the resident concerning his or her right to make decisions concerning medical care including the right to accept or refuse medical treatment. Information about whether or not the resident has executed an advance directive will be displayed in the medical record. The policy included that changes to a directive must be submitted in writing to the facility. The policy stated the facility will notify the physician of advance directives so that appropriate orders may be documented in the resident's medical record and plan of care.

Based on clinical record review, observations, interviews, and facility policy, the facility failed to ensure one resident (#25) received assistance to access and use her hearing aid. The sample size was one resident. The deficient practice could result in a decline in the resident's ability to communicate. Findings include: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission observation report on 10/8/2020 revealed the resident used hearing aids, could hear at normal conversation sound levels, and used the hearing aids 50-75% of time. Review of the baseline careplan indicated the resident had an alteration in communication, that her hearing was adequate, and the resident used a hearing aid in the right ear. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS also indicated that the resident's hearing was adequate but the resident used a hearing aid. The MDS indicated the resident required limited assistance with one person for dressing and personal hygiene, and extensive assistance with one person for transfers and bed mobility. Review of the clinical record revealed no other information about the resident's hearing aid such as when the hearing aid should be used, how much assistance the resident needed with the hearing aid, or that the resident had used the hearing aid while in the facility. An interview was conducted with the resident on 10/21/2020 at 9:42 a.m. She stated she has hearing aids but the batteries are dead and the staff has not addressed it. She said she has not mentioned this to the staff. Observations were conducted on 10/21/2020 at 9:45 a.m. The resident did not have hearing aids in her ears. When asked questions, the resident had some difficulty answering and could only answer when a louder than normal volume was used. Many questions had to be repeated due to the resident not hearing or understanding what was being said. During an interview with the resident on 10/22/2020 at 9:59 a.m. she said she only has one hearing aid for her right ear. The resident stated the hearing aid battery is dead and had been since admission to the facility. She said has not worn the hearing aid while in the facility because of the dead battery. She said she has the hearing aid in her room, but she does not know where it is. She said that the staff have not assisted her with her hearing aid. An observation was conducted on 10/22/2020 at 10:00 a.m. The resident did not have a hearing aid in her right ear. In the room there was a sign next to the door stating: Staff be aware that I have a right hearing aid. Please help me keep track of these items. If unable to locate immediately inform nurse or manager. In an interview with a Certified Nursing Assistant (CNA/staff #28) on 10/22/2020 at 10:03 a.m., he stated he is aware that the resident has a right hearing aid and she has worn it from time to time. He said that it depends on her mood. He said that that some days she seems to hear better than others and then she will not wear the hearing aid. He said that the hearing aid works as best he knows and she has not complained about it not working. An observation was conducted on 10/22/2020 at 10:13 a.m. A Registered Nurse (RN/staff #90) found the hearing aid in the resident's belongings. The RN turned on the hearing aid and it did not make any noise. The RN inserted a new battery and the hearing aid made a humming noise. The RN placed the hearing aid in the resident's ear. The resident stated it was working properly. The RN (staff #90) was interviewed on 10/22/2020 at 10:45 a.m. She stated that she reviews progress notes to determine if residents have hearing aides as this information is collected on admission. She stated she did not know for sure if she had seen a hearing aid for this resident prior to today. She stated the CNAs are typically responsible for assisting residents with their hearing aids. She said she believes the battery in the hearing aid was dead since it was not humming the first time she turned it on. She said that once she replaced the battery in the hearing aid, it starting humming, indicating it was working. In an interview with a CNA (staff #23) on 10/22/2020 at 10:50 a.m., she stated the resident does not have issues with communication. She said she has helped place the resident's hearing aid before and she knows it works. She said she gets the resident out of bed in the morning and places the hearing aid first thing. She also said she takes the hearing aid out for showers and at bedtime. An interview was conducted on 10/22/2020 at 10:55 a.m. with a CNA (staff #39). She stated the resident gets up on her own in the morning. She said she has never seen the resident with hearing aids and was not aware that she has them. She said she does not have trouble speaking with the resident. She said that she knows if a resident has a hearing aid if there is a sign by the door and she did see the sign on this resident's door on this date. She said nobody helped the resident get up this morning or with her hearing aid. A nursing note dated 10/22/2020 stated the resident appeared less confused once her hearing aid was placed because she was able to hear staff. During an interview with the Director of Nursing (DON/staff #73) on 10/23/2020 at 8:32 a.m., she said that upon admission the nurses should document the use of hearing aids on the admission observation report. She said there should be a yellow sheet hanging in the room to alert staff the resident has a hearing aid. She also said staff should assist with these devices if the resident requires the help. She said that most of the residents in the building are independent and that the staff should encourage them to be as self sufficient as possible. She said it should be documented on the baseline careplan if the resident has hearing aids but the staff do not document when they assist a resident with their hearing aids. Review of the facility's hearing aid policy revealed the purpose of the policy is to maintain the resident's hearing at the highest attainable level. Residents are permitted to manage their own hearing aid with staff oversight as needed. The policy is to check the batteries, assess the resident's knowledge of operating the hearing aid, explain use of the hearing aid to the resident, and report complaints to the nurse supervisor.

Based on facility documentation, staff interviews, review of the Center for Disease Control (CDC) recommendations and policy and procedure, the facility failed to consistently maintain an infection control program regarding ongoing surveillance. The deficient practice could result in the spread of infections, including COVID-19 to residents and staff. Findings include: A review of the facility's infection surveillance documentation revealed a patient infection report form, line listing of patient infections, infection surveillance map and the monthly infection control report for the month of August 2020. However, there was no infection surveillance documentation (i.e. a patient infection report form, line listing of patient infections, infection surveillance map or the monthly infection control report) for the month of September 2020. A telephone interview was conducted on October 13, 2020 at 2:30 p.m. with the Infection Preventionist (IP/staff #11), who stated that she worked full time at the facility as the IP and as the Wound Nurse. She stated that part of her IP duties included completing a line listing and mapping of infections and that she was a little behind in completing them. In an interview conducted on October 13, 2020 at 3:00 p.m. with the Director of Nursing (DON/staff #4), the DON said that she did not realize staff #11 was so far behind with completing the infection surveillance data. She stated that staff #11 was currently filling the role of IP and Wound Nurse. The DON stated line listing and infection control surveillance data was not completed for September 2020. She said that infection control surveillance documentation is expected to be completed monthly. The DON further stated that if they are behind in infection surveillance, they are unable to see where they are in terms of infection prevention. Review of the CDC Preparing for COVID-19 in Nursing Homes guidance revealed facilities should assign at least one individual with training in infection prevention and control (IPC) to provide on-site management of their COVID-19 prevention and response activities because the breath of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of healthcare personnel, and auditing adherence to recommended IPC practices. The facility's policy titled Infection Control Surveillance revealed the reason for this policy was to effectively monitor infections within the facility by gathering data and assessing possible trends and to assist in minimizing the spread of infection within the facility. This policy also revealed the Infection Control Nurse will complete the Monthly Infection Control Report by the 5th working day of each month for the previous month and that all completed records including the patient infection report form, infection criteria checklist, line listing of patient infections, infection surveillance map and the monthly infection control report will be kept in a binder separated by month.

Based on observations, staff interviews, facility documentation, review of the Centers for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure that infection control standards were followed. The deficient practice could result in the spread of infections, including COVID-19 to residents and staff. Findings include: An entrance conference was conducted on July 23, 2020 at 8:21 a.m., with the Clinical Nurse Manager (Licensed Practical nurse/LPN/staff #20) and the Minimum Data Set (MDS) nurse (LPN/staff #11). Both staff members stated that currently there were no COVID-19 positive residents in the building. They stated the current census was 25 residents. Review of the facility map and census information provided by the facility indicated there were three residents who were tested for COVID-19, one resident was on hallway #1 and two residents were on hallway #2. During an interview with the Infection Preventionist (staff #22) on July 23, 2020, she stated there were three residents that are currently being ruled out for COVID-19 and results are pending, and they should have the results this afternoon or tomorrow morning. She stated that all residents in the building are on quarantine isolation and strict contact isolation is followed, when staff are providing direct patient care. She also stated that 14 staff had tested positive for COVID-19 in July 2020. An observation was conducted on hallway #1 on July 23, 2020 at 9:16 a.m. A registered nurse (RN/staff #44) was standing in the hallway outside of a resident's room. Staff #44 was wearing a mask, goggles, a lab coat and gloves. Staff #44 then entered the resident's room without applying a gown over her lab coat. Once inside the room, the nurse did not don a gown and administered medication to the resident. An interview was conducted with staff #44 on July 23, 2020 at 9:22 a.m. She stated that she had received training on infection control procedures. She stated the training started in March and has been ongoing. She said when entering a resident's room, the Personal Protective Equipment (PPE) that should be applied depends on the type of isolation they are one. She said that she has been instructed that gowns are only needed when providing direct patient care, which means direct contact. An interview was conducted with a CNA (staff #1) on July 23, 2020 at 11:42 a.m. She stated that today she is working on hallway #2 and there are currently two residents that are under suspicion of having COVID-19. She stated they do not move residents to the COVID unit, until they test positive. Staff #1 further stated that she has been instructed to wear a mask, face shield and gown while in the hallways. She stated that if she plans on having direct resident contact, she has been instructed to don gloves and use either a disposable gown or a gown assigned to the resident. An interview was conducted with the Infection Preventionist (LPN/staff #22) on July 23, 2020 at 2:14 p.m. She stated that residents are admitted to the facility 72 hours after a negative result. She stated that the facility will request two negative results if the resident was positive at any time. She stated that during the initial quarantine period which is 14 days from admission, there is strict PPE adherence. Staff #22 stated that positive residents are placed in the COVID unit and transferred out to COVID facilities as soon as possible. She stated that all staff had one-to-one training on PPE and their policies. She further stated that staff are required to wear masks, face shields, and gowns when in the facility at all times. She said they don them when they enter the facility. She also stated that each resident has a designated gown that staff don when they enter a resident's room. She stated that gloves are to be worn when providing direct resident contact. -An observation was conducted on hallway #2 on July 23, 2020 at 9:29 a.m. A Certified Nursing Assistant (CNA/staff #1) removed a yellow bag liner from a bin that contained contaminated gowns. The CNA was not wearing any gloves, a gown or face shield/goggles. At this time, an interview was conducted with staff #1. She stated the reason she was not wearing gloves was because she didn't have any. Another interview was conducted with staff #1 on July 23, 2020 at 11:42 a.m. She said that she had received infection control training from the Infection Preventionist. She said that she should not have touched the yellow bag without gloves. Further observations on hallway #2 revealed there were multiple boxes of gloves and additional PPE available throughout the unit. -An observation was conducted of a medication cart on hallway #2 on July 23, 2020 at 9:32 a.m. At this time, there was an oxygen pulse oximeter that was lying on top of the cart without a barrier. An interview was conducted with a CNA (staff #40) on July 23, 2020 at 9:40 a.m. in hallway #2. She stated the oxygen pulse oximeter's are sometimes shared between residents because there are not enough to go around. She said that each pulse oximeter is sanitized in-between each resident and then stored in the storage area. She stated the pulse oximeter is wiped down with sanitizer wipes with a 5 minute dry time. At this time, an interview was conducted with a case manager (LPN/staff #10) whose medication cart had the oxygen pulse oximeter on top of the cart. The nurse stated that the CNA's leave the pulse oximeter on the cart after they use it, but she does not know the cleaning process for that piece of equipment. An interview was conducted with the Infection Preventionist (staff #22) on July 23, 2020 at 2:14 p.m. She stated that no one should have to share pulse oximeter equipment. She stated all staff have been trained on cleaning procedures, but some of the staff covering (staff #10) received the training some time ago. She stated that all staff should know the dry time of the cleaning products. According to an email from the Administrator received on July 23, 2020 at 8:00 p.m., two of the residents tested were positive for COVID-19. Both residents resided on hallway #2. An interview was conducted with the Infection Preventionist (staff #22) on July 24, 2020 at 12:40 p.m. Staff #22 stated that over the last 10 days, 9 residents have tested positive for COVID-19. She stated the majority of them have been on hallway #2. She stated the facility has been attempting to isolate the cause of the contamination with increased monitoring and education. She stated that two of the residents had been in the facility for more than 72 hours. She said this could suggest that it was facility acquired. She stated that all residents were tested on [DATE]. An interview was conducted with the Administrator and the Director of Nursing (DON/staff #30) telephonically on July 24, 2020 at 2:16 p.m. The DON stated it is their expectation that all staff continue with a heightened level of infection control. She stated she feels there are areas where some procedures need improved focus after the increased positives results for residents and staff. She stated that all staff need to follow the policies and the monitoring of practices needs to be increased. She said it is important to have all of the management team on the same page to prevent this type of outbreak of COVID again. She stated that in the future, tightening up procedures and moving residents more swiftly will help to decrease the risk of exposure. During the interview, the Administrator stated there was a lack of rigid processes and thinking that the facility was out of the woods when a resident tested negative. He stated in the past we wanted to save PPE equipment so there would not be a shortage. He stated that having tight restrictions on PPE seemed to be the wrong path. He said there are many resources available to us with the county health department and sister facilities. A facility policy titled, Soiled Laundry & Linen Handling included that the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Staff should consider all soiled linen to be potentially infectious. A facility policy titled, Soiled Laundry & Bedding revealed that soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and person handling the linen. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g. gowns if soiling of clothing is likely; protective eye wear, mask as needed). Review of a policy regarding COVID-19 Emergency Plan revealed that if equipment is utilized for multiple patients, it should be disinfected using an EPA-registered disinfectant for healthcare settings prior to use on another patient. The facility will have proper adherence to currently recommended infection control practices. All recommended PPE should protect staff having prolonged close contact with patients infected with COVID-19 A policy titled, COVID-19 stated that in accordance with an executive order of April 8, 2020, the facility implements the following policy guidelines effective April 9, 2020: The facility shall immediately comply with all infection control guidance from the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), including ensuring all staff use appropriate PPE when interacting with residents, per CDC guidelines. Review of the Centers for Disease Control and Prevention Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) during the Coronavirus Disease Pandemic dated July 15, 2020, revealed that residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face) gloves and gown. Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or healthcare personnel is newly identified in the facility. This could also be considered when there is sustained transmission in the community. HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. For HCP working in areas with minimal to no community transmission, HCP should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a facemask for source control is recommended for HCP.